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WO2025059425A1 - Glyt-1 inhibitors and uses thereof - Google Patents

Glyt-1 inhibitors and uses thereof Download PDF

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Publication number
WO2025059425A1
WO2025059425A1 PCT/US2024/046557 US2024046557W WO2025059425A1 WO 2025059425 A1 WO2025059425 A1 WO 2025059425A1 US 2024046557 W US2024046557 W US 2024046557W WO 2025059425 A1 WO2025059425 A1 WO 2025059425A1
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compound
alkyl
pharmaceutically acceptable
acceptable salt
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Srikanth Venkatraman
Yi XIANG
Yue Chen
Scott REISMAN
Min Wu
Brian Richard Macdonald
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Disc Medicine Inc
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Disc Medicine Inc
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    • C07D295/02—Heterocyclic compounds containing polymethylene-imine rings with at least five ring members, 3-azabicyclo [3.2.2] nonane, piperazine, morpholine or thiomorpholine rings, having only hydrogen atoms directly attached to the ring carbon atoms containing only hydrogen and carbon atoms in addition to the ring hetero elements
    • C07D295/027—Heterocyclic compounds containing polymethylene-imine rings with at least five ring members, 3-azabicyclo [3.2.2] nonane, piperazine, morpholine or thiomorpholine rings, having only hydrogen atoms directly attached to the ring carbon atoms containing only hydrogen and carbon atoms in addition to the ring hetero elements containing only one hetero ring
    • C07D295/03—Heterocyclic compounds containing polymethylene-imine rings with at least five ring members, 3-azabicyclo [3.2.2] nonane, piperazine, morpholine or thiomorpholine rings, having only hydrogen atoms directly attached to the ring carbon atoms containing only hydrogen and carbon atoms in addition to the ring hetero elements containing only one hetero ring with the ring nitrogen atoms directly attached to acyclic carbon atoms
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    • C07D471/02—Heterocyclic compounds containing nitrogen atoms as the only ring hetero atoms in the condensed system, at least one ring being a six-membered ring with one nitrogen atom, not provided for by groups C07D451/00 - C07D463/00 in which the condensed system contains two hetero rings
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    • C07D513/04—Ortho-condensed systems

Definitions

  • GLYT-1 INHIBITORS AND USES THEREOF Related Applications This application claims the benefit of priority to U.S. Provisional Patent Application No.63/538,539, filed September 15, 2023, and U.S. Provisional Patent Application No. 63/658,642, filed June 11, 2024, which applications are hereby incorporated by reference in their entirety.
  • Background There are two main types of glycine transporters (GlyTs): glycine transporter-1 (GlyT-1) and glycine transporter-2 (GlyT-2).
  • GlyT-1 shows a widespread distribution in the brain, erythrocytes, and peripheral tissues.
  • GlyT-2 is found primarily in the spinal cord and brainstem and is involved in the regulation of glycine.
  • Glycine transporter-1 is the primary source of glycine for heme biosynthesis in developing red blood cells. Consequently, inhibition of glycine transporter-1 could potentially reduce heme synthesis leading to new treatments for conditions in which excess heme, the accumulation of toxic intermediates of heme biosynthesis, or pathological increases in erythropoiesis lead to disease. For example, inhibition of red cell glycine uptake could reduce the accumulation of protoporphyrin IX (PPIX), an intermediate in heme biosynthesis that accumulates and causes disease in erythropoietic protoporphyria and X-linked protoporphyria.
  • PPIX protoporphyrin IX
  • the present application provides novel compounds that inhibit glycine transporter 1 and are amenable to treating various hematological conditions, particularly conditions in which excess heme, the accumulation of toxic intermediates of heme biosynthesis, or pathological increases in erythropoiesis lead to disease.
  • A is an aryl or heteroaryl ring system wherein the aryl or heteroaryl ring system is optionally substitued one or more times with R 1 ;
  • B is a 4- to 8-membered non-aromatic carbocycle or a 4- to 8-membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R 2 ;
  • R 1 is independently for each occurrence selected from the group consisting of OH, halogen, -CF 3 , - OCF 3 , -OCH 2 F, -OCHF 2 , -C 1-8 alkyl, –C 3-8 cycloalkyl, –C 4-16 cycloalkylalkyl, -OC 1-8 alkyl, - SC
  • A is selected from phenyl, pyrimidine, pyridine, and thiazole, wherein the phenyl, pyrimidine, pyridine, and thiazole, is optionally substituted one or more times with R 1 .
  • R 1 is halogen.
  • B is a 5-membered non-aromatic carbocycle optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic carbocycle optionally substituted one or more times with R 2 .
  • B is a 5-membered non-aromatic heterocyle comprising an oxygen atom wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 5-membered non-aromatic heterocyle comprising a sulfur atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 5-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom and an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising one nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising two nitrogen atoms, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • R 3 is -OC 1-8 alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CH 2 F, CHF 2 , CF 3 , aryl, heterocyclyl, and –C 3-8 cycloalkyl.
  • R 3 is -OC 1-8 alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from halogen.
  • R 3 is –OCH(CH 3 )CF 3 .
  • R 3 has (S) configuration.
  • R 3 has (R) configuration.
  • R 4 is H.
  • R 5 is H.
  • R 6 is C 1-8 alkyl. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R 6 is Me
  • the present application provides a compound selected from any one of compounds 1- 60, and pharmaceutically acceptable salts thereof.
  • the compound is compound (1), or a pharmaceutically acceptable salt thereof.
  • the compound is compound (11), or a pharmaceutically acceptable salt thereof.
  • the compound is compound (17), or a pharmaceutically acceptable salt thereof.
  • the compound is compound (52), or a pharmaceutically acceptable salt thereof.
  • the compound is compound (53), or a pharmaceutically acceptable salt thereof.
  • the compound is compound (54), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (55), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (56), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (57), or a pharmaceutically acceptable salt thereof.
  • the present application provides a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof; and (b) a pharmaceutically acceptable excipient.
  • the present application provides a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof; and (b) a pharmaceutically acceptable excipient for use as a medicament.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof e.g., any one of compounds 1-60
  • a pharmaceutically acceptable excipient for use as a medicament e.g., any one of compounds 1-60
  • the present application provides a method of treating a hematological disorder in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of treating porphyria in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of treating a hepatic porphyria in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method treating one or more complications of a hepatic porphyria in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the one or more complications of hepatic porphyria is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, severe abdominal pain, neuropsychiatric symptoms, autonomic neuropathy, peripheral motor neuropathy, electrolyte disturbances, nausea, vomiting, constipation, diarrhea, difficulty urinating, ileus, paresthesia, insomnia, restlessness, agitation, anxiety, confusion, hallucinations, psychosis, convulsions, pain associated with neuropathy, muscle paralysis, tetraparesis, decreased breathing, respiratory arrest, hyponatremia, tachycardia, hypertension, increased heart rate, increased blood pressure, red urine, dark urine, hepatocellular carcinoma, hypertensive renal damage, chronic kidney disease, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities
  • the hepatic porphyria is an acute hepatic porphyria, acute intermittent porphyria (AIP), ALA dehydratase porphyria (ADP), variegate porphyria (VP), hereditary coproporphyria (HCP), or harderoporphyria.
  • AIP acute intermittent porphyria
  • ADP ALA dehydratase porphyria
  • VP variegate porphyria
  • HCP hereditary coproporphyria
  • harderoporphyria the hepatic porphyria is non-acute hepatic porphyria.
  • the non-acute hepatic porphyria is familial or sporadic porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP).
  • the present application provides a method of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof e.
  • the present application provides a method of treating one or more complications of EPP, XLPP, or CEP in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the one or more complications of EPP, XLPP, or CEP is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholestasis, cytolysis, gallstones, cholestatic liver failure, cholelithiasis, mild liver disease, deteriorating liver disease, terminal phase liver disease, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero.
  • the present application provides a method of inhibiting protoporphyrin IX (PPIX) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of inhibiting 5-aminolevulinic acid (5- ALA) synthesis in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject
  • the present application provides a method of inhibiting coproporphyrin III synthesis in vivo, comprising administering (1 a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • the present application provides a method of inhibiting zinc-protoporphyrin IX (ZPPIX) synthesis in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of inhibiting porphobilinogen (PBG) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of inhibiting 5-aminolevulinic acid (5- ALA) and porphobilinogen (PBG) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • PBG porphobilinogen
  • the present application provides a method of inhibiting hydroxymethylbilane (HMB) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • the present application provides a method of inhibiting uroporphyrin III synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • a compound of formula (I) e.g., any one of compounds 1- 60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • the present application provides a method of inhibiting heptacarboxyl-porphyrin synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • the present application provides a method of inhibiting isocoproporphyrin synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject.
  • the present application provides a method of inhibiting synthesis of a porphyrin or porphyrin precursor in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject, wherein the porphyrin or porphyrin precursor is selected from the group consisting of: a. 5-ALA b. PBG c. Hydroxymethylbilane d. PPIX e. ZPPIX f. Uroporphyrinogen I g.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (
  • accumulation of one or more heme intermediates is inhibited, and wherein the one or more heme intermediates are selected from the group consisting of 5-ALA, coproporphyrin III, zinc-protoporphyrin IX (ZPPIX), porphobilinogen, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin.
  • the accumulation of the one or more heme intermediates is inhibited in a dose dependent manner.
  • the subject has EPP, XLPP, or CEP.
  • the subject has hepatic porphyria.
  • the subject has a mutation in UROS. In certain embodiments of the foregoing methods, the subject has a gene defect in GATA-1 erythroid-specific transcription factor. In certain embodiments of the foregoing methods, wherein the subject has liver disease associated with EPP, XLPP, or CEP. In certain embodiments of the foregoing methods, the method further comprises administering to the subject an additional active agent and/or supportive therapy.
  • the additional active agent and/or supportive therapy is selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse ®), bortezomib, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion.
  • the additional active agent and/or supportive therapy is selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse®), bortezomib, heme infusions, sufficient caloric support, Givosiran, RNAi mediated silencing of various enzymes (e.g., ALA synthase), avoiding precipitating factors, 4-aminoquinolines, chloroquine, hydroxychloroquine, phlebotomy, intravenous magnesium, LH-RH agonists, enzyme replacement therapy (e.g., recombinant human PBGD), gene therapy (e.g., transfer of PBGD gene in liver cells by viral vectors), hemodialysis, pharmacologic chaperone treatment, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and
  • the present application provides a method of treating anemia associated with a ribosomal disorder in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of treating of one or more complications of anemia associated with a ribosomal disorder in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the one or more complications of anemia associated with a ribosomal disorder is selected from the group consisting of: thrombocytosis, megakaryotypic hyperplasia, infections, bleeding (e.g., from the nose or gums), bruising, splenomegaly, the need for more frequent blood transfusions, the need for increased glucocorticoid use, the need for allogenic hematopoietic stem cell transplantation, the need for autologous gene therapy, marrow failure, leukemia, and acute myelogenous leukemia.
  • the anemia associated with a ribosomal disorder is Diamond-Blackfan anemia.
  • the subject is haploinsufficient for a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein L5 (RPL5), 60S ribosomal protein L11 (RPL11), and 40S ribosomal protein S7 (RPS7).
  • a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein L5 (RPL5)
  • the subject is haploinsufficient for a ribosomal protein selected from the group consisting of 40S ribosomal protein S10 (RPS10), 40S ribosomal protein S26 (RPS26), 60S ribosomal protein L15 (RPL15), 60S ribosomal protein L17 (RPL17), 60S ribosomal protein L19 (RPL19), 60S ribosomal protein L26 (RPL26), 60S ribosomal protein L27 (RPL27), 60S ribosomal protein L31 (RPL31), 40S ribosomal protein S15a (RPS15a), 40S ribosomal protein S20 (RPS20), 40S ribosomal protein S27 (RPS27), 40S ribosomal protein S28 (RPS28), and 40S ribosomal protein S29 (RPS29).
  • RPS10 40S ribosomal protein S10
  • RPS26 40S ribosomal protein S26
  • the subject has one or more mutations in a ribosomal protein gene.
  • the subject has one or more mutations in a ribosomal protein gene selected from the group consisting of RPL5, RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19, RPS20, RPS24, RPS26, RPS27a, RPS27, RPS28, and RPS29.
  • the subject has one or more mutations in a non-ribosomal protein gene selected from the group consisting of TSR2, GATA1, and EPO.
  • a non-ribosomal protein gene selected from the group consisting of TSR2, GATA1, and EPO.
  • the anemia associated with a ribosomal disorder is Shwachman-Diamond syndrome.
  • the subject has one or more mutations in the SBDS gene.
  • the anemia associated with a ribosomal disorder is dyskeratosis congenita.
  • the dyskeratosis congenita is x-linked dyskeratosis congenita.
  • the subject has one or more mutations in the DKC1 gene.
  • the method decreases the risk of bone marrow failure, pulmonary fibrosis, or liver fibrosis in the subject.
  • the anemia associated with a ribosomal disorder is cartilage hair hypoplasia.
  • the subject has one or more mutations in the RMRP gene.
  • the method reduces intracellular heme levels. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the method increases the subject’s red blood cell count. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the method further comprises administering to the subject an additional active agent and/or supportive therapy.
  • the additional active agent and/or supportive therapy is selected from the group consisting of: trifluoperazine, lenalidomide, HDAC inhibitors, glucocorticoids, sotatercept, luspatercept, iron chelators, blood transfusion, platelet transfusion,
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the present application provides a method of treating one or more complications of polycythemia in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia.
  • the polycythemia is primary polycythemia.
  • the primary polycythemia is polycythemia vera or pure erythrocytosis.
  • the primary polycythemia is primary familial polycythemia.
  • the polycythemia is secondary polycythemia.
  • the secondary polycythemia is associated with a disorder selected from the group consisting of hypoxia, central hypoxic process, lung disease, right-to-left cardiopulmonary vascular shunts (congenital or acquired), heart disease, heart failure, carbon monoxide poisoning, smoker’s erythrocytosis, high-altitude habitat, renal disease, kidney transplant, hemoglobinopathy with high-oxygen-affinity, decreased levels of erythrocyte 2,3,- DPG, bisphosphoglycerate mutase deficiency, methemoglobinemia, hereditary ATP increase, oxygen sensing pathway gene mutations, tumor, drug-induced secondary polycythemia, adrenal cortical hypersecretion, and idiopathic polycythemia.
  • the polycythemia is relative polycythemia.
  • the relative polycythemia is selected from the group consisting of Gaisbock’s syndrome, spurious polycythemia, or stress erythrocytosis.
  • the polycythemia is Chuvash polycythemia.
  • the present application provides a method of inhibiting heme synthesis in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the heme synthesis is inhibited in a dose dependent manner.
  • the present application provides a method of inhibiting hemoglobin synthesis in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the hemoglobin synthesis is inhibited in a dose dependent manner.
  • the present application provides a method of inhibiting red blood cell synthesis in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • red blood cell synthesis is inhibited in a dose dependent manner.
  • the present application provides a method of decreasing the red blood cell count in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject.
  • the red blood cell count is decreased in a dose dependent manner.
  • the method decreases the incidence of iron deficiency by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method further comprises administering to the subject an additional active agent and/or supportive therapy.
  • the additional active agent and/or supportive therapy is selected from the group consisting of: Hydroxyruea (e.g., Droxia®, Hydrea®), Interferon alpha, Interferon alpha-2b (e.g., Intron® A), Ruxolitinib (e.g., Jakafi®), Busulfan (e.g., Busulfex®, Myleran®), radiation treatment, hepcidin mimetics (e.g., PTG-300), matriptase-2 inhibitors, ferroportin inhibitors, JAK inhibitors, BET inhibitors, MDM2 inhibitors, and HDAC inhibitors.
  • Hydroxyruea e.g., Droxia®, Hydrea®
  • Interferon alpha e.g., Intron® A
  • Ruxolitinib e.g., Jakafi®
  • Busulfan e.g., Busulfex®, Myleran®
  • radiation treatment e.g.
  • FIGURE 1 illustrates the study procedure to evaluate the efficacy of a GlyT1 inhibitor in EPP phototoxicity assay.
  • FIGURE 2 shows compound 11 (“GlyT1 inhibitor”) reduces PPIX levels in RBCs in Fech m1Pas /Fech m1Pas homozygous mice as measured by flow cytometry on Day 14 and Day 18.
  • FIGURE 3 shows compound 11 (“GlyT1 inhibitor”) treatment reduces skin lesions in Fech m1Pas /Fech m1Pas homozygous mice after light exposure.
  • FIGURE 4 shows compound 11 (“GlyT1 inhibitor”) treatment reduces the percentage of area with skin lesions in Fech m1Pas /Fech m1Pas homozygous mice after light exposure.
  • FIGURE 5 shows a correlation between the quantification of skin lesions and PPIX levels in Fech m1Pas /Fech m1Pas homozygous mice at day 14 treated with vehicle or compound 11 (“GlyT1 inhibitor”).
  • GlyT1 inhibitor vehicle or compound 11
  • compounds of the present application, and pharmaceutical compositions thereof may inhibit the activity GlyT-1, or a mutant thereof, and thus treat certain diseases, disorders, via GlyT-1 inhibition, such as various hematological disorders, particularly those caused by iron overload and/or regulate heme synthesis.
  • Inhibition of heme synthesis via inhibition of PPIX synthesis could be used to treat numerous hematological disorders such as erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP).
  • Inhibition of heme synthesis with glycine transporter inhibitors also has the potential in treatment of iron overload disorder and hemoglobinopathies such as polycythemia (e.g., primary polycythemia, polycythemia vera, pure erythrocytosis, primary familial polycythemia, relative polycythemia, secondary polycythemia, Gaisbock’s syndrome, spurious polycythemia, stress erythrocytosis, Chuvash polycythemia), anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia, Shwachman-Diamond syndrome, Cartilage-hair hypoplasia, and dyskeratosis congenita), hepatic porphyria (e.g., acute hepatic porphyria, acute intermittent porphyria, ALA dehydratase porphyria, variegate porphyria, hereditary coproporphyria, harderoporphyr
  • A is an aryl or heteroaryl ring system wherein the aryl or heteroaryl ring system is optionally substitued one or more times with R 1 ;
  • B is a 4- to 8-membered non-aromatic carbocycle or a 4- to 8-membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R 2 ;
  • R 1 is independently for each occurrence selected from the group consisting of OH, halogen, - CF 3 , -OCF 3 , -OCH 2 F, -OCHF 2 , -C 1-8 alkyl, –C 3-8 cycloalky
  • A is a monocyclic aryl or heteroaryl ring system wherein the monocyclic aryl or heteroaryl ring system is fused to ring B, and wherein the monocyclic aryl or heteroaryl ring system is optionally substitued one or more times with R 1 .
  • A is selected from phenyl, pyrimidine, pyridine, and thiazole, wherein the phenyl, pyrimidine, pyridine, and thiazole, is optionally substituted one or more times with R 1 .
  • R 1 is halogen (e.g., fluoro or chloro) or -C 1-8 alkyl. In certain embodiments, R 1 is halogen (e.g., fluoro or chloro).
  • B is a 5- or 6-membered non-aromatic carbocycle or a 5- or 6- membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R 2 .
  • B is a 5-membered non-aromatic carbocycle optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic carbocycle optionally substituted one or more times with R 2 .
  • B is a 5-membered non-aromatic heterocyle comprising an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 5-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom and an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • B is a 6-membered non-aromatic heterocyle comprising two nitrogen atoms, wherein the non-aromatic heterocyle is optionally substituted one or more times with R 2 .
  • R 1 e.g., halogen, such as fluorine or chlorine, or -C 1-8 alkyl, such as methyl
  • R 2 e.g., alkyl, such as methyl, or -(CH 2 ) m C(O)OC 1-8 alkyl, such as C(O)OtBu
  • aryl or heteroaryl ring system of ring A is optionally substitued one or more times with R 1 (e.g., halogen, such as fluorine or chlorine, or -C 1-8 alkyl, such as methyl), and the 5- or 6 -membered non-aromatic carbocycle or heterocyle of ring B is optionally further substituted one or more times with R 2 (e.g., alkyl, such as methyl, or -(CH 2 ) m C(O)OC 1-8 alkyl, such as C(O)OtBu).
  • R 1 e.g., halogen, such as fluorine or chlorine, or -C 1-8 alkyl, such as methyl
  • R 2 e.g., alkyl, such as methyl, or -(CH 2 ) m C(O)OC 1-8 alkyl, such as C(O)OtBu
  • R a and R b together with the nitrogen atom to which they are attached form an optionally substituted monocyclic non-aromatic heterocyclyl containing 3-9 atoms having 1-4 heteroatoms independently selected from nitrogen, oxygen, and sulfur.
  • R a and R b together with the nitrogen atom to which they are attached form oxazolidinyl or oxazolidinyl group: .
  • R a and R b together with the nitrogen atom to which they are attached form thiazinyl or thiazinyl group: In certain embodiments, R a and R b together with the nitrogen atom to which they are attached form imidazolidinyl or an imidazolidinyl group: In certain embodiments, R a and R b together with the nitrogen atom to which they are attached form piperazinyl or a piperazinyl group: In certain embodiments, R a and R b together with the nitrogen atom to which they are attached form pyrrolidinyl or a pyrrolidinyl group: In certain embodiments, R a and R b together with the nitrogen atom to which they are attached form thiomorpholinyl or a thiomorpholinyl group: .
  • R a and R b together with the nitrogen atom to which they are attached form piperidinyl or a piperidinyl group: .
  • R a and R b together with the nitrogen atom to which they are attached form morpholinyl or a morpholinyl group:
  • R 3 is selected from the group consisting of OH, -OC 1-8 alkyl, - Oaryl, -Oheteroaryl, and – OC 0-8 alkylC 3-8 cycloalkyl, wherein -C 1-8 alkyl and -OC 1-8 alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, haloalkyl (e.g., CH 2 F, CHF 2 , CF 3 ), aryl, heterocyclyl, and –C 3-8 cycloalkyl.
  • halogen e.g., CH 2 F, CHF 2 , CF 3
  • R 3 is -OC 1-8 alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CF 3 , aryl, heterocyclyl, and –C 3-8 cycloalkyl.
  • R 3 is -OC 1-8 alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from halogen (e.g., fluorine).
  • R 3 is –OCH(CH 3 )CF 3 .
  • R 4 is H.
  • R 3 and R 4 together with the carbon atoms to which they are attached form a 4-8 membered heterocyclyl, wherein 4-8 membered heterocyclyl can be optionally substituted 1 or 2 times with -C 1-8 alkyl, aryl, and heterocyclyl, wherein -C 1-8 alkyl, aryl, and heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen.
  • R 3 and R 4 together with the carbon atoms to which they are attached form tetrahydrofuranyl or dihydrofuranyl, wherein tetrahydrofuranyl and dihydrofuranyl can be optionally substituted 1 or 2 times with -C 1-8 alkyl, wherein -C 1-8 alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen.
  • R 3 and R 4 together with the atoms to which they are attached form an optionally substituted 4-8 membered heterocyclyl.
  • R 3 and R 4 together with the atoms to which they are attached form tetrahydrothiophene 1,1-dioxide or dihydrothiophene 1,1-dioxide.
  • R 3 and R 4 together with the carbon atoms to which they are attached form tetrahydrofuranyl optionally substituted 1 or 2 times with -C 1-8 alkyl, wherein - C 1-8 alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen (e.g., Cl or F).
  • halogen e.g., Cl or F
  • R 3 and R 4 together with the carbon atoms to which they are attached form dihydrofuranyl optionally substituted 1 or 2 times with -C 1-8 alkyl, wherein -C 1- 8 alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen (e.g., Cl or F).
  • halogen e.g., Cl or F
  • R 5 is H. In certain embodiments, R 5 is selected from the group consisting of H and NH 2 . In certain embodiments, R 6 is C 1-8 alkyl. In certain embodiments, R 6 is Me. In certain embodiments, R 5 and R 6 together with the atoms to which they are attached form tetrahydrothiophene 1,1-dioxide. Thus, the compound of Formula (I) has the following structure: . In certain embodiments, R 5 and R 6 with the atoms to which they are attached form dihydrothiophene 1,1-dioxide. Thus, the compound of Formula (I) has the following structure: . In certain embodiments, l is 0. In certain embodiments, l is 8. The present application provides a compound selected from any one of compounds 1- 60, and pharmaceutically acceptable salts thereof:
  • the compound is selected from any one of compounds 1-51, and pharmaceutically acceptable salts thereof. In certain embodiments, the compound is selected from any one of compounds 1-57, and pharmaceutically acceptable salts thereof.
  • a compound e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof, such as any one of compounds 1-60, and pharmaceutically acceptable salts thereof
  • the application further contemplates the compound in its racemic or other enantiomeric form. For example, for any one of compounds 1-60 shown as the (S) enantiomer, the present application further provides the compound in its racemic or (R) enantiomeric form, and pharmaceutically acceptable salts thereof.
  • any one of compounds 1-60 shown as the (R) enantiomer the present application further provides the compound in its racemic or (S) enantiomeric form, and pharmaceutically acceptable salts thereof.
  • alkyl, alkenyl, alkynyl, alkoxy, aryl, heteroaryl, cycloalkyl, heterocyclyl, or oxime are substituted, they are substituted, valency permitting, with one or more substituents selected from substituted or unsubstituted alkyl, such as perfluoroalkyl (e.g., trifluoromethyl), alkenyl, alkoxy, alkoxyalkyl, aryl, aralkyl, arylalkoxy, aryloxy, aryloxyalkyl, hydroxyl, halo, alkoxy, such as perfluoroalkoxy (e.g., trifluoromethoxy), alkoxyalkoxy, hydroxyalkyl, hydroxyalkyl, hydroxyalkyl,
  • compounds of the present application containing one or multiple asymmetrically substituted atoms may be isolated in optically active or racemic forms. It is well known in the art how to prepare optically active forms, such as by resolution of racemic forms, by synthesis from optically active starting materials, or by synthesis using optically active reagents.
  • compounds of the application may be racemic.
  • a compound e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof
  • the application further contemplates the compound in its racemic form.
  • compounds of the application may be enriched in one enantiomer.
  • a compound of the application may have greater than 30% ee, 40% ee, 50% ee, 60% ee, 70% ee, 80% ee, 90% ee, or even 95% or greater ee.
  • the therapeutic preparation may be enriched to provide predominantly one enantiomer of a compound (e.g., of formula (I), or a pharmaceutically acceptable salt thereof).
  • An enantiomerically enriched mixture may comprise, for example, at least 60 mol percent of one enantiomer, or more preferably at least 75, 90, 95, or even 99 mol percent.
  • the compound enriched in one enantiomer is substantially free of the other enantiomer, wherein substantially free means that the substance in question makes up less than 10%, or less than 5%, or less than 4%, or less than 3%, or less than 2%, or less than 1% as compared to the amount of the other enantiomer, e.g., in the composition or compound mixture.
  • substantially free means that the substance in question makes up less than 10%, or less than 5%, or less than 4%, or less than 3%, or less than 2%, or less than 1% as compared to the amount of the other enantiomer, e.g., in the composition or compound mixture.
  • a composition or compound mixture contains 98 grams of a first enantiomer and 2 grams of a second enantiomer, it would be said to contain 98 mol percent of the first enantiomer and only 2% of the second enantiomer.
  • compounds of the application may have more than one stereocenter.
  • compounds of the application may be enriched in one or more diastereomer.
  • a compound of the application may have greater than 30% de, 40% de, 50% de, 60% de, 70% de, 80% de, 90% de, or even 95% or greater de.
  • the therapeutic preparation may be enriched to provide predominantly one diastereomer of a compound (e.g., a compound of formula (I), or a pharmaceutically acceptable salt thereof).
  • a diastereomerically enriched mixture may comprise, for example, at least 60 mol percent of one diastereomer, or more preferably at least 75, 90, 95, or even 99 mol percent.
  • a variety of compounds in the present application may exist in particular geometric or stereoisomeric forms.
  • the present application takes into account all such compounds, including tautomers, cis- and trans-isomers, R- and S-enantiomers, diastereomers, (D)- isomers, (L)-isomers, the racemic mixtures thereof, and other mixtures thereof, as being covered within the scope of this application. All tautomeric forms are encompassed in the present application. Additional asymmetric carbon atoms may be present in a substituent such as an alkyl group. All such isomers, as well as mixtures thereof, are intended to be included in this application, unless the stereochemistry or isomeric form is specifically indicated.
  • the present application further includes all pharmaceutically acceptable isotopically labelled compounds (e.g., compounds of formula (I), or pharmaceutically acceptable salts thereof).
  • An “isotopically” or “radio-labelled” compound is a compound where one or more atoms are replaced or substituted by an atom having an atomic mass or mass number different from the atomic mass or mass number typically found in nature (i.e., naturally occurring).
  • hydrogen atoms are replaced or substituted by one or more deuterium or tritium (e.g., hydrogen atoms on a C 1-6 alkyl or a C 1-6 alkoxy are replaced with deuterium, such as d 3 -methoxy or 1,1,2,2-d 4 -3-methylbutyl).
  • deuterium or tritium e.g., hydrogen atoms on a C 1-6 alkyl or a C 1-6 alkoxy are replaced with deuterium, such as d 3 -methoxy or 1,1,2,2-d 4 -3-methylbutyl.
  • Isotopically labelled compounds e.g., of formula (I), or pharmaceutically acceptable salts thereof
  • Suitable isotopes that may be incorporated in compounds of the present application include but are not limited to 2 H (also written as D for deuterium), 3 H (also written as T for tritium), 11 C, 13 C, 14 C, 13 N, 15 N, 15 O, 17 O, 18 O, 18 F, 35 S, 36 Cl , 82 B r, 75 Br, 76 B r, 77 Br, 123 I, 124 I, 125 I, and 131 I.
  • the present application provides a pharmaceutical preparation suitable for use in a human patient, comprising any of the compounds shown above (e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof) and one or more pharmaceutically acceptable excipients.
  • the pharmaceutical preparations may be for use in treating or preventing a condition or disease as described herein.
  • the pharmaceutical preparations have a low enough pyrogen activity to be suitable for use in a human patient.
  • a compound as disclosed herein e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof
  • demonstrates reduced brain pentration e.g., as compared to compounds known to cross the blood brain barrier, such as metoprolol.
  • a compound as disclosed herein e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof
  • is not capable of crossing the blood brain barrier i.e., the compound is peripherally restricted.
  • a compound as disclosed herein is a substrate for the human efflux transporter P- glycoprotein (P-gp).
  • a compound as disclosed herein e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof
  • the efflux ratio is determined in the absence of a P-gp inhibitor. In other such embodiments, at least a 50%, 60%, 70%, 80%, 90%, or 95% reduction of the efflux ratio is demonstrated when measured in the presence of a known P-gp inhibitor.
  • Compounds of any of the above structures may be used in the manufacture of medicaments for the treatment of any diseases or conditions disclosed herein.
  • Uses of the compounds Compounds of the present application may be administered orally, parenteral, buccal, vaginal, rectal, inhalation, insufflation, sublingually, intramuscularly, subcutaneously, topically, intranasally, intraperitoneally, intrathoracically, intravenously, epidurally, intrathecally, intracerebroventricularly and by injection into the joints.
  • the dosage will depend on the route of administration, the severity of the disease, age and weight of the patient and other factors normally considered by the attending physician, when determining the individual regimen and dosage level as the most appropriate for a particular patient.
  • the quantity of the compound to be administered will vary for the patient being treated and will vary from about 100 ng/kg of body weight to 100 mg/kg of body weight per day.
  • dosages can be readily ascertained by those skilled in the art from this disclosure and the knowledge in the art. This, the skilled artisan can readily determine the amount of compound and optional additives, vehicles, and/or carrier in compositions and to be administered in methods of the application.
  • the application relates to a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, for use as a medicament, e.g., for treatment of any of the disorders disclosed herein.
  • compounds and compositions described herein are generally useful for the inhibition of GlyT-1, or a mutant thereof.
  • the activity of a compound utilized in this disclosure as an inhibitor of GlyT-1, or a mutant thereof may be assayed in vitro, in vivo or in a cell line.
  • In vitro assays include assays that determine inhibition of GlyT-1, or a mutant thereof. Alternate in vitro assays quantitate the ability of the inhibitor to bind to GlyT-1, or a mutant thereof.
  • Detailed conditions for assaying a compound utilized in this disclosure as an inhibitor of GlyT-1, or a mutant thereof, are set forth in the Examples below.
  • the application relates to a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, for use as a medicament.
  • the present application provides methods of preventing or treating disorders associated with conditions in which excess heme, the accumulation of toxic intermediates of heme biosynthesis, or pathological increases in erythropoiesis lead to disease in a subject, the method comprising administering to the subject one or more glycine transporter inhibitor or a pharmaceutically acceptable salt thereof, or a prodrug of the one or more glycine transporter inhibitor or its pharmaceutically acceptable salt.
  • the disorder is a porphyria (e.g., as erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP)), a hepatic porphyria (e.g., acute hepatic porphyria, acute intermittent porphyria, ALA dehydratase porphyria, variegate porphyria, hereditary coproporphyria, harderoporphyria, non-acute hepatic porphyria, familial or sporadic porphyria cutanea tarda, hepatoerythropoietic porphyria), anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia, Shwachman-Diamond syndrome, Cartilage-hair hypoplasia, and dyskeratosis congen
  • the glycine transporter inhibitor is a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application provides a method of preventing or treating disorders associated with accumulation of PPIX in a subject, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • different compounds of the application may be (e.g., conjointly) administered with one or more other compounds of the application (e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof).
  • any one or more of a compound of formula (I) may be conjointly administered with other conventional therapeutic agents in treating one or more disease conditions referred to herein.
  • compounds of the present application may be used alone or conjointly administered with another type of therapeutic agent.
  • the phrase “conjoint administration” refers to any form of administration of two or more different therapeutic compounds such that the second compound is administered while the previously administered therapeutic compound is still effective in the body (e.g., the two compounds are simultaneously effective in the patient, which may include synergistic effects of the two compounds).
  • the different therapeutic compounds can be administered either in the same formulation or in a separate formulation, either simultaneously, sequentially, or by separate dosing of the individual components of the treatment.
  • the different therapeutic compounds can be administered within one hour, 12 hours, 24 hours, 36 hours, 48 hours, 72 hours, or a week of one another.
  • an individual who receives such treatment can benefit from a combined effect of different therapeutic compounds.
  • conjoint administration of compounds of the present application with one or more additional therapeutic agent(s) provides improved efficacy relative to each individual administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or the one or more additional therapeutic agent(s).
  • the conjoint administration provides an additive effect, wherein an additive effect refers to the sum of each of the effects of individual administration of the compound of the present application and the one or more additional therapeutic agent(s).
  • an additive effect refers to the sum of each of the effects of individual administration of the compound of the present application and the one or more additional therapeutic agent(s).
  • Such combination products employ the compounds of this present application within the dosage range described herein and the other pharmaceutically active compound or compounds within approved dosage ranges and/or the dosage described in the publication reference.
  • Porphyrias are a family of inherited or acquired disorders resulting from the deficient activity of specific enzymes in the heme biosynthetic pathway, also referred to herein as the porphyrin pathway. Porphyrins are the main precursors of heme.
  • Porphyrins and porphyrin precursors include 5-aminolevulinic acid (ALA), porphopilinogen (PBG), hydroxymethylbilane (HMB), uroporphyrinogen I or III, coproporphyrinogen I or III, protoporphrinogen IX, and protoporphyrin IX.
  • ALA 5-aminolevulinic acid
  • PBG porphopilinogen
  • HMB hydroxymethylbilane
  • uroporphyrinogen I or III coproporphyrinogen I or III
  • protoporphrinogen IX protoporphyrin IX
  • protoporphyrin IX protoporphyrin IX.
  • Heme is an essential part of hemoglobin, myoglobin, catalases, peroxidases, and cytochromes, the latter including the respiratory and P450 liver cytochromes. Heme is synthesized in most or all human cells. About 85% of heme is made
  • Porphyrias may be classified by the primary site of the overproduction and accumulation of porphyrins or their precursors. In hepatic porphyrias, porphyrins and porphyrin precursors are overproduced predominantly in the liver, whereas in erythropoietic porphyrias, porphyrins are overproduced in the erythroid cells in the bone.
  • the acute or hepatic porphyrias lead to dysfunction of the nervous system and neurologic manifestations that can affect both the central and peripheral nervous system, resulting in symptoms such as, for example, pain (e.g., abdominal pain and/or chronic neuropathic pain), vomiting, neuropathy (e.g., acute neuropathy progressive neuropathy), muscle weakness, seizures, mental disturbances (e.g., hallucinations, depression anxiety, paranoia), cardiac arrhythmias, tachycardia, constipation, and diarrhea.
  • the cutaneous or erythropoietic porphyrias primarily affect the skin, causing symptoms such as photosensitivity that can be painful, blisters, necrosis, itching, swelling, and increased hair growth on areas such as the forehead.
  • porphyrias are caused by mutations that encode enzymes in the heme biosynthetic pathway. However, not all porphyrias are genetic. For example, patients with liver disease may develop porphyria as a result of liver dysfunction. Patients with PCT can acquire the deficient activity of uroporphyrinogen decarboxylase (URO-D), due to the formation of a ORO-D enzyme with lower than normal enzymatic activity.
  • URO-D uroporphyrinogen decarboxylase
  • Acute Hepatic Porphyrias comprise eight inherited metabolic disorders of heme biosynthesis in which various enzymes in the complex heme biosynthetic pathway are disrupted. Porphyrias are broadly classified as acute vs non-acute or hepatic vs erythropoietic porphyrias, based on their clinical presentation. Acute hepatic porphyrias include acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), and aminolevulinic acid dehydratase deficient porphyria (ADP), and often lead to serious abdominal, psychiatric, neurologic, or cardiovascular symptoms.
  • AIP acute intermittent porphyria
  • VP variegate porphyria
  • HCP hereditary coproporphyria
  • ADP aminolevulinic acid dehydratase deficient porphyria
  • Each acute hepatic porphyria results from a genetic defect leading to deficiency in one of the enzymes of the heme synthesis pathway in the liver.
  • AIP, HCP, and VP are autosomal dominant porphyrias and ADP is autosomal recessive porphyria.
  • AIP, HCP, and VP occur as homozygous dominant forms.
  • Porphyria cutanea tarda is a non-acute hepatic porphyria in which patients often present with blisters, bullae, milia, and hypertrichosis on cheeks, temples, and eyebrows.
  • HEP hepatoerythropoietic porphyria
  • AIP Acute intermittent porphyria
  • PBG porphobilinogen
  • HMBS hydroxymethylbilane synthase
  • Non-acute hepatic porphyrias include porphyria cutanea tarda (PCT), a disease in which patients often present with blisters, bullae, milia, and hypertrichosis on cheeks, temples, and eyebrows.
  • PCT porphyria cutanea tarda
  • HEP hepatoerythropoietic porphyria
  • AIP has been found to have a prevalence as high as 1 in 10,000 in certain populations (e.g., in Northern Sweden).
  • the prevalence of mutations in the general population in United States and Europe, excluding the U.K., is estimated to be about 1 in 10,000 to 1 in 20,000.
  • Clinical disease manifests itself in only approximately 10-15% of individuals who carry mutations that are known to be associated with AIP.
  • the penetrance is as high as 40% in individuals with certain mutations (e.g., the W198X mutation).
  • AIP is typically latent prior to puberty. Symptoms are more common in females than in males. The prevalence of the disease is probably underestimated due to its incomplete penetrance and long periods of latency. In the United States, it is estimated that there are about 2000 patients who have suffered at least one attack.
  • AIP affects, for example, the visceral, peripheral, autonomic, and central nervous systems.
  • Symptoms of AIP are variable and include gastrointestinal symptoms (e.g., severe and poorly localized abdominal pain, nausea/vomiting, constipation, diarrhea, ileus), urinary symptoms (dysuria, urinary retention/incontinence, or dark urine), neurologic symptoms (e.g., sensory neuropathy, motor neuropathy (e.g., affecting the cranial nerves and/or leading to weakness in the arms or legs), seizures, neuropathic pain (e.g., pain associated with progressive neuropathy, e.g., chronic neuropathic pain), neuropsychiatric symptoms (e.g., mental confusion, anxiety, agitation, hallucination, hysteria, delirium, apathy, depression, phobias, psychosis, insomnia, somnolence, coma), autonomic nervous system involvement (resulting e.g., in cardiovascular symptoms such as tachycardia, hypertension, and/or arrhythmias, as well as other symptoms, such as, e.g
  • Attacks of acute porphyria may be precipitated by endogenous or exogenous factors.
  • the mechanisms by which such factors induce attacks may include, for example, increased demand for hepatic P450 enzymes and/or induction of ALAS1 activity in the liver.
  • Increased demand for hepatic P450 enzymes results in decreased hepatic free heme, thereby inducing the synthesis of hepatic ALAS1.
  • Precipitating factors include fasting (or other forms of reduced or inadequate caloric intake, due to crash diets, long-distance athletics, etc.), metabolic stresses (e.g., infections, surgery, international air travel, and psychological stress), endogenous hormones (e.g., progesterone), cigarette smoking, lipid-soluble foreign chemicals (including, e.g., chemicals present in tobacco smoke, certain prescription drugs, organic solvents, biocides, components in alcoholic beverages), endocrine factors (e.g., reproductive hormones (women may experience exacerbations during the premenstrual period), synthetic estrogens, progesterones, ovulation stimulants, and hormone replacement therapy).
  • metabolic stresses e.g., infections, surgery, international air travel, and psychological stress
  • endogenous hormones e.g., progesterone
  • cigarette smoking e.g., lipid-soluble foreign chemicals (including, e.g., chemicals present in tobacco smoke, certain prescription drugs, organic solvents, biocides,
  • Over 1000 drugs are contraindicated in the acute hepatic porphyrias (e.g., AIP, HCP, ADP, and VP) including, for example, alcohol, barbiturates, Carbamazepine, Carisoprodol, Clonazepam (high doses), Danazol, Diclofenac and possibly other NSAIDS, Ergots, estrogens, Ethyclorvynol, Glutethimide, Griseofulvin, Mephenytoin, Meprobamate (also mebutamate and tybutamate), Methyprylon, Metodopramide, Phenytoin, Primidone, progesterone and synthetic progestins, Pyrazinamide, Pyrazolones (aminopyrine and antipyrine), Rifampin, Succinimides (ethosuximide and methsuximide), sulfonamide antibiotics, and Valproic acid.
  • AIP acute hepatic
  • Objective signs of AIP include discoloration of the urine during an acute attack (the urine may appear red or red-brown), and increased concentrations of PBG and ALA in urine during an acute attack.
  • Molecular genetic testing identifies mutations in the PBG deaminase (also known as HMBS) gene in more than 98% of affected individuals.
  • the differential diagnosis of porphyrias may involve determining the type of porphyria by measuring individual levels of porphyrins or porphyrin precursors (e.g., ALA, PBG) in the urine, feces, and/or plasma (e.g., by chromatography and fluorometry) during an attack.
  • the diagnosis of AIP can be confirmed by establishing that erythrocyte PBG deaminase activity is at 50% or less of the normal level.
  • DNA testing for mutations may be carried out in patients and at-risk family members.
  • the diagnosis of AIP is typically confirmed by DNA testing to identify a specific causative gene mutation (e.g., an HMBS mutation).
  • Treatment of acute attacks typically requires hospitalization to control and treat acute symptoms, including, e.g., abdominal pain, seizures, dehydration/hyponatremia, nausea/vomiting, tachycardia/hypertension, urinary retention/ileus.
  • abdominal pain may be treated, e.g., with narcotic analgesics
  • seizures may be treated with seizure precautions and possibly medications (although many anti-seizure medications are contraindicated)
  • nausea/vomiting may be treated, e.g., with phenothiazines
  • tachycardia/hypertension may be treated, e.g., with beta blockers.
  • Treatment may include withdrawal of unsafe medications, monitoring of respiratory function, as well as muscle strength and neurological status.
  • Mild attacks e.g., those with no paresis or hyponatremia
  • Hemin Panhematin® or hemin for injection, previously known as hematin
  • Panhematin is the only heme product approved for use in the United States and was the first drug approved under the Orphan Drug Act.
  • Panhematin ® is hemin derived from processed red blood cells (PRBCs), and is Protoporphyrin IX containing a ferric iron ion (Heme B) with a chloride ligand.
  • the exact mechanism by which hemin produces symptomatic improvement in patients with acute episodes of the hepatic porphyrias has not been elucidated; however, its action is likely due to the (feedback) inhibition of ⁇ -aminolevulinic acid (ALA) synthase, the enzyme which limits the rate of the porphyrin/heme biosynthetic pathway.
  • ALA ⁇ -aminolevulinic acid
  • Inhibition of ALA synthase should result in reduced production of ALA and PBG as well as porphyrins and porphyrin intermediates.
  • Drawbacks of hemin include its delayed impact on clinical symptoms and its failure to prevent the recurrence of attacks.
  • Adverse reactions associated with hemin administration may include thrombophlebitis, anticoagulation, thrombocytopenia, renal shut down, or iron overload, which is particularly likely in patients requiring multiple courses of hemin treatment for recurrent attacks.
  • To prevent phlebitis an indwelling venous catheter is needed for access in patients with recurrent attacks.
  • Uncommonly reported side effects include fever, aching, malaise, hemolysis, anaphalaxis, and circulatory collapse.
  • Heme is difficult to prepare in a stable form for intravenous administration. It is insoluble at neutral pH but can be prepared as heme hydroxide at pH 8 or higher.
  • Panhematin® is a lyophilized hemin preparation. When lyophilized hemin is solubilized for intravenous administration, degradation products form rapidly; these degradation products are responsible for a transient anticoagulant effect and for phlebitis at the site of infusion.
  • Heme albumin and heme arginate Normal (Normosang, the European version of hemin) are more stable and may potentially cause less thrombophlebitis. However, heme arginate is not approved for use in the United States.
  • Panhemin® may be stabilized by solubilizing it for infusion in 30% human albumin rather than in sterile water; however, albumin adds intravascular volumeexpanding effects and increases the cost of treatment as well as risk of pathogens since it is isolated from human blood.
  • the current therapy for acute neurological attacks includes the intravenous administration of hemin (Panhematin®, Lundbeck or Normosang ®, Orphan Europe), which provides exogenous heme for the negative feedback inhibition of ALAS1, and thereby, decreases production of ALA and PBG.
  • Hemin is used for the treatment during an acute attack and for prevention of attacks, particularly in women having an acute porphyria who experience frequent attacks due to hormonal changes during their menstrual cycles. While patients generally respond well, its effect is slow, typically taking two to four days or longer for urinary ALA and PBG concentrations to trend towards normal levels.
  • Givosiran an aminolevulinate synthase 1-directed small interfering ribonucleic acid (siRNA) is also used to treat patients with acute hepatic porphyrias by targeting and degrading ALAS1 mRNA in hepatocytes using RNA interference.
  • the concerned risks associated with the use of givosiran include anaphylactic reactions, liver toxicity, and renal toxicity. For example, 15% patients in givosiran clinical trials showed transaminase (ALT) elevations 3 times the upper limit of normal.
  • givosiran have renal-related adverse reactions including elevated serum creatinine levels and decreased estimated glomerular filtration rate.
  • One final treatment is orthotrophic liver transplantation. While orthotrophic liver transplantation is curative, this procedure has significant morbidity and mortality and the availability of liver donors is limited. Accordingly, there is a need for new methods and compositions for treating and/or preventing hepatic porphyrias.
  • the methods and use of glycine transporter inhibitors such as, but not limited to, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, fulfill these needs as well as others. Limited experience with liver transplantation suggests that if successful, it is an effective treatment for AIP.
  • liver transplantation can restore normal excretion of ALA and PBG and prevent acute attacks. Furthermore, if the liver of a patient with AP is transplanted into another patient ("domino transplant"), the patient receiving the transplant may develop AIP. While orthotrophic liver transplantation is curative, this procedure has significant morbidity and mortality, and the availability of liver donors is limited.
  • acute porphyrias chronic neuropathic pain that may result from a progressive neuropathy due to neurotoxic effects, e.g., of elevated porphyrin precursors (e.g., ALA and/or PBG). Patients may suffer from neuropathic pain prior to or during an acute attack.
  • Treatment e.g., chronic treatment (e.g., periodic treatment with iRNA as described herein, e.g., treatment according to a dosing regimen as described herein, e.g., weekly or biweekly treatment) can continuously reduce the ALAS1 expression in acute porphyria patients who have elevated levels of porphyrin precursors, porphyrins, porphyrin products or their metabolites.
  • Such treatment may be provided as needed to prevent or reduce the frequency or severity of an individual patient's symptoms (e.g., pain and/or neuropathy) and/or to reduce a level of a porphyrin precursor, porphyrin, porphyrin product or metabolite.
  • existing treatments such as hemin, givosiran, and liver transplant have numerous drawbacks.
  • the impact of hemin on clinical symptoms is delayed, it is expensive, and it may have side effects (e.g., thrombophlebitis, anticoagulation, thrombocytopenia, iron overload, renal shutdown).
  • the present application provides the use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a pharmaceutical composition for the treatment of a hepatic porphyria in a subject in need thereof.
  • the disclosure provides methods of preventing or treating a hepatic porphyria in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application provides a method of preventing, treating, or reducing the progression rate and/or severity of a hepatic porphyria in a subject, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • methods disclosed herein for preventing, treating, or reducing the progression rate and/or severity of one or more complications of a hepatic porphyria may further comprise administering to the patient one or more supportive therapies or additional active agents for treating porphyria (e.g., AIP, HCP, VP, HARPO, ADP, PCT, and HEP).
  • a hepatic porphyria e.g., AIP, HCP, VP, HARPO, ADP, PCT, and HEP
  • the patient also may be administered one or more supportive therapies or active agents selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse®), bortezomib, heme infusions, sufficient caloric support, Givosiran, RNAi mediated silencing of various enzymes (e.g., ALA synthase), avoiding precipitating factors, 4-aminoquinolines, chloroquine, hydroxychloroquine, phlebotomy, intravenous magnesium, LH-RH agonists, enzyme replacement therapy (e.g., recombinant human PBGD), gene therapy (e.g., transfer of PBGD gene in liver cells by viral vectors), hemodialysis, pharmacologic chaperone treatment, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy
  • the subject is administered a combination treatment, e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and one or more additional treatments known to be effective against AIP, HCP, VP, HARPO, ADP, PCT, and HEP (e.g., glucose and/or a heme product such as hemin, as described herein) or its associated symptoms.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof is administered in combination with glucose or dextrose.
  • glucose or dextrose for example, 10-20% dextrose in normal saline may be provided intravenously.
  • glucose when glucose is administered, at least 300 g of 10% glucose is administered intravenously daily.
  • the compound selected from a compound of formula (I) e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may also be administered intravenously, as part of the same infusion that is used to administer the glucose or dextrose, or as a separate infusion that is administered before, concurrently, or after the administration of the glucose or dextrose.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof is administered via a different route of administration (e.g., subcutaneously).
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with total parenteral nutrition.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be administered before, concurrent with, or after the administration of total parenteral nutrition.
  • a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered in combination with one or more additional treatments, e.g., another treatment known to be effective in treating a hepatic porphyria or symptoms of a hepatic porphyria.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product (e.g., hemin, heme arginate, or heme albumin).
  • a heme product e.g., hemin, heme arginate, or heme albumin.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product and glucose, a heme product and dextrose, or a heme product and total parenteral nutrition.
  • the additional treatment(s) may be administered before, after, or concurrent with the administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and an additional therapeutic agent can be administered in combination in the same composition, e.g., intravenously, or the additional therapeutic agent can be administered as part of a separate composition or by another method described herein.
  • the subject has previously been treated with a heme product (e.g., hemin, heme arginate, or heme albumin), as described herein.
  • administration of the compound of formula (I) decreases the frequency of acute attacks (e.g., by preventing acute attacks so that they no longer occur, or by reducing the number of attacks that occur in a certain time period, e.g., fewer attacks occur per year).
  • additional treatments e.g., glucose, dextrose
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered according to a regular dosing regimen, e.g., b.i.d., daily, weekly, biweekly, or monthly.
  • the subject has or is at risk for developing a hepatic porphyria (e.g., AIP, HCP, VP, ADP, PCT, HARPO, and HEP).
  • the hepatic porphyria is an acute hepatic porphyria (e.g., AIP, HCP, VP, and ADP).
  • the hepatic porphyria is a non-acute hepatic porphyria (e.g., PCT and HEP).
  • the hepatic porphyria is a dual hepatic porphyria, e.g., at least two hepatic porphyrias.
  • the dual hepatic porphyria comprises two or more hepatic porphyrias selected from the group consisting of AIP, HCP, VP, ADP, HARPO, PCT, and HEP.
  • the hepatic porphyria is a caused by a heterozygous mutation resulting in reduced enzymatic activity.
  • the hepatic porphyria is a caused by a homozygous mutation resulting in reduced enzymatic activity.
  • the hepatic porphyria is an autosomal recessive diseases (e.g., ADP).
  • the subject carries a genetic alteration (e.g., a mutation) as described herein but is otherwise asymptomatic.
  • a mutation associated with a hepatic porphyria includes mutations in a gene encoding certain enzymes in the heme biosynthetic pathway (porphyrin pathway) or a gene which alters the expression of a gene in the heme biosynthetic pathway (e.g., ALAD, HMBS, UROD, UROS, CPOX, and PPOX).
  • the subject carries one or more mutations in an enzyme of the porphyrin pathway (e.g., ALA-dehydratase, PBG deaminase, uroporphyrinogen III synthase, uroporphyrinogen III synthase, uroporphyrinogen decarboxylase, coproporphyrinogen oxidase, and protoporphyrinogen oxidase).
  • the hepatic porphyria is acute hepatic porphyria. In some embodiments, the hepatic porphyria is non-acute hepatic porphyria.
  • the hepatic porphyria is acute intermittent porphyria (AIP). In some embodiments, the hepatic porphyria is ALA dehydratase porphyria (ADP). In some embodiments, the hepatic porphyria is variegate porphyria (VP). In some embodiments, the hepatic porphyria is hereditary coproporphyria (HCP). In some embodiments, the hepatic porphyria is harderoporphyria (HARPO). In some embodiments, the hepatic porphyria is porphyria cutanea tarda (PCT).
  • the PCT is familial or sporadic PCT.
  • the hepatic porphyria is hepatoerythropoietic porphyria (HEP).
  • patients with an acute hepatic porphyria e.g., AIP
  • patients who carry mutations associated with an acute hepatic porphyria e.g., AIP
  • patients who carry mutations associated with an acute hepatic porphyria e.g., AIP
  • patients who carry mutations associated with an acute hepatic porphyria e.g., AIP
  • the level of ALA and/or PBG can be elevated even when the patient is not having, or has never had, an attack.
  • the patient is otherwise completely asymptomatic.
  • the patient suffers from pain, e.g., neuropathic pain, which can be chronic pain (e.g., chronic neuropathic pain).
  • the patient has a neuropathy.
  • the patient has a progressive neuropathy.
  • the subject has an acute attack of hepatic porphyria.
  • the subject has a non-acute attack of hepatic porphyria.
  • the subject has never experienced an acute attack of hepatic porphyria.
  • the subject suffers from chronic pain.
  • the subject has nerve damage.
  • the subject has EMG changes and/or changes in nerve conduction velocity.
  • the subject is asymptomatic.
  • the subject is at risk for developing a hepatic porphyria (e.g., carries a gene mutation associated with a hepatic porphyria) and is asymptomatic.
  • the subject has previously had an acute attack of hepatic porphyria but is asymptomatic at the time of treatment.
  • the subject is at risk for developing a hepatic porphyria and is treated prophylactically to prevent the development of a hepatic porphyria.
  • the subject has an elevated level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG).
  • the prophylactic treatment begins at puberty. In some embodiments the treatment lowers the level (e.g., the plasma level or the urine level) of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG). In some embodiments, the treatment prevents the development of an elevated level of a porphyrin or a porphyrin precursor, (e.g., ALA and/or PBG). In some embodiments, the treatment prevents the development of, or decreases the frequency or severity of, a symptom associated with a hepatic porphyria (e.g., pain or nerve damage).
  • a porphyrin or a porphyrin precursor e.g., ALA and/or PBG
  • the treatment prevents the development of an elevated level of a porphyrin or a porphyrin precursor, (e.g., ALA and/or PBG). In some embodiments, the treatment prevents the development of, or decreases the frequency or severity of, a
  • the present application further provides use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of a hepatic porphyria in a subject.
  • the subject to be treated according to the methods described suffers from pain, e.g., chronic pain.
  • the method is effective to treat the pain (e.g., by reducing the severity of the pain or curing the pain).
  • the method is effective to decrease or prevent nerve damage.
  • the subject to be treated according to the methods described herein (a) has an elevated level of ALA and/or PBG and (b) suffers from pain (e.g., chronic pain).
  • the method is effective to decrease an elevated level of ALA and/or PBG and/or to treat the pain (e.g., by reducing the severity of the pain or curing the pain).
  • the subject is a subject who has suffered one or more acute attacks of one or more hepatic porphyric symptoms.
  • the subject is a subject who has suffered chronically from one or more symptoms of hepatic porphyria (e.g., pain, e.g., neuropathic pain and or neuropathy, e.g., progressive neuropathy).
  • the subject to be treated according to the methods described herein has recently experienced or is currently experiencing a prodrome.
  • a “prodrome,” as used herein, includes any symptom that the individual subject has previously experienced immediately prior to developing an acute attack.
  • Typical symptoms of a prodrome include, e.g., abdominal pain, nausea, headaches, psychological symptoms (e.g., anxiety), restlessness and/or insomnia.
  • the subject experiences pain (e.g., abdominal pain and/or a headache) during the prodrome.
  • the subject experiences nausea during the prodrome.
  • the subject becomes restless and/or suffers from insomnia during the prodrome.
  • An acute “attack” of hepatic porphyria involves the onset of one or more symptoms of hepatic porphyria, typically in a patient who carries a mutation associated with hepatic porphyria (e.g., a mutation in a gene that encodes an enzyme in the porphyrin pathway).
  • the compound of formula (I) e.g., any one of compounds 1- 60
  • a pharmaceutically acceptable salt thereof is administered after an acute attack of a hepatic porphyria.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof is administered during an acute attack of a hepatic porphyria.
  • administration of a compound of formula (I) is effective to lessen the severity of the attack (e.g., by ameliorating one or more signs or symptoms associated with the attack). In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to shorten the duration of an attack. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to stop an attack.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered prophylactically to prevent an acute attack of hepatic porphyria.
  • the prophylactic administration is before, during, or after exposure to or occurrence of a precipitating factor.
  • the subject is at risk of developing porphyria.
  • a “precipitating factor” as used herein, refers to an endogenous or exogenous factor that may induce an acute attack of one or more symptoms associated with porphyria.
  • Precipitating factors include fasting (or other forms of reduced or inadequate caloric intake, due to crash diets, long-distance athletics, etc.), metabolic stresses (e.g., infections, surgery, international air travel, and psychological stress), endogenous hormones (e.g., progesterone), cigarette smoking, lipid-soluble foreign chemicals (including, e.g., chemicals present in tobacco smoke, certain prescription drugs, organic solvents, biocides, components in alcoholic beverages), endocrine factors (e.g., reproductive hormones (women may experience exacerbations during the premenstrual period), synthetic estrogens, progesterones, ovulation stimulants, and hormone replacement therapy), and lead.
  • metabolic stresses e.g., infections, surgery, international air travel, and psychological stress
  • endogenous hormones e.g., progesterone
  • cigarette smoking e.g., lipid-soluble foreign chemicals (including, e.g., chemicals present in tobacco smoke, certain prescription drugs, organic solvents, bio
  • the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered during a prodrome.
  • the prodrome is characterized by pain (e.g., headache and/or abdominal pain), nausea, psychological symptoms (e.g., anxiety), restlessness and/or insomnia.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered during a particular phase of the menstrual cycle, e.g., during the luteal phase.
  • administration of a compound of formula (I) is effective to prevent attacks (e.g., recurrent attacks that are associated with a prodrome and/or with a precipitating factor, e.g., with a particular phase of the menstrual cycle, e.g., the luteal phase).
  • administration of a compound of formula (I) is effective to reduce the frequency of attacks.
  • administration of a compound of formula (I) is effective to lessen the severity of the attack (e.g., by ameliorating one or more signs or symptoms associated with the attack). In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to shorten the duration of an attack. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to stop an attack.
  • administration of a compound of formula (I) is effective to prevent or decrease the frequency or severity of pain, e.g., neuropathic pain.
  • administration of a compound of formula (I) is effective to prevent or decrease the frequency or severity of neuropathy.
  • the subject has or is at risk for developing a hepatic porphyria and suffers from pain (e.g., neuropathic pain, e.g., chronic neuropathic pain) or neuropathy (e.g., progressive neuropathy).
  • the subject has an elevated level of ALA and/or PBG and suffers from chronic pain.
  • Effects of administration of a compound of formula (I) can be established, for example, by comparison with an appropriate control.
  • a decrease in the frequency of acute attacks, as well as a decrease in the level of one or more porphyrins or porphyrin precursors may be established, for example, in a group of patients with AIP, as a decreased frequency compared with an appropriate control group.
  • a control group may include, for example, an untreated population, a population that has been treated with a conventional treatment for hepatic porphyria (e.g., a conventional treatment for AIP may include glucose, hemin, or both); a population that has been treated with placebo, or a GlyT1 inhibitor, optionally in combination with one or more conventional treatments for hepatic porphyria (e.g., glucose, e.g., IV glucose).
  • a subject “at risk” of developing hepatic porphyria includes a subject with a family history of hepatic porphyria and/or a history of one or more recurring or chronic hepatic porphyria symptoms, and/or a subject who carries a genetic alteration (e.g., a mutation) in a gene encoding an enzyme of the heme biosynthetic pathway, and a subject who carries a genetic alteration, e.g., a mutation known to be associated with hepatic porphyria.
  • a genetic alteration e.g., a mutation
  • the alteration makes an individual susceptible to an acute attack (e.g., upon exposure to a precipitating factor, e.g., a drug, dieting or other precipitating factor, e.g., a precipitating factor as disclosed herein).
  • the alteration e.g., the mutation
  • the alteration, e.g., the mutation is associated with chronic pain (e.g., chronic neuropathic pain) and/or neuropathy (e.g., progressive neuropathy).
  • the alteration e.g., the mutation
  • the alteration is associated with changes in EMG and/or nerve conduction velocities.
  • the alteration is a mutation in a gene selected from the group consisting of ALAD, HMBS, UROD, CPOX, and PPOX.
  • the alteration is an alteration, e.g., a mutation, in a gene that encodes an enzyme in the heme biosynthetic pathway.
  • the subject has a genetic alteration but does not suffer from acute attacks.
  • the subject has a mutation associated with AIP, HCP, VP, ADP, PCT, or HEP.
  • the hepatic porphyria is AIP.
  • the subject has an alteration, e.g., at least one mutation, in PBGD (gene encoding PBG deaminase). Many PBGD mutations are known in the art.
  • the subject is heterozygous for a PBGD mutation.
  • the subject is homozygous for a PBGD mutation.
  • a homozygous subject may carry two identical mutations or two different mutations in the PBGD gene.
  • the hepatic porphyria is HCP.
  • the subject has an alteration, e.g., at least one mutation, in CPOX (i.e, gene that encodes the enzyme coproporphyrinogen III oxidase).
  • CPOX i.e, gene that encodes the enzyme coproporphyrinogen III oxidase
  • the hepatic porphyria is VP.
  • the subject has an alteration, e.g., at least one mutation, in PPOX (i.e., gene that encodes protoporphrinogen oxidase).
  • the hepatic porphyria is ADP (e.g., autosomal recessive ADP).
  • the subject has an alteration, e.g., at least one mutation, in ALAD (gene that encodes ALA dehydratase).
  • the hepatic porphyria is PCT.
  • the subject has an alteration, e.g., at least one mutation, in UROD (gene that encodes uro-decarboxylase).
  • the hepatic porphyria is CEP.
  • the subject has an alteration, e.g., at least one mutation, in UROS (gene that encodes uroporphyrinogen III synthase).
  • the increased levels of porphyrin precursors are due to lead poisoning.
  • Lead poisoning inhibits the activity of each of ALAD, CPOX, and FECH, enzymes which are involved in heme biosynthesis. Patients with lead poisoning are frequently misdiagnosed with ADP or other acute porphyrias.
  • a subject with lead poisoning has decreased enzymatic activity of ALAD.
  • a subject with lead poisoning has decreased enzymatic activity of CPOX.
  • a subject with lead poisoning has decreased enzymatic activity of FECH.
  • a subject with lead poisoning has increased levels of lead in the blood and/or urine.
  • a subject with lead poisoning has increased levels of ALA.
  • a subject with lead poisoning has increased levels of ALA and PBG. In some embodiments, a subject with lead poisoning has ALA levels which are increased by at least 10 fold over a reference value. In some embodiments, a subject with lead poisoning has ALA levels which are increased by at least 5 fold over a reference value. In some embodiments, the disclosure relates to methods of treating lead poisoning in a subject, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject is further administered a chelating agent. In some embodiments the chelating agent is 2,3- dimercaptosuccinic acid.
  • the chelating agent is calcium disodium ethylenediamine-tetraacetate.
  • Porphyrins e.g., 5-ALA, PBG, uroporphyrin, and coproporphyrin
  • the porphyrins may be extracted from the biological sample (e.g., plasma) into a solution for fluorescence analysis.
  • Porphyrins can be detected in these biological samples by direct inspection using long wavelength ultraviolet light (e.g., 400-420 nm light).
  • Porphyrins have the greatest absorption wavelengths near 400-420 nm, with their highest absorption peak occurring at 415 nm.
  • the emission maxima of porphyrins is typically around 600 nm and varies slightly based on the type of porphyrins and the solvent used for analysis.
  • diagnosis of a hepatic porphyria may be made using fluorescence analysis.
  • skin porphyrin levels can be measured by calculating the difference before and after complete photobleaching of the skin porphyrin using controlled illumination. See, e.g., Heerfordt IM. Br J Dermatol.2016;175(6):1284-1289.
  • the subject’ s plasma porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak of 632 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light).
  • a sample from the subject containing a porphyrin or porphyrin precursor fluoresces at a peak between 615 nm and 620 nm when illuminated with blue light (e.g., 400-420 nm light).
  • a sample from the subject e.g., plasma or skin
  • a porphyrin or porphyrin precursor fluoresces at a peak between 624 nm and 627 nm when illuminated with blue light (e.g., 400-420 nm light).
  • the subject’s plasma is excited using a 405 nm laser.
  • the subject has red fluorescent urine.
  • Erythropoietic Protoporphyria Erythropoietic Protoporphyria, X-linked Protoporphyria, and Congenital Erythropoietic Porphyria Erythropoietic protoporphyria (EPP) is prevalent globally and affects about 5,000- 10,000 individuals worldwide (Michaels et al.2010). EPP is considered the most common form of porphyria in children. Erythropoietic protoporphyria is a form of porphyria, which varies in severity and can be very painful.
  • Erythropoietic protoporphyria is due to an inherited or acquired deficiency in the activity of the enzyme ferrochelatase.
  • X-linked protoporphyria is due to an inherited increase in the activity of delta-aminolevulinic acid synthase-2 (ALAS2). Enzymes that cause both EPP and XLPP are in the heme biosynthetic pathway. EPP and XLPP are nearly identical clinically.
  • Congenital erythropoietic porphyria also known as Gunther disease, caused by mutations in the gene for uroporphyrinogen synthase resulting in reduced activity of this enzyme and accumulation of the upstream metabolite coproporphyrin I.
  • Current treatments for erythropoietic protoporphyria (EPP), X- linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) are limited.
  • glycine transporter inhibitors such as, but not limited to, GlyT1 inhibitors (e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof) fulfill these needs as well as others.
  • the present application provides methods of preventing or treating disorders associated with accumulation of PPIX in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application relates to methods of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application provides methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • mammals such as humans, non-human primates, laboratory animals, livestock animals (including bovines, porcines, camels, etc.), companion animals (e.g., canines, felines, other domesticated animals, etc.) and rodents (e.g., mice and rats).
  • livestock animals including bovines, porcines, camels, etc.
  • companion animals e.g., canines, felines, other domesticated animals, etc.
  • rodents e.g., mice and rats.
  • the patient, subject or individual is a human.
  • the present application provides methods of preventing or treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP), or related syndrome (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) thereof in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • EPP erythropoietic protoporphyria
  • XLPP X-linked protoporphyria
  • CEP congenital erythropoietic porphyria
  • related syndrome e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome
  • the present application further provides methods of preventing or treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application provides methods of treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application further provides methods of preventing or treating EPP, XLPP, or CEP, or related syndrome thereof (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application further provides methods of preventing or treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the pharmaceutical composition further comprises a pharmaceutically acceptable carrier.
  • EPP Erythropoietic protoporphyria
  • XLPP X-linked protoporphyria
  • EPP is caused by a partial deficiency in ferrochelatase (FECH), which catalyzes the final step in the heme biosynthesis pathway.
  • FECH deficiency increases levels of metal-free erythrocyte PPIX (also referred to herein as “free-protoporphyrin IX” and “PPIX”).
  • XLPP is typically caused by C-terminal deletions in the ALAS2 gene which result in a gain-of-function mutation. These gain-of-function mutations increase the enzymatic activity of ALAS2 and cause an accumulation of both metal-free and zinc-bound PPIX. Both EPP and XLPP result in an accumulation of PPIX in erythrocytes and other tissues or biological fluids (e.g., skin, liver, bile, or stool). PPIX, which is lipophilic and eliminated via bile, is hepatotoxic at high concentrations. Patients with EPP or XLPP usually develop photosensitivity during early childhood. Patients frequently present with symptoms of burning, itching, pain erythema, and edema on sun-exposed areas.
  • EPP and XLPP can be determined by measuring the levels of total erythrocyte, free-protoporphyrin IX, and zinc-protoporphyrin IX in hemolyzed anticoagulated whole blood. A diagnosis of EPP and/or XLPP can be made based on increased levels of free-protoporphyrin IX in blood.
  • EPP XLPP
  • XLPP patients with XLPP have a significantly higher proportion of zinc-protoporphyrin IX to free-protoporphyrin IX (e.g., >25%) as compared to those with EPP (e.g., ⁇ 15%).
  • the diagnosis of EPP can also be determined by measuring the level of ferrocheletase activity in a subject.
  • Ferrocheletase is a mitochondrial enzyme that catalyzes the insertion of ferrous iron into PPIX to form heme.
  • Ferrocheletase also catalyzes the insertion of zinc, to form zinc protoporphyrin IX (ZPPIX) from any PPIX that remains after completion of heme synthesis.
  • the disclosure relates to methods of a treating a subject whose ferrochelatase activity level is reduced to between 10 to 35% of the ferrocheletase activity level observed in normal subjects. In some embodiments, the disclosure relates to methods of a treating a subject whose ferrochelatase activity level is reduced to less than 50% of the ferrocheletase activity level observed in normal subjects.
  • XLPP has a similar phenotype to EPP, and can be differentiated based on genetic analysis of ALAS2 or by determining the enzymatic activity level of ALAS2.
  • the disclosure relates to methods of a treating a subject having a gain-of- function mutation in ALAS2.
  • the subject s ALAS2 enzyme activity is increased. Since ferrocheletase is not deficient in XLPP, some of the excess PPIX measured in erythrocytes is ZPPIX and a lower percentage (e.g., 50-85%) is metal-free.
  • the subject has increased zinc-protoporphyrin IX levels in erythrocytes. In some embodiments, the method decreases zinc-protoporphyrin IX levels in the subject’s erythrocytes.
  • method decreases zinc-protoporphyrin IX levels in the subject’s erythrocytes by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the disclosure relates to methods of treating erythropoietic protoporphyria (EPP) and/or X-linked protoporphyria (XLPP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased PPIX levels.
  • the method relates to subjects having PPIX levels that are at least 10%, 20%, 30%, 40%, or 50% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having PPIX levels that are at least 10% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 20% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having PPIX levels that are at least 30% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 40% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having PPIX levels that are at least 50% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has increased protoporphyrin IX levels in the stool.
  • the subject has increased protoporphyrin IX levels in the skin.
  • the subject has increased free-protoporphyrin IX levels in erythrocytes.
  • the subject has greater than 31 ⁇ mol L-1 protoporphyrin IX levels in the erythrocytes.
  • the subject has between 31 ⁇ mol L-1 and 53 ⁇ mol L-1 protoporphyrin IX levels in the erythrocytes. In some embodiments, the subject has greater than 53 ⁇ mol L-1 protoporphyrin IX levels in the erythrocytes.
  • the present application further provides methods of inhibiting PPIX synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of inhibiting PPIX synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 50%.
  • the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 100%.
  • the present application further provides methods of decreasing the rate of PPIX synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • PPIX accumulation is inhibited in a dose dependent manner.
  • the method relates to methods of decreasing free- protoporphyrin IX levels in the subject. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject’s erythrocytes. In some embodiments, the method decreases protoporphyrin IX levels in the erythrocytes of the subject to levels less than 53 ⁇ mol L-l. In some embodiments, the method decreases protoporphyrin IX levels in the erythrocytes of the subject to levels less than 31 ⁇ mol L- 1. In some embodiments, the method decreases protoporphyrin IX levels in the erythrocytes of the subject to levels less than 15 ⁇ mol L-l.
  • the method relates to decreasing protoporphyrin IX levels in the stool of the subject. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 15%.
  • the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 20%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 25%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 30%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 35%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 40%.
  • the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 45%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 50%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 55%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 60%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 65%.
  • the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 70%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 75%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 80%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 85%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 90%.
  • the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 95%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 100%. In certain aspects, the disclosure relates to methods of treating X-linked protoporphyria (XLPP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased zinc-protoporphyrin IX (ZPPIX) levels.
  • XLPP X-linked protoporphyria
  • the method relates to subjects having ZPPIX levels that are at least 10%, 20%, 30%, 40%, or 50% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 10% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having ZPPIX levels that are at least 20% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 30% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having ZPPIX levels that are at least 40% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 50% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has increased ZPPIX levels in erythrocytes.
  • the disclosure relates to methods of treating X-linked protoporphyria (XLPP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased proportion of zinc-protoporphyrin IX (ZPPIX) to free-protoporphyrin IX (ZPPIX/PPIX ratio) as compared to those with EPP.
  • the method relates to subjects having a ZPPIX/PPIX ratio that is at least 15% (e.g., 15%, 20%, 25%, 30%, 35%, 40%, or 45%).
  • the method relates to subjects having a ZPPIX/PPIX ratio that is at least 20%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 25%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 30%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 35%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 40%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 45%.
  • the disclosure relates to methods of inhibiting zinc protoporphyrin IX (ZPPIX) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%).
  • the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 20%.
  • the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 30%.
  • the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 90%.
  • the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 100%.
  • the disclosure relates to methods of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased 5-aminolevulinic acid (5-ALA) levels.
  • EPP erythropoietic protoporphyria
  • XLPP X-linked protoporphyria
  • CEP congenital erythropoietic porphyria
  • the method relates to subjects having 5-ALA levels that are at least 10%, 20%, 30%, 40%, or 50% more than 5- ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 10% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having 5-ALA levels that are at least 20% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 30% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 40% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having 5-ALA levels that are at least 50% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting 5-aminolevulinic acid (5-ALA) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%).
  • the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 80%.
  • the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 100%.
  • the present application further provides use of one or more compound selected from a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of EPP, XLPP, CEP or related syndrome thereof (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) in a subject.
  • the present application provides use of one or more compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of EPP, XLPP, or CEP in a subject.
  • the present application provides the use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a pharmaceutical composition for the treatment of EPP, XLPP, or CEP, or related syndrome thereof (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) in a subject.
  • the pharmaceutical composition further comprises a pharmaceutically acceptable carrier.
  • Congenital erythropoietic porphyria is an erythropoietic cutaneous porphyria characterized by blistering cutaneous photosensitivity. Severe cases of CEP can present in utero with hydrops fetalis, or shortly after birth with severe blistering photosensitivity, red urine, splenomegaly, hemolysis, and transfusion dependence. Milder cases and later onset forms typically present with red urine, severe blistering, and hemolytic anemia. CEP individuals are often homozygous or compound heterozygous for UROS mutations. Some cases of CEP are due to mutations in the gene encoding the transcriptional regulator GATA1.
  • UROIII-S uroporphyrinogen III synthase
  • the diagnosis of CEP can be determined by analyzing the enzyme activity of uroporphyrinogen III synthase (UROIII-S), by evaluating mutations in the UROS gene, by evaluating the function of GATA-1 erythroid-specific transcription factor, by evaluating mutations in GATA1, and by determining the levels of uroporphyrin I and coproporphyrin I in the subject.
  • the subject has a mutation in UROS.
  • the subject has a gene defect in GATA-1 erythroid-specific transcription factor.
  • the method relates to methods of treating a subject, wherein the subject has decreased activity of uroporphyrinogen III synthase.
  • the increased levels of uroporphyrin I and/or coproporphyrin I are measured in the subject’s urine or red blood cells. In some embodiments, the increased levels of coproporphyrin I are measured in the subject’s stool.
  • the disclosure relates to methods of treating congenital erythropoietic porphyria (CEP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased uroporphyrin I and/or coproporphyrin I levels.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased uroporphyrin I and/or coproporphyrin I levels.
  • the subject has increased levels of uroporphyrin I and/or coproporphyrin I.
  • the method relates to subjects having uroporphyrin I levels that are at least 10%, 20%, 30%, 40%, or 50% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having uroporphyrin I levels that are at least 10% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having uroporphyrin I levels that are at least 20% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 30% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having uroporphyrin I levels that are at least 40% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 50% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of treating subjects having coproporphyrin I levels that are at least 10%, 20%, 30%, 40%, or 50% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having coproporphyrin I levels that are at least 10% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having coproporphyrin I levels that are at least 20% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 30% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method relates to subjects having coproporphyrin I levels that are at least 40% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 50% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels.
  • the patient’s PPIX levels decrease by at least 50% (e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the patient’s PPIX levels decrease by at least 55%.
  • the patient’s PPIX levels decrease by at least 60%.
  • the patient’s PPIX levels decrease by at least 65%. In some embodiments, the patient’s PPIX levels decrease by at least 70%. In some embodiments, the patient’s PPIX levels decrease by at least 75%. In some embodiments, the patient’s PPIX levels decrease by at least 80%. In some embodiments, the patient’s PPIX levels decrease by at least 85%. In some embodiments, the patient’s PPIX levels decrease by at least 90%. In some embodiments, the patient’s PPIX levels decrease by at least 95%. In some embodiments, the patient’s PPIX levels decrease by at least 100%. In some embodiments, the patient’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%).
  • the patient’s heme levels decrease no more than 15%. In some embodiments, the patient’s heme levels decrease no more than 20%. In some embodiments, the patient’s heme levels decrease no more than 25%. In some embodiments, the patient’s heme levels decrease no more than 30%. In some embodiments, the accumulation of one or more of the following heme intermediates is inhibited, wherein the one or more heme intermediates is selected from the group consisting of PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA.
  • the disclosure relates to methods of inhibiting the accumulation of PPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of ZPPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of uroporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of coproporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of 5-ALA, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the accumulation of the one or more heme intermediates e.g., PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA
  • the accumulation of the one or more heme intermediates e.g., PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of liver disease associated with EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the liver disease associated with EPP, XLPP, or CEP is cholelithiasis.
  • the liver disease associated with EPP, XLPP, or CEP is mild liver disease.
  • the liver disease associated with EPP, XLPP, or CEP is deteriorating liver disease.
  • the liver disease associated with EPP, XLPP, or CEP is terminal phase liver disease.
  • coproporphyrin excretion in the urine may be analyzed to assess liver function in the subject.
  • ultrasound, or magnetic resonance elastography may be used to measure liver stiffness in the subject.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • the compound of formula (I) demonstrates PPIX inhibition with an EC50 of less than 500 nM, less than 400 nM, less than 300 nM, less than 200 nM, or less than 100 nM.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 50 nM. In certain such embodiments, the EC50 is measured in a flow cytometry assay.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 500 nM, less than 400 nM, less than 300 nM, less than 200 nM, or less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 100 nM.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 50 nM.
  • the EC50 is measured in a flow cytometry assay.
  • at least 50%, at least 60%, at least 70%, at least 80%, at least 85%, at least 90%, or at least 95% cell viability is maintained. In certain such embodiments, at least 90% cell viability is maintained.
  • Heme and Heme Intermediates Glycine is one of the key initial substrates for heme and globin synthesis.
  • the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%).
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%).
  • the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 15%. In some embodiments, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 20%. In some embodiments, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 25%.
  • the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 30%.
  • the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels.
  • the synthesis of one or more of the following heme intermediates is inhibited, wherein the one or more heme intermediates is selected from the group consisting of 5-ALA, PBG, hydroxymethylbilane, ZPPIX, uroporphyrinogen I, uroporphyrinogen III, heptacarboxyporphyrinogen I, heptacarboxyporphyrinogen III, hexacarboxyporphyrinogen I, hexacarboxyporphyrinogen III, pentacarboxyporphyrinogen I, pentacarboxyporphyrinogen III, coproporphyrinogen I, coproporphyrinogen III, isocoproporphyrin, porphobilinogen; and protoporphyrinogen IX.
  • the one or more heme intermediates is selected from the group consisting of 5-ALA, PBG, hydroxymethylbilane, ZPPIX, uroporphyrinogen
  • the disclosure relates to methods of inhibiting 5-aminolevulinic acid (5- ALA) synthesis in a subject, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has a hepatic porphyria, EPP, XLPP, or CEP.
  • the disclosure relates to methods of inhibiting coproporphyrin III synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting zinc-protoporphyrin IX (ZPPIX) synthesis in a subject, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has ALA dehydratase porphyria (ADP).
  • the disclosure relates to methods of inhibiting porphobilinogen (PBG) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting 5- aminolevulinic acid (5-ALA) and porphobilinogen (PBG) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting hydroxymethylbilane (HMB) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • HMB hydroxymethylbilane
  • the disclosure relates to methods of inhibiting uroporphyrin III synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting heptacarboxyl-porphyrin synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting isocoproporphyrin synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • the synthesis of the one or more heme intermediates e.g., 5-ALA, coproporphyrin III, ZPPIX, PBG, HMB, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin
  • is inhibited in a dose dependent manner e.g., 5-ALA, coproporphyrin III, ZPPIX, PBG, HMB, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin
  • the accumulation of one or more of the following heme intermediates is inhibited, wherein the one or more heme intermediates is selected from the group consisting of 5-ALA, PBG, hydroxymethylbilane, ZPPIX, uroporphyrinogen I, uroporphyrinogen III, heptacarboxyporphyrinogen I, heptacarboxyporphyrinogen III, hexacarboxyporphyrinogen I, hexacarboxyporphyrinogen III, pentacarboxyporphyrinogen I, pentacarboxyporphyrinogen III, coproporphyrinogen I, coproporphyrinogen III, isocoproporphyrin, porphobilinogen; and protoporphyrinogen IX.
  • the one or more heme intermediates is selected from the group consisting of 5-ALA, PBG, hydroxymethylbilane, ZPPIX, uroporphyrinogen I
  • the accumulation of the one or more heme intermediates is inhibited in a dose dependent manner.
  • the subject to be treated according to the methods described herein has an elevated level of a porphyrin or a porphyrin precursor, e.g., ALA and/or PBG.
  • the subject has porphyrin precursor level that is at least 10%, 20%, 30%, 40%, or 50% more than porphyrin precursor level in a healthy subject prior to administration of the v.
  • the subject has increased levels of a porphyrin precursor.
  • the porphyrin precursor is selected from the group consisting of 5-ALA, HMB, coproporphyrin III, ZPPIX, porphobilinogen, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin.
  • the subject has increased uroporphyrin III levels (e.g., increased uroporphyrin III levels in the urine).
  • the subject has increased levels of 5-ALA (e.g., increased levels of 5- ALA in the urine or plasma).
  • the subject has increased levels of HMB.
  • the subject has increased levels of coproporphyrin III (e.g., increased levels of coproporphyrin III in the urine and stool).
  • the subject has increased levels of PBG (e.g., increased levels of PBG in the urine).
  • the subject has an increased proportion of protoporphyrin to coproporphyrin in the stool.
  • the subject has increased heptacarboxyl-porphyrin levels (e.g., increased heptacarboxyl-porphyrin levels in the urine or stool).
  • the subject has increased isocoproporphyrin levels (e.g., increased isocoproporphyrin levels in the stool).
  • the subject has increased ZPPIX levels in erythrocytes.
  • Levels of a porphyrin or a porphyrin precursor can be assessed using methods known in the art or methods described herein.
  • the level of a porphyrin or a porphyrin precursor (e.g., ALA or PBG) in the subject is assessed based on the absolute level of the porphyrin or the porphyrin precursor, e.g., ALA or PBG in a sample from the subject.
  • the level of a porphyrin or a porphyrin precursor (e.g., ALA or PBG) in the subject is assessed based on the relative level of the porphyrin or porphyrin precursor (e.g., ALA or PBG) in a sample from the subject.
  • the relative level is relative to the level of another protein or compound, e.g., the level of creatinine, in a sample from the subject.
  • the sample is a urine sample.
  • the sample is a plasma sample.
  • the sample is a stool sample.
  • An elevated level of a porphyrin or a porphyrin precursor can be established by showing that the subject has a level of a porphyrin or a porphyrin precursor (e.g., a plasma or urine level of ALA and/or PBG) that is greater than, or greater than or equal to, a reference value.
  • a level of a porphyrin or a porphyrin precursor e.g., a plasma or urine level of ALA and/or PBG
  • a physician with expertise in the treatment of porphyrias would be able to determine whether the level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) is elevated, e.g., for the purpose of diagnosing a hepaticporphyria, EPP, XLPP, or CEP or for determining whether a subject is at risk for developing a hepatic porphyria, EPP, XLPP, or CEP, e.g., a subject may be predisposed to an acute attack or to pathology associated with a porphyria, such as, e.g., chronic pain (e.g., neuropathic pain) and neuropathy (e.g., progressive neuropathy).
  • a porphyria such as, e.g., chronic pain (e.g., neuropathic pain) and neuropathy (e.g., progressive neuropathy).
  • a “reference value” refers to a value from the subject when the subject is not in a disease state, or a value from a normal or healthy subject, or a value from a reference sample or population, e.g., a group of normal or healthy subjects (e.g., a group of subjects that does not carry a mutation associated with a hepatic porphyria, EPP, XLPP, or CEP and/or a group of subjects that does not suffer from symptoms associated with a hepatic porphyria, EPP, XLPP, or CEP).
  • the reference value is a pre-disease level in the same individual.
  • the reference value is a level in a reference sample or population. In some embodiments, the reference value is the mean or median value in a reference sample or population. In some embodiments, the reference value the value that is two standard deviations above the mean in a reference sample or population. In some embodiments, the reference value is the value that is 2.5, 3, 3.5, 4, 4.5, or 5 standard deviations above the mean in a reference sample or population. In some embodiments, the subject has a plasma level or a urine level of ALA or PBG that is greater than a reference value.
  • the subject has an elevated level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) the subject has a level of ALA and/or PBG that is at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% higher than a reference value.
  • the subject has a level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) that is at least 2, 3, 4, 5, 6, 7, 8, 9, or 10 fold higher than a reference value.
  • the reference value is an upper reference limit.
  • an “upper reference limit” refers to a level that is the upper limit of the 95% confidence interval for a reference sample or population, e.g., a group of normal (e.g., wild type) or healthy individuals, e.g., individuals who do not carry a genetic mutation associated with a porphyria and/or individuals who do not suffer from a hepatic porphyria, EPP, XLPP, or CEP. Accordingly, a lower reference limit refers to a level that is the lower limit of the same 95% confidence interval.
  • the subject has an elevated level (e.g., a plasma level or a urine level) of a porphyrin or a porphyrin precursor that is greater than or equal to 2 times, 3 times, 4 times, or 5 times that of a reference value (e.g., an upper reference limit).
  • a reference value e.g., an upper reference limit
  • the subject has a urine level of a porphyrin or a porphyrin precursor that is greater than 4 times that of an upper reference limit.
  • the subject has a urine level of PBG that is greater than or equal to 1.4 mmol/mol creatinine.
  • the subject has a urine level of PBG that is greater than or equal to 4.8 mmol/mol creatinine.
  • the subject has a urine level of PBG that is greater than, or greater than or equal to, about 3, 4, 5, 6, 7, or 8 mmol/mol creatinine.
  • the reference value for plasma PBG is 0.12 ⁇ mol/L.
  • the subject has a plasma PBG level that is greater than, or greater than or equal to 0.10 ⁇ mol/L, 0.12 ⁇ mol/L, 0.24 ⁇ mol/L, 0.36 ⁇ mol/L, 0.48 ⁇ mol/L, or 0.60 ⁇ mol/L.
  • the subject has a plasma level of PBG that is greater than, or greater than or equal to 0.48 ⁇ mol/L.
  • the reference value for urine PBG is 1.2 mmol/mol creatinine. In some embodiments, the reference value for urine PBG is 1.4 mmol/mol creatinine. In some embodiments, the subject has a urine PBG level that is greater than, or greater than or equal to 1.0 mmol/mol creatinine, 1.2 mmol/mol creatinine, 2.4 mmol/mol creatinine, 3.6 mmol/mol creatinine, 4.8 mmol/mol creatinine, or 6.0 mmol/mol creatinine. In some embodiments, the subject has a urine level of PBG that is greater than, or greater than or equal to 4.8 mmol/mol creatinine.
  • the reference value for plasma ALA is 0.12 ⁇ mol/L.
  • the subject has a plasma ALA level that is greater than, or greater than or equal to 0.10 ⁇ mol/L, 0.12 ⁇ mol/L, 0.24 ⁇ mol/L, 0.36 ⁇ mol/L, 0.48 ⁇ mol/L, or 0.60 ⁇ mol/L.
  • the subject has a plasma ALA level that is greater than, or greater than or equal to 0.48 ⁇ mol/L.
  • the reference value for urine ALA is 3.1 mmol/mol creatinine. In some embodiments, the reference value for urine ALA is 6.3 mmol/mol creatinine. In some embodiments, the subject has a urine ALA level that is greater than, or greater than or equal to 2.5 mmol/mol creatinine, 3.1 mmol/mol creatinine, 6.2 mmol/mol creatinine, 6.3 mmol/mol creatinine, 9.3 mmol/mol creatinine, 12.4 mmol/mol creatinine, or 15.5 mmol/mol creatinine.
  • the reference value for urine uroporphyrin is less than 4.5 ⁇ mol/mol creatinine. In some embodiments, the subject has a urine uroporphyrin level that is greater than, or greater than or equal to 4.5 ⁇ mol/mol creatinine, 9.0 ⁇ mol /mol creatinine, 13.5 ⁇ mol/mol creatinine, 18.0 ⁇ mol/mol creatinine, 22.5 ⁇ mol/mol creatinine, 27 ⁇ mol/mol creatinine, or 31.5 ⁇ mol/mol creatinine. In some embodiments, the reference value for urine coproporphyrin is less than 20.7 ⁇ mol/mol creatinine.
  • the subject has a urine coproporphyrin level that is greater than, or greater than or equal to 20.7 ⁇ mol /mol creatinine, 41.4 ⁇ mol /mol creatinine, 62.1 ⁇ mol /mol creatinine, 82.8 ⁇ mol /mol creatinine, 103.5 ⁇ mol /mol creatinine, 124.2 ⁇ mol /mol creatinine, or 144.9 ⁇ mol /mol creatinine.
  • the reference value for plasma porphyrin is 10 nmol/L.
  • the subject has a plasma porphyrin level that is greater than, or greater than or equal to 10 nmol/L. In some embodiments, the subject has a plasma porphyrin level that is greater than, or greater than or equal to 8, 10, 15, 20, 25, 30, 35, 40, 45, or 50 nmol/L. In some embodiments, he subject has a plasma porphyrin level that is greater than, or greater than or equal to 40 nmol/L.
  • the reference value for urine porphyrin is 25 ⁇ mol/mol creatinine. In some embodiments, the reference value for urine porphyrin is less than 28.4 ⁇ mol/mol creatinine. In some embodiments, the subject has a urine porphyrin level that is greater than, or greater than or equal to 25 ⁇ mol/mol creatinine. In some embodiments, the subject has a urine porphyrin level that is greater than, or equal to 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 ⁇ mol/mol creatinine.
  • the subject has a level (e.g. , a plasma level or a urine level) of a porphyrin or a porphyrin precursor that is greater than that of 99% of individuals in a sample of healthy individuals.
  • a level e.g. , a plasma level or a urine level
  • the subject has a level (e.g., a plasma level or a urine level) of ALA or PBG that is greater than two standard deviations above the mean level in a sample of healthy individuals.
  • a level e.g., a plasma level or a urine level
  • the subject has a urine level of ALA that is 1.6 or more times that of the mean level in a normal subject (e.g., a subject that does not carry a mutation associated with a porphyria). In some embodiments, the subject has a plasma level of ALA that is 2 or 3 times that of the mean level in a normal subject. In some embodiments, the subject has a urine level of PBG that is four or more times that of the mean level in a normal subject. In some embodiments, the subject has a plasma level of PBG that is four or more times that of the mean level in a normal subject.
  • a compound of formula (I) results in a decrease in the level of one or more porphyrins or porphyrin precursors, as described herein (e.g., ALA and/or PBG).
  • the decrease may be measured relative to any appropriate control or reference value.
  • the decrease in the level of one or more porphyrins or porphyrin precursors may be established in an individual subject, e.g., as a decrease of at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50% or more compared with the level prior to treatment (e.g., immediately prior to treatment).
  • a decrease in the level of a porphyrin precursor, a porphyrin, or a porphyrin metabolite may be measured using any method known in the art.
  • administration of a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof is effective to reduce the level of ALA and/or PBG in the subject.
  • the level of ALA or PBG in the subject can be assessed, e.g., based on the absolute level of ALA or PBG, or based on the relative level of ALA or PBG (e.g., relative to the level of another protein or compound, e.g., the level of creatinine) in a sample from the subject.
  • the sample is a urine sample. In some embodiments, the sample is a plasma sample. In some embodiments, the method decreases 5-ALA levels in the subject. In some embodiments, the method decreases 5-ALA levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases HMB levels in the subject.
  • the method decreases HMB levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method decreases coproporphyrin III levels in the subject.
  • the method decreases coproporphyrin III levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method decreases PBG levels in the subject.
  • the method decreases PBG levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases uroporphyrin III levels in the subject. In some embodiments, the method decreases uroporphyrin III levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method decreases the proportion of protoporphyrin to coproporphyrin in the subject. In some embodiments, the method decreases the proportion of protoporphyrin to coproporphyrin in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases heptacarboxyl-porphyrin levels in the subject.
  • the method decreases heptacarboxyl-porphyrin levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases isocoproporphyrin levels in the subject. In some embodiments, the method decreases isocoproporphyrin levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method decreases ZPPIX levels in the subject. In some embodiments, the method decreases ZPPIX levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases porphyrin or porphyrin precursor (e.g., ALA or PBG) levels in the subject to a normal level.
  • porphyrin or porphyrin precursor e.g., ALA or PBG
  • the normal level is a reference value for a porphyrin or porphyrin precursor (e.g., urine ALA levels ⁇ 6.3 mmol/mol creatine and urine PBG levels ⁇ 1.4 mmol/mol creatine) as described herein.
  • a porphyrin or porphyrin precursor e.g., urine ALA levels ⁇ 6.3 mmol/mol creatine and urine PBG levels ⁇ 1.4 mmol/mol creatine
  • the disclosure relates to methods of inhibiting uroporphyrin I and/or coproporphyrin I synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 40%.
  • the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 90%.
  • the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 100%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 40%.
  • the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 90%.
  • the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 100%.
  • Porphyrins e.g., PPIX, ZPPIX, uroporphyrin I, and coproporphyrin I
  • the porphyrins may be extracted from the biological sample into a solution for fluorescence analysis.
  • Porphyrins can be detected in these biological samples by direct inspection using long wavelength ultraviolet light (e.g., 400-420 nm light).
  • Porphyrins have the greatest absorption wavelengths near 400-420 nm, with their highest absorption peak occurring at 415 nm.
  • the emission maxima of porphyrins is typically around 600 nm and varies slightly based on the type of porphyrins and the solvent used for analysis.
  • diagnosis of a hepatic porphyria, EPP, XLPP, and CEP may be made using fluorescence analysis.
  • skin porphyrin levels e.g., PPIX levels
  • PPIX levels can be measured by calculating the difference before and after complete photobleaching of PPIX using controlled illumination. See, e.g., Heerfordt IM. Br J Dermatol.2016;175(6):1284- 1289.
  • the subject’ s plasma porphyrin fluoresces at a peak of 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s plasma porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak of 632 nm when illuminated with blue light (e.g., 400-420 nm light).
  • the subject s skin porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light).
  • the subject has greater than 0.2 FluoDerm Units (FDU) of protoporphyrin IX levels in the skin.
  • FDU FluoDerm Units
  • the subject has greater than 1.0 FDU of protoporphyrin IX levels in the skin.
  • the subject has between 1.0 FDU and 2.5 FDU of protoporphyrin IX levels in the skin.
  • the subject has greater than 2.5 FDU of protoporphyrin IX levels in the skin.
  • the method decreases protoporphyrin IX levels in the skin of the subject to less than 0.5 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 1.0 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 1.5 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 2.0 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 2.5 FDU. In some embodiments, the subject has red fluorescent urine.
  • the subject has a peak between 615 nm and 620 nm using plasma porphyrin fluorescence analysis.
  • the methods provided herein comprise administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject’s PPIX levels decrease while the patient’s heme levels are substantially maintained.
  • the patients PPIX levels decrease by at least 50% (e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%) and the patient’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%). In some embodiments, the patient’s PPIX levels decrease by at least 85% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 80% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 75% and the patient’s heme levels decrease no more than 15%.
  • the patients PPIX levels decrease by at least 70% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 65% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 60% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 55% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 50% and the patient’s heme levels decrease no more than 15%.
  • the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels.
  • the patient’s PPIX levels decrease by at least 50% (e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the patient’s PPIX levels decrease by at least 55%.
  • the patient’s PPIX levels decrease by at least 60%. In some embodiments, the patient’s PPIX levels decrease by at least 65%. In some embodiments, the patient’s PPIX levels decrease by at least 70%. In some embodiments, the patient’s PPIX levels decrease by at least 75%. In some embodiments, the patient’s PPIX levels decrease by at least 80%. In some embodiments, the patient’s PPIX levels decrease by at least 85%. In some embodiments, the patient’s PPIX levels decrease by at least 90%. In some embodiments, the patient’s PPIX levels decrease by at least 95%. In some embodiments, the patient’s PPIX levels decrease by at least 100%.
  • the patient’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%). In some embodiments, the patient’s heme levels decrease no more than 15%. In some embodiments, the patient’s heme levels decrease no more than 20%. In some embodiments, the patient’s heme levels decrease no more than 25%. In some embodiments, the patient’s heme levels decrease no more than 30%. In some embodiments, the accumulation of one or more of the following heme intermediates is inhibited, wherein the one or more heme intermediates is selected from the group consisting of PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA.
  • the disclosure relates to methods of inhibiting the accumulation of PPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of ZPPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of uroporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of coproporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of inhibiting the accumulation of 5-ALA, the method comprising administering to the subject a pharmaceutical composition comprising a v.
  • the accumulation of the one or more heme intermediates is inhibited in a dose dependent manner.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the one or more complications of a hepatic porphyria is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, severe abdominal pain, neuropsychiatric symptoms, autonomic neuropathy, peripheral motor neuropathy, electrolyte disturbances, nausea, vomiting, constipation, diarrhea, difficulty urinating, ileus, paresthesia, insomnia, restlessness, agitation, anxiety, confusion, hallucinations, psychosis, convulsions, pain associated with neuropathy, muscle paralysis, tetraparesis, decreased breathing, respiratory arrest, hyponatremia, tachycardia, hypertension, increased heart rate, increased blood pressure, red urine, dark urine, hepatocellular carcinoma, hypertensive renal damage, chronic kidney disease, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, de
  • the one or more complications are improved indirectly.
  • the one or more complications of EPP, XLPP, or CEP is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholelithiasis, cholestasis, cytolysis, gallstones, cholestatic liver failure, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero.
  • the disclosure contemplates methods of treating one or more complications of EPP, XLPP, or CEP (e.g., acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholelithiasis, cholestasis, cytolysis, gallstones, cholestatic liver failure, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero) comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one
  • the one or more complications are improved indirectly.
  • the disclosure contemplates methods of preventing one or more complications of a hepatic porphyria, EPP, XLPP, or CEP comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure contemplates methods of reducing the progression rate of one or more complications of a hepatic porphyria, EPP, XLPP, or CEP comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure contemplates methods of reducing the severity of one or more complications of a hepatic porphyria, EPP, XLPP, or CEP comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • Methods of treatment provided herein may serve to ameliorate one or more symptoms associated with a hepatic porphyria or to reduce the risk of developing conditions associated with porphyria (e.g., neuropathy (e.g., progressive neuropathy), hepatocellular cancer).
  • Symptoms associated with a hepatic porphyria may include abdominal pain or cramping, headaches, effects caused by nervous system abnormalities, and light sensitivity, causing rashes, blistering, and scarring of the skin (photodermatitis).
  • the hepatic porphyria is AIP.
  • Symptoms of AIP include gastrointestinal symptoms (e.g., severe and poorly localized abdominal pain, nausea/vomiting, constipation, diarrhea, ileus), urinary symptoms (dysuria, urinary retention/incontinence, or dark urine), neurologic symptoms (e.g., sensory neuropathy, motor neuropathy (e.g., affecting the cranial nerves and/or leading to weakness in the arms or legs), seizures, neuropathic pain, progressive neuropathy, headaches, neuropsychiatric symptoms (e.g., mental confusion, anxiety, agitation, hallucination, hysteria, delirium, apathy, depression, phobias, psychosis, insomnia, somnolence, coma), autonomic nervous system involvement (resulting e.g., in cardiovascular symptoms such as tachycardia, hypertension, and/or arrhythmias, as well as other symptoms, such as, e.g., increased circulating catecholamine levels, sweating, restlessness, and/or tre
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered together with (e.g., before, after, or concurrent with) another treatment that may serve to alleviate one or more of the above symptoms.
  • another treatment e.g., abdominal pain may be treated, e.g., with narcotic analgesics, seizures may be treated, e.g., with anti-seizure medications, nausea/vomiting may be treated, e.g., with phenothiazines, and tachycardia/hypertension may be treated, e.g., with beta blockers.
  • methods disclosed herein for preventing, treating, or reducing the progression rate and/or severity of one or more complications of EPP, XLPP, or CEP in a subject may further comprise administering to the patient one or more supportive therapies or additional active agents for treating EPP, XLPP, or CEP.
  • the patient also may be administered one or more supportive therapies or active agents selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse ®), bortezomib, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion.
  • the methods described herein may further comprise administering to the patient Afamelanotide (Scenesse ®).
  • Afamelanotide Scenesse ®
  • Porphyrin photosensitization in certain hepatic porphyrias e.g., VP, HCP, PCT, and HEP
  • EPP, XLPP, and CEP produces two distinct clinical syndromes: (1) acute photosensitivity on exposure to sunlight with erythema and edema and (2) a syndrome wherein subepidermal bullae occur in sun-exposed areas of the skin.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof is administered during a particular phase of the menstrual cycle or based on hormone levels of the patient being treated (e.g., based on hormone levels that are associated with a particular phase of the menstrual cycle).
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered on one or more particular days of the menstrual cycle, e.g., on day 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, or on day 28 (or later day for subjects who have a longer menstrual cycle).
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product (e.g., hemin, heme arginate, or heme albumin).
  • a heme product e.g., hemin, heme arginate, or heme albumin.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product and glucose, a heme product and dextrose, or a heme product and total parenteral nutrition.
  • the additional treatment(s) may be administered before, after, or concurrent with the administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the present application further provides use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia) in a subject.
  • Diamond-Blackfan anemia Diamond-Blackfan anemia
  • Diamond-Blackfan anemia is a congenital erythroid aplasia that usually develops during the neonatal period.
  • DBA is characterized by low red blood cell counts (anemia) with decreased erythroid progenitors in the bone marrow.
  • levels of other blood components such as platelets and the white blood cells are normal.
  • DBA1 Diamond-Blackfan anemia-l
  • OMIM #105650 is caused by heterozygous mutations in the RPS19 gene on chromosome l9ql3.
  • DBA7 (OMIM #612562), caused by mutation in the RPL11 gene on lp36; DBA8 (OMIM #612563), caused by mutation in the RPS7 gene on 2p25; DBA9 (OMIM #613308), caused by mutation in the RPS10 gene on 6p; DBA10 (OMIM #613309), caused by mutation in the RPS26 gene on l2q; DBA11 (OMIM #614900), caused by mutation in the RPL26 gene on 17r13; DBA12 (OMIM #615550), caused by mutation in the RPL15 gene on 3p24; DBA13 (OMIM #615909), caused by mutation in the RPS29 gene on l4q; DBA 14 (OMIM #300946), caused by mutation in the /'SR 2 gene on Xpl 1; DBA 15 (OMIM #606164), caused by mutation in the RPS28 gene on 19p 13 ; DBA 16 (OMIM #617408), caused by mutation in the RPL27 gene
  • ribosomal proteins Mutations in ribosomal proteins impact ribosomal protein function, leading to ribosomal insufficiency and increased stress. Impaired ribosome biogenesis has been linked to p53 induction and cell-cycle arrest. Ribosomal protein knockdown leads to an increase of free ribosomal proteins. Some ribosomal proteins, including RPL11, RPL5, and RPL13, bind to MDM2 and block MDM2 -mediated p53 ubiquitination and degradation (Lindstrom et al, Cell Cycle 6:4, 434-437, 15 February 2007; Fumagalli et al, Nat Cell Biol.2009 Apr; l l(4):50l-8). Other ribosomal proteins may activate p53 by different mechanisms.
  • RPL26 has been found to increase the translation rate of p53 mRNA by binding to its 5’ untranslated region (Tagaki et al., Cell.2005 Oct 7; l23(l):49-63).
  • the negative impact of DBA on ribosomal protein function results in decreased globin synthesis, which is required to produce hemoglobin. Heme synthesis does not appear to be impacted.
  • the imbalance between heme synthesis and globin leads to the accumulation of free heme in DBA erythroid cells (Rio S, et al. Blood.2019;133(12):1358-1370). Heme is toxic for the cells by increasing reactive oxygen species production, lipid peroxidation, and apoptosis.
  • a diagnosis of DBA is made through a blood count and a bone marrow biopsy.
  • a diagnosis of DBA is made on the basis of anemia, low reticulocyte (immature red blood cells) counts, and diminished erythroid precursors in bone marrow.
  • Features that support a diagnosis of DBA include the presence of congenital abnormalities, macrocytosis, elevated fetal hemoglobin, and elevated adenosine deaminase levels in red blood cells. Most patients are diagnosed in the first two years of life. However, some mildly affected individuals only receive attention after a more severely affected family member is identified.
  • the disclosure relates to methods of treating anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the anemia associated with a ribosomal disorder is Diamond Blackfan anemia (DBA).
  • the DBA is caused by haploinsufficiency for a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein L5 (RPL5), 60S ribosomal protein L11 (RPL11), and 40S ribosomal protein S7 (RPS7).
  • a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein
  • the DBA is caused by haploinsufficiency for a ribosomal protein selected from the group consisting of 40S ribosomal protein S10 (RPS10), 40S ribosomal protein S26 (RPS26), 60S ribosomal protein L15 (RPL15), 60S ribosomal protein L17 (RPL17), 60S ribosomal protein L19 (RPL19), 60S ribosomal protein L26 (RPL26), 60S ribosomal protein L27 (RPL27), 60S ribosomal protein L31 (RPL31), 40S ribosomal protein S15a (RPS15a), 40S ribosomal protein S20 (RPS20), 40S ribosomal protein S27 (RPS27), 40S ribosomal protein S28 (RPS28), and 40S ribosomal protein S29 (RPS29).
  • a ribosomal protein selected from the group consisting of 40S ribosomal protein S10
  • the patient has one or more mutations in a ribosomal protein gene.
  • the compound of formula (I) e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, can be used in a method of treating anemia associated with a ribosomal disorder, wherein the subject has a mutation in ribosomal protein 19 (RPS19).
  • RPS19 ribosomal protein 19
  • the phenotype of DBA patients indicates a hematological stem cell defect specifically affecting the erythroid progenitor population.
  • the RPS19 protein is involved in the production of ribosomes. Disease features may be related to the nature of RPS19 mutations. The disease is characterized by dominant inheritance, and therefore arises due to a partial loss of RPS19 protein function.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, can be used in a method of treating anemia associated with a ribosomal disorder, wherein the subject has a mutation in ribosomal protein from at least one of, but not limited to RPL5, RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19, RPS20, RPS24, RPS26, RPS27a, RPS27, RPS28, and RPS29.
  • RPL5 RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19,
  • a mutation or variant in RPS19 causes DBA1
  • a mutation or variant in RPS24 causes DBA3
  • a mutation or variant in RPS17 causes DBA4
  • a mutation or variant in RPS34A causes DBA5
  • a mutation or variant in RPLS causes DBA6
  • a mutation or variant in RPL11 causes DBA7
  • a mutation or variant in RPS7 causes DBA8.
  • the subject with a ribosomal disorder has a mutation in a non-ribosomal protein selected from the group consisting of TSR2, GATA1, and EPO.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the one or more complications of anemia associated with a ribosomal disorder is selected from the group consisting of: thrombocytosis, megakaryotypic hyperplasia, infections, bleeding (e.g., from the nose or gums), bruising, splenomegaly, the need for more frequent blood transfusions, the need for increased glucocorticoid use, the need for allogenic hematopoietic stem cell transplantation, the need for autologous gene therapy, marrow failure, leukemia, and acute myelogenous leukemia.
  • the disclosure relates to methods of treating splenomegaly associated with anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has an increased spleen size (e.g., splenomegaly).
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof reduce splenomegaly in a subject with anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia).
  • the method reduces the subject’s spleen size. In some embodiments, the method reduces the subject’s spleen size by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the subject’s spleen size by at least 15%. In some embodiments, the method reduces the subject’s spleen size by at least 20%. In some embodiments, the method reduces the subject’s spleen size by at least 25%. In some embodiments, the method reduces the subject’s spleen size by at least 30%.
  • 10% e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%.
  • the method reduces the subject’s sple
  • the method reduces the subject’s spleen size by at least 35%. In some embodiments, the method reduces the subject’s spleen size by at least 40%. In some embodiments, the method reduces the subject’s spleen size by at least 45%. In some embodiments, the method reduces the subject’s spleen size by at least 50%. In some embodiments, the method reduces the subject’s spleen size by at least 55%. In some embodiments, the method reduces the subject’s spleen size by at least 60%. In some embodiments, the method reduces the subject’s spleen size by at least 65%. In some embodiments, the method reduces the subject’s spleen size by at least 70%.
  • the method reduces the subject’s spleen size by at least 75%. In some embodiments, the method reduces the subject’s spleen size by at least 80%. In some embodiments, the method reduces the subject’s spleen size by at least 85%. In some embodiments, the method reduces the subject’s spleen size by at least 90%. In some embodiments, the method reduces the subject’s spleen size by at least 95%. In some embodiments, the method reduces the subject’s spleen size by at least 100%.
  • the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, can be used to treat a subject with a ribosomal disorder, such as DBA, wherein the subject has a symptom of macrocytic anemia and/or craniofacial abnormalities.
  • Shwachman-Diamond syndrome Shwachman-Diamond syndrome (SDS) or Shwachman-Bodian-Diamond syndrome is a rare genetic disorder that that affects many parts of the body, particularly the pancreas, bone marrow, and skeletal system. Shwachman-Diamond syndrome is inheritated in an autosomal recessive pattern.
  • Diagnosis of Shwachman-Diamond syndrome can be made based on clinical findings, including pancreatic dysfunction and characteristic hematologic abnormalities (e.g., neutropenia and thrombocytopenia). Genetic testing may be used to confirm the diagnosis. SBDS gene mutations are known to cause about 90% of cases of Shwachman-Diamond syndrome. The remaining 10% cases have unknown genetic cause, and hence genetic testing is not an option for these cases. There is no cure for Shwachman-Diamond syndrome. Treatment usually include oral pancreatic enzyme replacement, vitamin supplementation, blood and/or platelet transfusion, administration of granulocyte-colony stimulating factor (G-CSF), and/or hematopoietic stem cell transplantation.
  • G-CSF granulocyte-colony stimulating factor
  • the disclosure relates to methods of treating Shwachman-Diamond syndrome in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of Shwachman- Diamond syndrome in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has one or more mutations in the SBDS gene.
  • the method decreases the need for hematopoietic stem cell transplant in the subject.
  • the method decreases neutropenia in the subject.
  • the method decreases thrombocytopenia in the subject.
  • the method decreases the subject’s risk of developing leukemia.
  • the method decreases the subject’s risk of developing an infection. In some embodiments, the method decreases the subject’s risk of developing pneumonia. In some embodiments, the subject has low neutrophil levels.
  • Dyskeratosis congenita also known as Zinsser-Engman-Cole syndrome, is a rare genetic form of bone marrow failure which is classically associated with oral leukoplakia, nail dystrophy, and reticular hyperpigmentation. Inheritance is most commonly x-linked recessive. As such, males are three times more likely to be affected than females. Symptoms vary widely and may include atrophic wrinkled skin, eye disease, and bone marrow failure.
  • Dyskeratosis congenita patients are at increased risk of developing leukemia and other cancers (e.g., cancers of the head, neck, anus, or genitals) as well as fibrosis (e.g., pulmonary fibrosis and liver fibrosis).
  • fibrosis e.g., pulmonary fibrosis and liver fibrosis.
  • DKC1 dyskerin gene
  • telomerase a protein which is directly involved in stabilizing an enzyme called telomerase that is responsible for catalyzing a reaction that sustains the length of telomeres. Without proteins like dyskerin, the telomeres progressively shorten casing the cells to undergo apoptosis or senescence.
  • TINF2 tet al.
  • TERT tet al.
  • C16orf57 tet al.
  • NOLA2 tet al.
  • WRAP53/TCAB1 tet al.
  • RTEL1 tet al.
  • Treatment options for patients with dyskeratosis congenita are limited.
  • the only long-term treatment option for bone failure in dyskeratosis congenita patients is hematopoietic stem cell transplantation.
  • long-term outcomes remain poor, with an estimated 10-year survival rate of 23%.
  • Short-term treatment options include anabolic steroids (e.g., oxymetholone), granulocyte macrophage colony-stimulating factor, granulocyte colony-stimulating factor, and erythropoietin.
  • the disclosure relates to methods of treating dyskeratosis congenita in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of dyskeratosis congenita in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has dyskeratosis congenita.
  • the dyskeratosis congenita is x-linked dyskeratosis congenita.
  • the subject has one or more mutations in the DKC1 gene.
  • the subject has one or more mutations in a gene selected from the group consisting of TINF2, TERC, TERT, C16orf57, NOLA2, NOLA3, WRAP53/TCAB1, PARN, CTC1, and RTEL1.
  • the method decreases the risk of bone marrow failure in the subject.
  • the method decreases the risk of pulmonary fibrosis in the subject.
  • the method decreases the risk of liver fibrosis in the subject.
  • Cartilage-hair hypoplasia also known as McKusick type metaphyseal chondrodysplasia, is a disorder of bone growth characterized by short stature (dwarfism) with other skeletal abnormalities; fine, sparse hair; joint hypermobility; anemia; increased risk for malignancy; gastrointestinal dysfunction; impaired spermatogenesis; and abnormal immune system function which often leads to recurrent infections.
  • Patients with cartilage-hair hypoplasia Most patients with cartilage-hair hypoplasia have a mutation in the RMRP gene (OMIM no.157660), with a 70A#G transition mutation commonly present.
  • the RMRP gene encodes the untranslated RNA component of the mitochondrial RNA–processing ribonuclease, RNase MRP.
  • Diagnosis of cartilage-hair hypoplasia is based primarily on clinical findings, characteristic radiographic findings, and in some cases, evidence of immune dysfunction, macrocytic anemia, and/or gastrointestinal problems.
  • Molecular genetic testing can be used in patients to identify pathogenic variants by RMRP. Treatment of patients often incudes repeated blood transfusions and surgeries to fuse unstable vertebrae or to treat progressive kyphoscoliosis which compromises lung function. Corrective osteotomies may also be required to treat progressive varus deformity associated with ligament laxity in the knees.
  • the disclosure relates to methods of treating cartilage-hair hypoplasia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of cartilage-hair hypoplasia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has one or more mutations in the RMRP gene.
  • the method reduces the need for bone marrow transplantation in the subject.
  • Defects in erythropoiesis refers generally to the process by which red blood cells (erythrocytes) are produced from HSCs, and includes the formation of erythroid progenitor cells.
  • Erythropoiesis is a carefully ordered sequence of events. Initially occurring in fetal hepatocytes, the process is taken over by the bone marrow in the child and adult. Although multiple cytokines and growth factors are dedicated to the proliferation of the red blood cell, the primary regulator is erythropoietin (EPO). Red blood cell development is initially regulated by stem cell factor (SCF), which commits hematopoietic stem cells to develop into erythroid progenitors. Subsequently, EPO continues to stimulate the development and terminal differentiation of these progenitors. In the fetus, EPO is produced by monocytes and macrophages found in the liver.
  • SCF stem cell factor
  • EPO Epo messenger RNA
  • EPO protein are also found in the brain and in red blood cells (RBCs), suggesting the presence of paracrine and autocrine functions.
  • Erythropoiesis escalates as increased expression of the EPO gene produces higher levels of circulating EPO.
  • EPO gene expression is known to be affected by multiple factors, including hypoxemia, transition metals (Co2+, Ni2+, Mn2+), and iron chelators.
  • hypoxia including factors of decreased oxygen tension, red blood cell loss, and increased oxygen affinity of hemoglobin. For instance, EPO production may increase as much as 1000-fold in severe hypoxia.
  • Erythropoiesis requires the proper biosynthesis of heme and as erythroblasts mature, their demand for heme and iron dramatically increase. Erythroid cells synthesize large amounts of heme and hemoglobin while simultaneously absorbing lots of iron into the cell. A disequilibrium between the globin chain and the heme synthesis is known to occur in the erythroid cells of Diamond-Blackfan anemia patients. This imbalance leads to the accumulation of excess free heme and increased reactive oxygen species production. Blockade of erythroid differentiation and proliferation in Diamond-Blackfan anemia have been shown to affect immature progenitor cells or erythroid-Burst-Forming Unit (BFU- e) resulting in impaired hematopoiesis.
  • BFU- e erythroid-Burst-Forming Unit
  • Circulating EPO levels are increased in Diamond- Blackfan anemia patients, indicating the unresponsiveness of the bone marrow to anemia related EPO stimulation.
  • An increased propensity of erythroid progenitors to apoptosis during in vitro EPO deprivation and in RPS19 deficiency has also been reported.
  • Glycine is one of the key initial substrates for heme synthesis. As such, decreased levels of glycine due to GlyT1 inhibition could lead to a decrease in heme synthesis.
  • the disclosure relates to methods of inhibiting heme synthesis in a subject with anemia associated with a ribosomal disorder, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the heme synthesis is inhibited in a dose dependent manner.
  • the subject with anemia associated with a ribosomal disorder e.g., Diamond-Blackfan anemia
  • the subject has heme levels that are at least 20% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 30% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 40% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has heme levels that are at least 50% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 60% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 70% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has heme levels that are at least 80% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 90% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 100% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the method reduces the heme levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the heme levels in the subject by at least 15%. In some embodiments, the method reduces the heme levels in the subject by at least 20%. In some embodiments, the method reduces the heme levels in the subject by at least 25%. In some embodiments, the method reduces the heme levels in the subject by at least 30%. In some embodiments, the method reduces the heme levels in the subject by at least 35%.
  • the method reduces the heme levels in the subject by at least 80%. In some embodiments, the method reduces the heme levels in the subject by at least 85%. In some embodiments, the method reduces the heme levels in the subject by at least 90%. In some embodiments, the method reduces the heme levels in the subject by at least 95%. In some embodiments, the method reduces the heme levels in the subject by at least 100%. In some embodiments, the method reduces heme synthesis in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • 10% e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method reduces heme synthesis in the subject by at least 15%. In some embodiments, the method reduces heme synthesis in the subject by at least 20%. In some embodiments, the method reduces heme synthesis in the subject by at least 25%. In some embodiments, the method reduces heme synthesis in the subject by at least 30%. In some embodiments, the method reduces heme synthesis in the subject by at least 35%. In some embodiments, the method reduces heme synthesis in the subject by at least 40%. In some embodiments, the method reduces heme synthesis in the subject by at least 45%. In some embodiments, the method reduces heme synthesis in the subject by at least 50%.
  • the method reduces heme synthesis in the subject by at least 55%. In some embodiments, the method reduces heme synthesis in the subject by at least 60%. In some embodiments, the method reduces heme synthesis in the subject by at least 65%. In some embodiments, the method reduces heme synthesis in the subject by at least 70%. In some embodiments, the method reduces heme synthesis in the subject by at least 75%. In some embodiments, the method reduces heme synthesis in the subject by at least 80%. In some embodiments, the method reduces heme synthesis in the subject by at least 85%. In some embodiments, the method reduces heme synthesis in the subject by at least 90%.
  • the method reduces heme synthesis in the subject by at least 95%. In some embodiments, the method reduces heme synthesis in the subject by at least 100%. In some embodiments, the method reduces intracellular heme levels. In some embodiments, the method reduces intracellular heme levels in erythroid precursors. In some embodiments, the method reduces the risk of heme toxicity in the subject. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • 10% e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%.
  • the method reduces the risk of heme toxicity in the subject by at least 15%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 20%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 25%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 30%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 35%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 40%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 45%.
  • the method reduces the risk of heme toxicity in the subject by at least 50%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 55%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 60%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 65%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 70%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 75%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 80%.
  • the method reduces the risk of heme toxicity in the subject by at least 85%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 90%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 95%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 100%. In some embodiments, the subject has liver iron overload. In some embodiments, the method reduces the risk of liver iron overload. In some embodiments, the method reduces the levels of iron in the liver.
  • the method reduces the levels of iron in the liver by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the levels of iron in the liver by at least 15%. In some embodiments, the method reduces the levels of iron in the liver by at least 20%. In some embodiments, the method reduces the levels of iron in the liver by at least 25%. In some embodiments, the method reduces the levels of iron in the liver by at least 30%. In some embodiments, the method reduces the levels of iron in the liver by at least 35%.
  • the method reduces the levels of iron in the liver by at least 40%. In some embodiments, the method reduces the levels of iron in the liver by at least 45%. In some embodiments, the method reduces the levels of iron in the liver by at least 50%. In some embodiments, the method reduces the levels of iron in the liver by at least 55%. In some embodiments, the method reduces the levels of iron in the liver by at least 60%. In some embodiments, the method reduces the levels of iron in the liver by at least 65%. In some embodiments, the method reduces the levels of iron in the liver by at least 70%. In some embodiments, the method reduces the levels of iron in the liver by at least 75%.
  • the method reduces the levels of iron in the liver by at least 80%. In some embodiments, the method reduces the levels of iron in the liver by at least 85%. In some embodiments, the method reduces the levels of iron in the liver by at least 90%. In some embodiments, the method reduces the levels of iron in the liver by at least 95%. In some embodiments, the method reduces the levels of iron in the liver by at least 100%. In some embodiments, the subject has cardiac iron overload. In some embodiments, the method reduces the risk of cardiac iron overload. In some embodiments, the method reduces the level of iron in the heart.
  • the method reduces the levels of iron in the heart by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the levels of iron in the heart by at least 15%. In some embodiments, the method reduces the levels of iron in the heart by at least 20%. In some embodiments, the method reduces the levels of iron in the heart by at least 25%. In some embodiments, the method reduces the levels of iron in the heart by at least 30%. In some embodiments, the method reduces the levels of iron in the heart by at least 35%.
  • the method reduces the levels of iron in the heart by at least 40%. In some embodiments, the method reduces the levels of iron in the heart by at least 45%. In some embodiments, the method reduces the levels of iron in the heart by at least 50%. In some embodiments, the method reduces the levels of iron in the heart by at least 55%. In some embodiments, the method reduces the levels of iron in the heart by at least 60%. In some embodiments, the method reduces the levels of iron in the heart by at least 65%. In some embodiments, the method reduces the levels of iron in the heart by at least 70%. In some embodiments, the method reduces the levels of iron in the heart by at least 75%.
  • the method reduces the levels of iron in the heart by at least 80%. In some embodiments, the method reduces the levels of iron in the heart by at least 85%. In some embodiments, the method reduces the levels of iron in the heart by at least 90%. In some embodiments, the method reduces the levels of iron in the heart by at least 95%. In some embodiments, the method reduces the levels of iron in the heart by at least 100%.
  • the subject has decreased erythroid precursor survival as compared to a healthy subject. In some embodiments, the subject has decreased erythroid precursor differentiation into mature red blood cells as compared to a healthy subject. In some embodiments, the subject has impaired hematopoiesis.
  • the method increases the subject’s erythroid precursor survival. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s erythroid precursor survival by at least 15%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 20%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 25%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 30%.
  • 10% e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%.
  • the method increases the subject’s erythroid
  • the method increases the subject’s erythroid precursor survival by at least 35%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 40%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 45%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 50%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 55%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 60%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 65%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 70%.
  • the method increases the subject’s erythroid precursor survival by at least 75%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 80%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 85%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 90%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 95%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 100%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells in the subject.
  • the method increases erythroid precursor differentiation into mature red blood cells in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 15%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 20%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 25%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 30%.
  • the method increases erythroid precursor differentiation into mature red blood cells by at least 35%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 40%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 45%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 50%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 55%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 60%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 65%.
  • the method increases erythroid precursor differentiation into mature red blood cells by at least 70%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 75%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 80%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 85%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 90%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 95%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 100%.
  • the subject has elevated erythrocyte adenosine deaminase activity. In some embodiments, the subject has normal marrow cellularity with a paucity of red cell precursors. In some embodiments, the subject has normal neutrophil and/or platelet counts. In some embodiments, the anemia is due to a failure in erythropoiesis. In some embodiments, the method reduces anemia in the subject. In some embodiments, the method reduces anemia in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method reduces anemia in the subject by at least 15%. In some embodiments, the method reduces anemia in the subject by at least 20%. In some embodiments, the method reduces anemia in the subject by at least 25%. In some embodiments, the method reduces anemia in the subject by at least 30%. In some embodiments, the method reduces anemia in the subject by at least 35%. In some embodiments, the method reduces anemia in the subject by at least 40%. In some embodiments, the method reduces anemia in the subject by at least 45%. In some embodiments, the method reduces anemia in the subject by at least 50%. In some embodiments, the method reduces anemia in the subject by at least 55%.
  • the method reduces anemia in the subject by at least 60%. In some embodiments, the method reduces anemia in the subject by at least 65%. In some embodiments, the method reduces anemia in the subject by at least 70%. In some embodiments, the method reduces anemia in the subject by at least 75%. In some embodiments, the method reduces anemia in the subject by at least 80%. In some embodiments, the method reduces anemia in the subject by at least 85%. In some embodiments, the method reduces anemia in the subject by at least 90%. In some embodiments, the method reduces anemia in the subject by at least 95%. In some embodiments, the method reduces anemia in the subject by at least 100%. In some embodiments, the subject has macrocytic anemia. In some embodiments, the method reduces anemia in the subject by reducing free heme toxicity.
  • the method increases red cell mass. In some embodiments, the method decreases the mean corpuscular volume of red cells. In some embodiments, the method decreases red cell adenosine deaminase. In some embodiments, the method decreases red cell adenosine deaminase in a subject with DBA. In some embodiments, the method decreases fetal hemoglobin content in red cells.
  • Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an low red blood cell count (e.g, less than about 4.5 million red blood cells per ⁇ l of blood for men and about 4.1 million red blood cells per ⁇ l of blood for women, often by a clinically or statistically significant amount), or a low hematocrit (e.g, greater than about 38% for men or about 35% for women, often by a clinically or statistically significant amount).
  • the subject has hematocrit levels that are less than 38%.
  • the subject has hematocrit levels that are less than 35%.
  • the subject’s hematocrit levels are at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 10% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject’s hematocrit levels are at least 20% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 30% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject’s hematocrit levels are at least 40% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 50% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject’s hematocrit levels are at least 60% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 70% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject’s hematocrit levels are at least 80% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 90% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 10% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 20% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 30% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 40% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 50% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 60% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 70% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 80% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 90% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count less than 4.5 x10 12 /L. In some embodiments, the subject has a red blood cell count less than 4.1 x10 12 /L.
  • the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, increase red blood cell synthesis (also known as erythropoiesis), and may be used to treat a condition associated with decreased red blood cells.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof may modulate red blood cell synthesis by reducing the formation of heme.
  • the disclosure relates to methods of increasing red blood cell synthesis in a subject with anemia associated with a ribosomal disorder, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the red blood cell synthesis is increased in a dose dependent manner.
  • the red blood cell count is increased in a dose dependent manner.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof may be administered directly to a subject to increase red blood count, if desired.
  • Red blood count may also be reflected by a person's hematocrit (i.e., packed cell volume (PCV) or erythrocyte volume fraction (EVF)), which is the proportion or percentage of blood volume that is occupied by red blood cells.
  • PCV packed cell volume
  • EVF erythrocyte volume fraction
  • a normal hematocrit is normally about 49% for men and about 48% for women.
  • a lower hematocrit value indicates a lower number of red blood cells.
  • administration of a compound of formula (I) e.g., any one of compounds 1-60
  • the method increases the subject’s red blood cell count.
  • the method increases the subject’s red blood cell count by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s red blood cell count by at least 15%. In some embodiments, the method increases the subject’s red blood cell count by at least 20%. In some embodiments, the method increases the subject’s red blood cell count by at least 25%. In some embodiments, the method increases the subject’s red blood cell count by at least 30%. In some embodiments, the method increases the subject’s red blood cell count by at least 35%.
  • the method increases the subject’s red blood cell count by at least 40%. In some embodiments, the method increases the subject’s red blood cell count by at least 45%. In some embodiments, the method increases the subject’s red blood cell count by at least 50%. In some embodiments, the method increases the subject’s red blood cell count by at least 55%. In some embodiments, the method increases the subject’s red blood cell count by at least 60%. In some embodiments, the method increases the subject’s red blood cell count by at least 65%. In some embodiments, the method increases the subject’s red blood cell count by at least 70%. In some embodiments, the method increases the subject’s red blood cell count by at least 75%.
  • the method increases the subject’s red blood cell count by at least 80%. In some embodiments, the method increases the subject’s red blood cell count by at least 85%. In some embodiments, the method increases the subject’s red blood cell count by at least 90%. In some embodiments, the method increases the subject’s red blood cell count by at least 95%. In some embodiments, the method increases the subject’s red blood cell count by at least 100%. In some embodiments, the method increases the subject’s red blood cell count to normal levels. In some embodiments, the method increases the subject’s red blood cell count to between 4.5-5.9 x10 12 /L. In some embodiments, the method increases the subject’s red blood cell count to between 4.1-5.1 x10 12 /L.
  • the method increases the subject’s hematocrit levels. In some embodiments, the method increases the subject’s hematocrit levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s hematocrit levels by at least 15%. In some embodiments, the method increases the subject’s hematocrit levels by at least 20%. In some embodiments, the method increases the subject’s hematocrit levels by at least 25%. In some embodiments, the method increases the subject’s hematocrit levels by at least 30%.
  • 10% e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%.
  • the method increases the subject’s hemato
  • the method increases the subject’s hematocrit levels by at least 35%. In some embodiments, the method increases the subject’s hematocrit levels by at least 40%. In some embodiments, the method increases the subject’s hematocrit levels by at least 45%. In some embodiments, the method increases the subject’s hematocrit levels by at least 50%. In some embodiments, the method increases the subject’s hematocrit levels by at least 55%. In some embodiments, the method increases the subject’s hematocrit levels by at least 60%. In some embodiments, the method increases the subject’s hematocrit levels by at least 65%. In some embodiments, the method increases the subject’s hematocrit levels by at least 70%.
  • the method increases the subject’s hematocrit levels by at least 75%. In some embodiments, the method increases the subject’s hematocrit levels by at least 80%. In some embodiments, the method increases the subject’s hematocrit levels by at least 85%. In some embodiments, the method increases the subject’s hematocrit levels by at least 90%. In some embodiments, the method increases the subject’s hematocrit levels by at least 95%. In some embodiments, the method increases the subject’s hematocrit levels by at least 100%. In some embodiments, the method increases the subject’s hematocrit levels to at least 38%. In some embodiments, the method increases the subject’s hematocrit levels to at least 35%.
  • the present application relates to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof to a subject in need thereof, wherein the subject has a decreased reticulocyte (e.g., less than 1%, often by a clinically or statistically significant amount), or decreased hemoglobin levels (e.g., less than about 13.2 g/dL for men or about 11.6 g/dL for women, often by a clinically or statistically significant amount).
  • reticulocyte e.g., less than 1%, often by a clinically or statistically significant amount
  • hemoglobin levels e.g., less than about 13.2 g/dL for men or about 11.6 g/dL for women, often by a clinically or statistically significant amount.
  • the subject has hemoglobin levels that are at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 10% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has hemoglobin levels that are at least 20% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 30% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 40% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has hemoglobin levels that are at least 50% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 60% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 70% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has hemoglobin levels that are at least 80% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 90% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are less than 13 g/dL. In some embodiments, the subject has hemoglobin levels that are less than 11 g/dL. In some embodiments, the subject has elevated fetal hemoglobin levels.
  • the subject has a low reticulocyte count, also known as reticulocytopenia. In some embodiments, the subject has a reticulocyte count of less than 1%. In some embodiments, the subject has a reticulocyte count of less than 0.9%. In some embodiments, the subject has a reticulocyte count of less than 0.8%. In some embodiments, the subject has a reticulocyte count of less than 0.7%. In some embodiments, the subject has a reticulocyte count of less than 0.6%. In some embodiments, the subject has a reticulocyte count of less than 0.5%. In some embodiments, the subject has a reticulocyte count of less than 0.4%.
  • the subject has a reticulocyte count of less than 0.3%. In some embodiments, the subject has a reticulocyte count of less than 0.2%. In some embodiments, the subject has a reticulocyte count of less than 0.1%. In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject increases their reticulocyte or hemoglobin levels.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof increases their reticulocyte or hemoglobin levels.
  • the compound of formula (I) e.g., any one of compounds 1- 60
  • the compound of formula (I) increase hemoglobin synthesis in a subject with anemia associated with a ribosomal disorder, and may be used to treat a condition associated with decreased red blood cells.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may modulate hemoglobin synthesis by reducing the formation of heme.
  • the disclosure relates to methods of increasing hemoglobin synthesis in a subject with anemia associated with a ribosomal disorder, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the hemoglobin synthesis is increased in a dose dependent manner.
  • the method increases the subject’s hemoglobin levels.
  • the method increases the subject’s hemoglobin levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s hemoglobin levels by at least 15%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 20%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 25%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 30%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 35%.
  • the method increases the subject’s hemoglobin levels by at least 40%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 45%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 50%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 55%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 60%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 65%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 70%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 75%.
  • the method increases the subject’s hemoglobin levels by at least 80%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 85%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 90%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 95%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 100%. In some embodiments, the method increases the subject’s hemoglobin levels to at least 13 g/dL. In some embodiments, the method increases the subject’s hemoglobin levels to at least 11 g/dL. In some embodiments, the method increases the subject’s reticulocyte count.
  • the method increases the subject’s reticulocyte count to between 1% to 2%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.5%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.6%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.7%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.8%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.9%. In some embodiments, the method increases the subject’s reticulocyte count to at least 1%. In some embodiments, the method increases the subject’s reticulocyte count to at least 1.5%.
  • the method increases the subject’s reticulocyte count to at least 2%. In some embodiments, the method increases the subject’s reticulocyte count by 0.5%. In some embodiments, the method increases the subject’s reticulocyte count by 1%.
  • Combination Therapies Certain embodiments may include combination therapies for treating anemia associated with a ribosomal disorder, including the administration of compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in combination with other therapeutic agents or treatment modalities.
  • combination therapies include, without limitation, any one or more additional active agents and/or supportive therapies selected from the group consisting of: trifluoperazine, HDAC inhibitors, glucocorticoids, sotatercept, luspatercept, iron chelators, blood transfusion, platelet transfusion, allogeneic hematopoietic stem cell transplant, autologous gene therapy, lenalidomide (REVLIMID®), and antibiotics.
  • the method further comprises administering another therapeutic agent to treat the ribosomal protein defect, selected from the group consisting of: corticosteroids and bone marrow transplants and other treatments known to persons of ordinary skill in the art.
  • corticosteroids can be used to treat anemia associated with a ribosomal disorder, such as DBA.
  • Blood transfusions can also be used to treat severe anemia associated with a ribosomal disorder, such as DBA. Periods of remission may occur, during which transfusions and steroid treatments are not required.
  • Bone marrow transplantation (BMT) can treat hematological aspects of DBA. However, adverse events in transfusion patients can occur.
  • the method reduces the need for corticosteroid treatments in the subject.
  • the method reduces the dose of corticosteroid treatment needed in the subject.
  • the corticosteroid is a glucocorticoid steroid.
  • a common therapy for treating anemia associated with a ribosomal disorder includes the use of regularly scheduled blood transfusions.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof is useful in treating a subject who has anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia) requiring blood transfusions.
  • the method reduces the subject’s need for blood transfusions.
  • the method reduces the subject’s need for blood transfusions by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the subject’s need for blood transfusions by at least 15%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 20%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 25%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 30%.
  • the method reduces the subject’s need for blood transfusions by at least 35%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 40%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 45%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 50%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 55%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 60%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 65%.
  • the method reduces the subject’s need for blood transfusions by at least 70%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 75%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 80%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 85%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 90%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 95%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 100%. In some embodiments, the method eliminates the subject’s need for blood transfusions.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder (e.g., treating, preventing, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder) comprising administering to a patient in need thereof an effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases the patient’s quality of life by at least 1% (e.g., 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100%).
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof e.g., any one of compounds 1-60
  • the method relates to increasing the patient’s quality of life. In some embodiments, the method relates to increasing the patient’s quality of life by at least 1%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 2%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 3%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 4%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 5%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 10%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 15%.
  • the method relates to increasing the patient’s quality of life by at least 20%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 25%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 30%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 35%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 40%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 45%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 50%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 55%.
  • the method relates to increasing the patient’s quality of life by at least 60%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 65%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 70%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 75%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 80%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 85%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 90%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 95%.
  • the method relates to increasing the patient’s quality of life by at least 100%.
  • the patients has a low quality of life.
  • the patient’s quality of life is measured using the Functional Assessment of Cancer Therapy Anemia (FACT-An).
  • the patient’s quality of life is measured using the Functional Assessment of Cancer Therapy Fatigue (FACT-Fatigue).
  • the patient’s quality of life is measured using the Functional Assessment of Chronic Illness Therapy (FACIT).
  • the patient’s quality of life is measured using the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-Fatigue).
  • the patient’s quality of life is measured using the Functional Assessment of Chronic Illness Therapy Anemia (FACIT- Anemia). In some embodiments, the patient’s quality of life is measured using the SF-36 generic PRO tool. In some embodiments, the patient’s quality of life is measured using the SF-6D generic PRO tool. In some embodiments, the patient’s quality of life is measured using the linear analog scale assessment (LASA).
  • FACIT- Anemia Functional Assessment of Chronic Illness Therapy Anemia
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder (e.g., treating, preventing, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder) comprising administering to a patient in need thereof an effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases the patient’s survival by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • a compound of formula (I) e.g., any one of compounds 1-60
  • the method increases the patient’s survival by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%,
  • the method increases the patient’s survival. In some embodiments, the method increases the patient’s survival by at least 15%. In some embodiments, the method increases the patient’s survival by at least 20%. In some embodiments, the method increases the patient’s survival by at least 25%. In some embodiments, the method increases the patient’s survival by at least 30%. In some embodiments, the method increases the patient’s survival by at least 35%. In some embodiments, the method increases the patient’s survival by at least 40%. In some embodiments, the method increases the patient’s survival by at least 45%. In some embodiments, the method increases the patient’s survival by at least 50%. In some embodiments, the method increases the patient’s survival by at least 55%.
  • the method increases the patient’s survival by at least 60%. In some embodiments, the method increases the patient’s survival by at least 65%. In some embodiments, the method increases the patient’s survival by at least 70%. In some embodiments, the method increases the patient’s survival by at least 75%. In some embodiments, the method increases the patient’s survival by at least 80%. In some embodiments, the method increases the patient’s survival by at least 85%. In some embodiments, the method increases the patient’s survival by at least 90%. In some embodiments, the method increases the patient’s survival by at least 95%. In some embodiments, the method increases the patient’s survival by at least 100%.
  • the method increases the patient’s survival by at least 1 month. In some embodiments, the method increases the patient’s survival by at least 2 months. In some embodiments, the method increases the patient's survival by at least 3 months. In some embodiments, the method increases the patient’s survival by at least 4 months. In some embodiments, the method increases the patient’s survival by at least 5 months. In some embodiments, the method increases the patient’s survival by at least 6 months. In some embodiments, the method increases the patient’s survival by at least 7 months. In some embodiments, the method increases the patient’s survival by at least 8 months. In some embodiments, the method increases the patient’s survival by at least 9 months. In some embodiments, the method increases the patient’s survival by at least 10 months. In some embodiments, the method increases the patient’s survival by at least 11 months.
  • the method increases the patient’s survival by at least 1 year. In some embodiments, the method increases the patient’s survival by at least 2 years. In some embodiments, the method increases the patient’s survival by at least 3 years. In some embodiments, the method increases the patient’s survival by at least 4 years. In some embodiments, the method increases the patient’s survival by at least 5 years. In some embodiments, the method increases the patient’s survival by at least 6 years. In some embodiments, the method increases the patient’s survival by at least 7 years. In some embodiments, the method increases the patient’s survival by at least 8 years. In some embodiments, the method increases the patient’s survival by at least 9 years. In some embodiments, the method increases the patient’s survival by at least 10 years.
  • Polycythemia or erythrocytosis, is a disease characterized by an abnormally high level of red blood cells, which often leads to hyperviscosity and an increased risk of thrombosis.
  • the increase in red blood cells can be due to an increase in the red blood cell mass (“absolute polycythemia") or to a decrease in the volume of plasma (“relative polycythemia”).
  • Absolute polycythemia can be distinguished from relative polycythemia secondary to fluid loss or decreased intake, because absolute polycythemia results in increased total blood volume, and relative polycythemia does not.
  • polycythemias Two basic categories of polycythemia are typically recognized: primary polycythemias, due to factors intrinsic to red cell precursors and include the diagnoses of primary familial and congenital polycythemia (PFCP) and polycythemia vera (PV); and secondary polycythemias, which are caused by factors extrinsic to red cell precursors.
  • Primary Polycythemia refers to a variety of myeloproliferative syndromes that include, for example, polycythemia vera and pure erythrocytosis. Polycythemia vera has a significant genetic component.
  • JAK2V617F tyrosine kinase JAK2
  • JAK2V617F tyrosine kinase JAK2
  • JAK2H538-K539delinsI tyrosine kinase JAK2
  • EPO myeloid progenitor cells
  • IL-3 myeloid progenitor cells
  • SCF IL-3
  • GM-CSF insulin-like growth factor
  • IGF insulin-like growth factor-1
  • erythrocytosis includes patients who have an isolated elevated RBC mass in the absence of any other precipitating factor.
  • Primary familial polycythemia is caused by a hypersensitivity of erythroid precursors to EPO.
  • EPOR EPO receptor gene
  • Most of the identified EPOR mutations cause truncation of the c-terminal cytoplasmic receptor domain of the receptor.
  • the disclosure relates to methods of treating polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the polycythemia is primary polycythemia.
  • the primary polycythemia is polycythemia vera.
  • the primary polycythemia is pure erythrocytosis.
  • the primary polycythemia is primary familial polycythemia.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be used in treating or reducing the risk of primary polycythemia, such as polycythemia vera, pure erythrocytosis, or primary familial polycythemia.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia.
  • the myelofibrosis is selected from the group consisting of low-risk myelofibrosis, intermediate-risk myelofibrosis, high-risk myelofibrosis, primary myelofibrosis, post-essential thrombocythemia myelofibrosis, and post-polycythemia vera myelofibrosis.
  • the disclosure relates to methods of treating splenomegaly associated with polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has an increased spleen size (e.g., splenomegaly).
  • the compound of formula (I) e.g., any one of compounds 1-60
  • the method reduces the subject’s spleen size.
  • the method reduces the subject’s spleen size by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the subject’s spleen size by at least 15%. In some embodiments, the method reduces the subject’s spleen size by at least 20%. In some embodiments, the method reduces the subject’s spleen size by at least 25%. In some embodiments, the method reduces the subject’s spleen size by at least 30%.
  • the method reduces the subject’s spleen size by at least 35%. In some embodiments, the method reduces the subject’s spleen size by at least 40%. In some embodiments, the method reduces the subject’s spleen size by at least 45%. In some embodiments, the method reduces the subject’s spleen size by at least 50%. In some embodiments, the method reduces the subject’s spleen size by at least 55%. In some embodiments, the method reduces the subject’s spleen size by at least 60%. In some embodiments, the method reduces the subject’s spleen size by at least 65%. In some embodiments, the method reduces the subject’s spleen size by at least 70%.
  • the method reduces the subject’s spleen size by at least 75%. In some embodiments, the method reduces the subject’s spleen size by at least 80%. In some embodiments, the method reduces the subject’s spleen size by at least 85%. In some embodiments, the method reduces the subject’s spleen size by at least 90%. In some embodiments, the method reduces the subject’s spleen size by at least 95%. In some embodiments, the method reduces the subject’s spleen size by at least 100%.
  • the disclosure relates to methods of treating polycythemia associated with Janus Kinase 2 (JAK2) mutation in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the mutation in JAK2 is a JAK2 V617F exon 14 mutation.
  • the mutation in JAK2 is a JAK2 exon 12 mutation.
  • the mutation in JAK2 is a gain-of-function mutation.
  • the subject’s JAK2 enzyme activity is increased.
  • the disclosure relates to methods of treating polycythemia associated with a gene mutation in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a mutation in Tet Methylcytosine Dioxygenase 2 (TET2) or Nuclear Factor Erythroid 2 (NFE2).
  • TET2 Tet Methylcytosine Dioxygenase 2
  • NFE2 Nuclear Factor Erythroid 2
  • the subject has a mutation in gene selected from the group consisting of VHL, EPO, EPOR, ELG1, EPAS1, HIF2A, and BPGM.
  • the subject has a high oxygen affinity variant selected from the group consisting of hemoglobin B (HBB) and hemoglobin A (HBA).
  • HBB hemoglobin B
  • HBA hemoglobin A
  • Secondary polycythemia may result from functional hypoxia induced by lung disease, heart disease, increased altitude (hemoglobin increase of 4% for each 1000-m increase in altitude), congenital methemoglobinemia, and other high-oxygen affinity hemoglobinopathies stimulating increased EPO production. Secondary polycythemia may also result from increased EPO production secondary to benign and malignant EPO-secreting lesions. Secondary polycythemia may also be a benign familial polycythemia. In some embodiments, secondary polycythemia is due to genetic abnormalities.
  • the patient has an elevated erythropoietin (EPO) level.
  • EPO erythropoietin
  • An elevated EPO level usually as a secondary response to chronic hypoxemia, often leads to secondary polycythemia.
  • the elevated EPO level in the patient is in response to chronic hypoxemia.
  • the secondary polycythemia is associated chronic hypoxemia.
  • the secondary polycythemia is associated with lung disease.
  • the secondary polycythemia is associated with renal disease.
  • the renal disease is selected from the group consisting of local renal hypoxia, renal artery stenosis, cysts, polycystic kidney disease, hydronephrosis, nephrotic syndrome, diffuse parenchymal disease, Bartter’s syndrome, end-stage renal disease, long-term hemodialysis, and post-renal transplant erythrocytosis.
  • the secondary polycythemia is associated with oxygen sensing pathway gene mutations.
  • the oxygen sensing pathway gene mutations are selected from the group consisting of EpoR, VHL, HIF2A, and PHD2.
  • the secondary polycythemia is associated with a tumor.
  • the tumor is a tumor with an excessive production of erythropoietin or erythropoietin related factors.
  • the tumor is selected from the group consisting of renal cell carcinoma, renal tumors, hepatocellular carcinoma, pheochromocytoma, cerebellar hemangioblastoma, uterine leiomyoma, ovarian carcinoma, meningioma, parathyroid carcinoma, and parathyroid adenoma.
  • the secondary polycythemia is drug-associated secondary polycythemia.
  • combination therapy with a compound of formula (I) may allow the use of higher concentrations of gentamicin, methyldopa, or related drugs.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof may be used to reduce erythropoiesis, and also to reduce the formation of erythroid progenitors, red blood cells, or both.
  • methods of reducing erythropoiesis or red blood cell formation may be used to treat a subject that has or is at risk for having increased red blood cell count, increased hemoglobin levels, or increased total red blood cell volume, as described herein.
  • therapies for polycythemia A well-established hitherto existing method for treating polycythemia includes treatment using regularly scheduled phlebotomies (bloodletting). When first diagnosed, the phlebotomies are usually scheduled fairly frequent, e.g. multiple times per week, until RBC levels are brought to within normal range (e.g., hematocrit less than 45%), followed by phlebotomies which are then scheduled once a month or every other month depending upon the patient's rate of RBC formation.
  • the released iron is taken up via the intestine, in particular via specific transport systems (DMT-1, ferroportin), transferred into the blood circulation and thereby conveyed to the appropriate tissues and organs (transferrin, transferrin receptors).
  • DMT-1 specific transport systems
  • ferroportin transferrin, transferrin receptors
  • the element iron is of great importance, inter alia for oxygen transport, oxygen uptake, cell functions such as mitochondrial electron transport, cognitive functions, etc. and ultimately for the entire energy metabolism.
  • Iron uptake and storage is regulated by hepcidin. Hepcidin is produced in the liver and functions as the master iron regulatory hormone controlling intestinal iron uptake, and also regulates iron storage in other organs. Hepcidin limits iron-uptake by binding to the iron transport molecule ferroportin and causing its degradation.
  • Hepcidin deficiency is a frequently found pathogenic feature in patients with iron overload.
  • One method for decreasing iron levels in a patient uses hepcidin agonists, such as hepcidin mimetics. It has been shown in animal models that high doses of hepcidin mimetics can ameliorate certain polycythemias, such as polycythemia vera, by diminishing erythropoiesis.
  • hepcidin agonists can cause suppression of intestinal iron uptake and macrophage iron recycling, with potential exacerbation of suboptimal production of RBCs, as in polycythemia vera.
  • hepcidin is limited in its use as a drug because of its complex structure which requires a complicated manufacturing, and also its limited in vivo duration of action.
  • Another method of decreasing iron levels in the patient includes the use of chelating agents.
  • deferoxamine also known Desferal®
  • Desferal® which is a bacterial siderophore
  • Deferoxamine binds iron in the bloodstream as an chelator and enhances its elimination via urine and feces.
  • Two additional drugs, licensed for use in patients receiving regular blood transfusions, resulting in the development of iron overload, are deferasirox and deferiprone.
  • Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has polycythemia.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof treat polycythemia while maintaining the subject’s iron levels.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof treat polycythemia while increasing the subject’s stored iron levels.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, treat polycythemia while decreasing the incidence of iron deficiency.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis while maintaining the subject’s iron levels.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis while increasing the subject’s stored iron levels.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis while decreasing the incidence of iron deficiency.
  • Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an iron deficiency associated with polycythemia.
  • the method decreases the incidence of iron deficiency by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the incidence of iron deficiency by at least 15%. In some embodiments, the method decreases the incidence of iron deficiency by at least 20%. In some embodiments, the method decreases the incidence of iron deficiency by at least 25%. In some embodiments, the method decreases the incidence of iron deficiency by at least 30%. In some embodiments, the method decreases the incidence of iron deficiency by at least 35%.
  • the method decreases the incidence of iron deficiency by at least 40%. In some embodiments, the method decreases the incidence of iron deficiency by at least 45%. In some embodiments, the method decreases the incidence of iron deficiency by at least 50%. In some embodiments, the method decreases the incidence of iron deficiency by at least 55%. In some embodiments, the method decreases the incidence of iron deficiency by at least 60%. In some embodiments, the method decreases the incidence of iron deficiency by at least 65%. In some embodiments, the method decreases the incidence of iron deficiency by at least 70%. In some embodiments, the method decreases the incidence of iron deficiency by at least 75%.
  • the method decreases the incidence of iron deficiency by at least 80%. In some embodiments, the method decreases the incidence of iron deficiency by at least 85%. In some embodiments, the method decreases the incidence of iron deficiency by at least 90%. In some embodiments, the method decreases the incidence of iron deficiency by at least 95%. In some embodiments, the method decreases the incidence of iron deficiency by at least 100%. In some embodiments, the method further improves iron deficiency in the subject.
  • the method improves iron deficiency in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method improves iron deficiency in the subject by at least 15%. In some embodiments, the method improves iron deficiency in the subject by at least 20%. In some embodiments, the method improves iron deficiency in the subject by at least 25%. In some embodiments, the method improves iron deficiency in the subject by at least 30%. In some embodiments, the method improves iron deficiency in the subject by at least 35%.
  • the method improves iron deficiency in the subject by at least 40%. In some embodiments, the method improves iron deficiency in the subject by at least 45%. In some embodiments, the method improves iron deficiency in the subject by at least 50%. In some embodiments, the method improves iron deficiency in the subject by at least 55%. In some embodiments, the method improves iron deficiency in the subject by at least 60%. In some embodiments, the method improves iron deficiency in the subject by at least 65%. In some embodiments, the method improves iron deficiency in the subject by at least 70%. In some embodiments, the method improves iron deficiency in the subject by at least 75%.
  • the method improves iron deficiency in the subject by at least 80%. In some embodiments, the method improves iron deficiency in the subject by at least 85%. In some embodiments, the method improves iron deficiency in the subject by at least 90%. In some embodiments, the method improves iron deficiency in the subject by at least 95%. In some embodiments, the method improves iron deficiency in the subject by at least 100%.
  • Erythropoiesis refers generally to the process by which red blood cells (erythrocytes) are produced from HSCs, and includes the formation of erythroid progenitor cells. Erythropoiesis is a carefully ordered sequence of events.
  • EPO erythropoietin
  • SCF stem cell factor
  • EPO Epo messenger RNA
  • EPO protein are also found in the brain and in red blood cells (RBCs), suggesting the presence of paracrine and autocrine functions.
  • Erythropoiesis escalates as increased expression of the EPO gene produces higher levels of circulating EPO.
  • EPO gene expression is known to be affected by multiple factors, including hypoxemia, transition metals (Co2+, Ni2+, Mn2+), and iron chelators.
  • hypoxia including factors of decreased oxygen tension, red blood cell loss, and increased oxygen affinity of hemoglobin. For instance, EPO production may increase as much as 1000-fold in severe hypoxia.
  • the disclosure relates to methods of inhibiting heme synthesis in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the heme synthesis is inhibited in a dose dependent manner.
  • the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis (also known as erythropoiesis), and may be used to treat a condition associated with increased red blood cells.
  • a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, may modulate red blood cell synthesis by reducing the formation of heme.
  • the disclosure relates to methods of inhibiting red blood cell synthesis in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the red blood cell synthesis is inhibited in a dose dependent manner.
  • the disclosure relates to methods of decreasing the red blood cell count in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the red blood cell count is decreased in a dose dependent manner.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be administered directly to a subject to reduce red blood count, if desired.
  • a normal red blood cell count typically ranges from about 4.7 to about 6.1 million red blood cells per ⁇ l in men, and about 4.2 to about 5.4 million red blood cells per ⁇ l in women.
  • a high red blood cell count is generally defined as more than about 5.3 million red blood cells per ⁇ l of blood for men and about 5.1 million red blood cells per ⁇ l of blood for women. In children, the threshold for high red blood cell count varies with age and sex.
  • Red blood count may also be reflected by a person's hematocrit (i.e., packed cell volume (PCV) or erythrocyte volume fraction (EVE)), which is the proportion or percentage of blood volume that is occupied by red blood cells.
  • PCV packed cell volume
  • EVE erythrocyte volume fraction
  • a normal hematocrit is normally about 49% for men and about 48% for women.
  • a higher hematocrit value indicates a greater number of red blood cells.
  • a high red blood cell count can impair circulation and lead to abnormal clotting, among other problems.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduces hemoglobin synthesis in a subject with polycythemia, and may be used to treat a condition associated with increased red blood cells.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may modulate hemoglobin synthesis by reducing the formation of heme.
  • the disclosure relates to methods of inhibiting hemoglobin synthesis in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the hemoglobin synthesis is inhibited in a dose dependent manner.
  • Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an increased red blood cell count (e.g, greater than about 5.3 million red blood cells per ⁇ l of blood for men and about 5.1 million red blood cells per ⁇ l of blood for women, often by a clinically or statistically significant amount), or an increased hematocrit (e.g, greater than about 49% for men or about 48% for women, often by a clinically or statistically significant amount).
  • the subject has hematocrit levels that are at least 48%.
  • the subject has hematocrit levels that are at least 49%.
  • the subject’s hematocrit levels are at least 10%, 20%, 30%, 40%, or 50% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 10% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject’s hematocrit levels are at least 20% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 30% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject’s hematocrit levels are at least 40% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 50% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 10%, 20%, 30%, 40%, or 50% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 10% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 20% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 30% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has a red blood cell count that is at least 40% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 50% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count greater than 5.1 x10 12 /L. In some embodiments, the subject has a red blood cell count greater than 5.3 x10 12 /L.
  • administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject reduces their red blood cell count or hematocrit.
  • methods of reducing red blood cells in a subject and methods of reducing hematocrit in a subject, including a subject that has a higher than normal red blood cell count or hematocrit, or is at risk for developing such a condition, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and thereby reducing red blood cell count or hematocrit in the subject.
  • the method decreases the subject’s red blood cell levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the subject’s red blood cell levels by at least 15%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 20%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 25%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 30%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 35%.
  • the method decreases the subject’s red blood cell levels by at least 40%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 45%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 50%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 55%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 60%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 65%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 70%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 75%.
  • the method decreases the subject’s red blood cell levels by at least 80%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 85%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 90%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 95%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 100%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • 10% e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method decreases the subject’s hematocrit levels by at least 15%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 20%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 25%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 30%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 35%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 40%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 45%.
  • the method decreases the subject’s hematocrit levels by at least 50%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 55%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 60%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 65%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 70%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 75%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 80%.
  • the method decreases the subject’s hematocrit levels by at least 85%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 90%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 95%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 100%. In some embodiments, the method decreases the subject’s hematocrit levels to less than 48%.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • high red blood cell count may result from increases in red blood cell production, mainly to compensate for low oxygen levels, which may be caused by poor heart or lung function.
  • high red blood cell count may result from increased release of erythropoietin (EPO) from the kidneys (EPO enhances red blood cell production), production of too many red blood cells by the bone marrow, impairment of the oxygen-carrying capacity of red blood cells (leading to over-production), compensation for a limited oxygen supply in higher altitudes, and the loss of blood plasma (i.e., the liquid component of blood), which may create relatively high levels of red blood cells, volume-wise.
  • EPO erythropoietin
  • conditions that are associated with high red blood cell count include, without limitation, living at a high altitude, smoking, congenital heart disease, failure of the right side of the heart (i.e., cor pulmonale), scarring and thickening of the lung tissue (i.e., pulmonary fibrosis), bone marrow disorders (e.g., polycythemia vera), dehydration, such as from severe diarrhea or excessive sweating, kidney disease/cancer, exposure to carbon monoxide, anabolic steroid use, COPD or other lung diseases, such as pulmonary fibrosis, and EPO doping, mainly to enhance athletic performance.
  • the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, can be used to treat or reduce the risk of developing high red blood cell count or volume as it is associated with these or any other conditions known in the art.
  • a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be used to reduce erythropoiesis, and also to reduce the formation of red blood cells.
  • methods of reducing erythropoiesis or red blood cell formation may be used to treat a subject that has or is at risk for having increased red blood cell count, increased hemoglobin levels, or increased total red blood cell volume, as described herein and known in the art.
  • the present application relates to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an increased red blood cell mass (e.g., more than 25% above mean normal predicted value, often by a clinically or statistically significant amount), or increased hemoglobin levels (e.g., greater than about 16.5 g/dL for men or about 16.0 g/dL for women, often by a clinically or statistically significant amount).
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof e.g., any one of compounds 1-60
  • the subject has an increased red blood cell mass (e.g., more than 25% above mean normal predicted value, often by a clinically or statistically significant amount)
  • increased hemoglobin levels e.g., greater than about 16.5 g/dL for men or about 16.0 g/dL for women, often by
  • the subject has red blood cell mass levels that are at least 20% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 30% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 40% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has red blood cell mass levels that are at least 50% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has red blood cell mass levels that are at least 25% above mean normal predicted value.
  • the subject has hemoglobin levels that are at least 10%, 20%, 30%, 40%, 50%, or 60% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has hemoglobin levels that are at least 10% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 20% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 30% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has hemoglobin levels that are at least 40% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 50% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 60% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the subject has hemoglobin levels that are greater than 16.0 g/dL. In some embodiments, the subject has hemoglobin levels that are greater than 16.5 g/dL. In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject reduces their red blood cell mass or hemoglobin levels.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof to such a subject reduces their red blood cell mass or hemoglobin levels.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof e.g., any one of compounds 1-60
  • the method decreases the subject’s red blood cell mass by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the subject’s red blood cell mass by at least 15%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 20%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 25%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 30%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 35%.
  • the method decreases the subject’s red blood cell mass by at least 40%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 45%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 50%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 55%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 60%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 65%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 70%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 75%.
  • the method decreases the subject’s red blood cell mass by at least 80%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 85%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 90%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 95%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 100%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the method decreases the subject’s hemoglobin levels by at least 15%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 20%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 25%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 30%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 35%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 40%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 45%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 50%.
  • the method decreases the subject’s hemoglobin levels by at least 55%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 60%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 65%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 70%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 75%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 80%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 85%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 90%.
  • the method decreases the subject’s hemoglobin levels by at least 95%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 100%. In some embodiments, the method decreases the subject’s hemoglobin levels to less than 16 g/dL. In some embodiments, the method decreases the subject’s hemoglobin levels to less than 16.5 g/dL.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • the one or more complications of polycythemia is a thromboembolic event.
  • the method reduces the risk of thromboembolic events.
  • the thromboembolic event is arterial thrombosis.
  • the thromboembolic event is venous thrombosis.
  • the one or more complications of polycythemia is blurred vision.
  • the method reduces the risk of blurred vision by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the one or more complications of polycythemia is a headache.
  • the method reduces the risk of headaches by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
  • the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia.
  • the myelofibrosis is selected from the group consisting of low-risk myelofibrosis, intermediate-risk myelofibrosis, high-risk myelofibrosis, primary myelofibrosis, post-essential thrombocythemia myelofibrosis, and post-polycythemia vera myelofibrosis.
  • Combination Therapies may include combination therapies for treating polycythemias, including the administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in combination with other polycythemia-based therapeutic agents or treatment modalities.
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof in combination with other polycythemia-based therapeutic agents or treatment modalities.
  • combination therapies included, without limitation, any one or more additional active agents and/or supportive therapies selected from the group consisting of: Hydroxyruea (e.g., Droxia®, Hydrea®), Interferon alpha, Interferon alpha-2b (e.g., Intron® A), Ruxolitinib (e.g., Jakafi®), Busulfan (e.g., Busulfex®, Myleran®), radiation treatment, hepcidin mimetics (e.g., PTG-300), matriptase-2 inhibitors, ferroportin inhibitors, JAK inhibitors, BET inhibitors, MDM2 inhibitors, and HDAC inhibitors.
  • Hydroxyruea e.g., Droxia®, Hydrea®
  • Interferon alpha e.g., Intron® A
  • Ruxolitinib e.g., Jakafi®
  • Busulfan e.g., Busulfex®, Myleran®
  • hydroxyurea is a chemotherapeutic agent that can be used for decades, though some studies suggest that it may increase the risk of PV transforming into acute myeloid leukemia. Additionally, many patients do not respond well to or are intolerant of hydroxyurea (mucocutaneous ulcers are the leading toxicity), and require a different therapy.
  • the compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof are useful in treating a subject who has an inadequate response or a subject who is intolerant to hydroxyurea. In some embodiments, the subject has an inadequate response to hydroxyurea.
  • the subject is intolerant to hydroxyurea.
  • Another well-established method for treating polycythemia includes treatment using regularly scheduled phlebotomies (bloodletting).
  • the compound of formula (I) e.g., any one of compounds 1-60
  • the method reduces the patient’s need for therapeutic phlebotomies.
  • the method reduces the patient’s need for therapeutic phlebotomies by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 15%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 20%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 25%.
  • the method reduces the patient’s need for therapeutic phlebotomies by at least 30%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 35%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 40%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 45%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 50%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 55%.
  • the method reduces the patient’s need for therapeutic phlebotomies by at least 60%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 65%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 70%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 75%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 80%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 85%.
  • the method reduces the patient’s need for therapeutic phlebotomies by at least 90%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 95%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 100%. In some embodiments, the method eliminates the patient’s need for therapeutic phlebotomies.
  • the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of polycythemia (e.g., treating, preventing, or reducing the progression rate and/or severity of one or more complications of polycythemia) comprising administering to a patient in need thereof an effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases the patient’s quality of life by at least 1% (e.g., 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100%).
  • a compound of formula (I) e.g., any one of compounds 1-60
  • a pharmaceutically acceptable salt thereof e.g., any one of compounds 1-60
  • the method increases the patient’s quality of life by at least 1% (e.
  • the method relates to increasing the patient’s quality of life by at least 1%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 2%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 3%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 4%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 5%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 10%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 15%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 20%.
  • the method relates to increasing the patient’s quality of life by at least 25%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 30%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 35%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 40%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 45%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 50%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 55%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 60%.
  • the method relates to increasing the patient’s quality of life by at least 65%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 70%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 75%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 80%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 85%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 90%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 95%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 100%.
  • the patient’s quality of life is measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). In some embodiments, the patient’s quality of life is measured using the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF). In some embodiments, the patient’s quality of life is measured using the Pruritus Symptom Impact Scale (PSIS). In some embodiments, the patient’s quality of life is measured using the Patient Global Impression of Change (PGIC). In certain embodiments of the methods as disclosed herein, the compound is a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof.
  • EORTC QLQ-C30 European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30
  • the patient’s quality of life is measured using the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF).
  • the patient’s quality of life is measured using the Pruritus
  • the application relates to a pharmaceutical composition
  • a pharmaceutical composition comprising as active ingredient a therapeutically effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable excipient, carrier or diluent.
  • the pharmaceutical composition is for treating a disease or disorder in a patient in need thereof, such as a disease or disorder as disclosed herein.
  • the application relates to a pharmaceutical composition
  • a pharmaceutical composition comprising (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, (2) an additional therapeutic agent, or a pharmaceutically acceptable salt thereof, and (3) pharmaceutically acceptable excipients, carriers or diluents.
  • acylamino is art-recognized and refers to an amino group substituted with an acyl group and may be represented, for example, by the formula hydrocarbylC(O)NH-.
  • acyloxy is art-recognized and refers to a group represented by the general formula hydrocarbylC(O)O-, preferably alkylC(O)O-.
  • alkoxy refers to an alkyl group, preferably a lower alkyl group, having an oxygen attached thereto. Representative alkoxy groups include methoxy, ethoxy, propoxy, tert-butoxy and the like.
  • alkoxyalkyl refers to an alkyl group substituted with an alkoxy group and may be represented by the general formula alkyl-O-alkyl.
  • alkenyl refers to an aliphatic group containing at least one double bond and is intended to include both "unsubstituted alkenyls" and “substituted alkenyls", the latter of which refers to alkenyl moieties having substituents replacing a hydrogen on one or more carbons of the alkenyl group. Such substituents may occur on one or more carbons that are included or not included in one or more double bonds.
  • substituents include all those contemplated for alkyl groups, as discussed below, except where stability is prohibitive. For example, substitution of alkenyl groups by one or more alkyl, carbocyclyl, aryl, heterocyclyl, or heteroaryl groups is contemplated.
  • An “alkyl” group or “alkane” is a straight chained or branched non-aromatic hydrocarbon which is completely saturated. Typically, a straight chained or branched alkyl group has from 1 to about 20 carbon atoms, preferably from 1 to about 10 unless otherwise defined.
  • straight chained and branched alkyl groups include methyl, ethyl, n- propyl, iso-propyl, n-butyl, sec-butyl, tert-butyl, pentyl, hexyl, pentyl and octyl.
  • a C 1 -C 6 straight chained or branched alkyl group is also referred to as a "lower alkyl" group.
  • alkyl (or “lower alkyl) as used throughout the specification, examples, and claims is intended to include both “unsubstituted alkyls” and “substituted alkyls”, the latter of which refers to alkyl moieties having substituents replacing a hydrogen on one or more carbons of the hydrocarbon backbone.
  • Such substituents can include, for example, a halogen, a hydroxyl, a carbonyl (such as a carboxyl, an alkoxycarbonyl, a formyl, or an acyl), a thiocarbonyl (such as a thioester, a thioacetate, or a thioformate), an alkoxyl, a phosphoryl, a phosphate, a phosphonate, a phosphinate, an amino, an amido, an amidine, an imine, a cyano, a nitro, an azido, a sulfhydryl, an alkylthio, a sulfate, a sulfonate, a sulfamoyl, a sulfonamido, a sulfonyl, a heterocyclyl, an aralkyl, or an aromatic or heteroaromatic moiety.
  • a halogen
  • the moieties substituted on the hydrocarbon chain can themselves be substituted, if appropriate.
  • the substituents of a substituted alkyl may include substituted and unsubstituted forms of amino, azido, imino, amido, phosphoryl (including phosphonate and phosphinate), sulfonyl (including sulfate, sulfonamido, sulfamoyl and sulfonate), and silyl groups, as well as ethers, alkylthios, carbonyls (including ketones, aldehydes, carboxylates, and esters), -CF 3 , -CN and the like.
  • Cycloalkyls can be further substituted with alkyls, alkenyls, alkoxys, alkylthios, aminoalkyls, carbonyl- substituted alkyls, -CF 3 , -CN, and the like.
  • C x-y when used in conjunction with a chemical moiety, such as, acyl, acyloxy, alkyl, alkenyl, alkynyl, or alkoxy is meant to include groups that contain from x to y carbons in the chain.
  • C x-y alkyl refers to substituted or unsubstituted saturated hydrocarbon groups, including straight-chain alkyl and branched-chain alkyl groups that contain from x to y carbons in the chain, including haloalkyl groups such as trifluoromethyl and 2,2,2-tirfluoroethyl, etc.
  • C 0 alkyl indicates a hydrogen where the group is in a terminal position, a bond if internal.
  • C 2-y alkenyl and “C 2-y alkynyl” refer to substituted or unsubstituted unsaturated aliphatic groups analogous in length and possible substitution to the alkyls described above, but that contain at least one double or triple bond respectively.
  • alkylamino refers to an amino group substituted with at least one alkyl group.
  • alkylthio refers to a thiol group substituted with an alkyl group and may be represented by the general formula alkylS-.
  • alkynyl refers to an aliphatic group containing at least one triple bond and is intended to include both "unsubstituted alkynyls" and “substituted alkynyls”, the latter of which refers to alkynyl moieties having substituents replacing a hydrogen on one or more carbons of the alkynyl group.
  • substituents may occur on one or more carbons that are included or not included in one or more triple bonds.
  • substituents include all those contemplated for alkyl groups, as discussed above, except where stability is prohibitive. For example, substitution of alkynyl groups by one or more alkyl, carbocyclyl, aryl, heterocyclyl, or heteroaryl groups is contemplated.
  • amide refers to a group wherein each R 30 independently represent a hydrogen or hydrocarbyl group, or two R 30 are taken together with the N atom to which they are attached complete a heterocycle having from 4 to 8 atoms in the ring structure.
  • amine and “amino” are art-recognized and refer to both unsubstituted and substituted amines and salts thereof, e.g., a moiety that can be represented by wherein each R 30 independently represents a hydrogen or a hydrocarbyl group, or two R 30 are taken together with the N atom to which they are attached complete a heterocycle having from 4 to 8 atoms in the ring structure.
  • aminoalkyl refers to an alkyl group substituted with an amino group.
  • aralkyl refers to an alkyl group substituted with an aryl group.
  • aryl as used herein include substituted or unsubstituted single-ring aromatic groups in which each atom of the ring is carbon.
  • the ring is a 5- to 7- membered ring, more preferably a 6-membered ring.
  • aryl also includes polycyclic ring systems having two or more cyclic rings in which two or more carbons are common to two adjoining rings wherein at least one of the rings is aromatic, e.g., the other cyclic rings can be cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls.
  • Aryl groups include benzene, naphthalene, phenanthrene, phenol, aniline, and the like.
  • the term “carbamate” is art-recognized and refers to a group wherein R 29 and R 30 independently represent hydrogen or a hydrocarbyl group, such as an alkyl group, or R 29 and R 30 taken together with the intervening atom(s) complete a heterocycle having from 4 to 8 atoms in the ring structure.
  • the term carbocycle includes both aromatic carbocycles and non-aromatic carbocycles.
  • Non-aromatic carbocycles include both cycloalkane rings, in which all carbon atoms are saturated, and cycloalkene rings, which contain at least one double bond.
  • “Carbocycle” includes 5-7 membered monocyclic and 8-12 membered bicyclic rings. Each ring of a bicyclic carbocycle may be selected from saturated, unsaturated and aromatic rings. Carbocycle includes bicyclic molecules in which one, two or three or more atoms are shared between the two rings.
  • the term “fused carbocycle” refers to a bicyclic carbocycle in which each of the rings shares two adjacent atoms with the other ring. Each ring of a fused carbocycle may be selected from saturated, unsaturated and aromatic rings.
  • an aromatic ring e.g., phenyl
  • a saturated or unsaturated ring e.g., cyclohexane, cyclopentane, or cyclohexene.
  • Exemplary “carbocycles” include cyclopentane, cyclohexane, bicyclo[2.2.1]heptane, 1,5-cyclooctadiene, 1,2,3,4-tetrahydronaphthalene, bicyclo[4.2.0]oct-3-ene, naphthalene and adamantane.
  • Exemplary fused carbocycles include decalin, naphthalene, 1,2,3,4-tetrahydronaphthalene, bicyclo[4.2.0]octane, 4,5,6,7-tetrahydro- 1H-indene and bicyclo[4.1.0]hept-3-ene.
  • Carbocycles may be susbstituted at any one or more positions capable of bearing a hydrogen atom.
  • a “cycloalkyl” group is a cyclic hydrocarbon which is completely saturated.
  • Cycloalkyl includes monocyclic and bicyclic rings. Typically, a monocyclic cycloalkyl group has from 3 to about 10 carbon atoms, more typically 3 to 8 carbon atoms unless otherwise defined.
  • the second ring of a bicyclic cycloalkyl may be selected from saturated, unsaturated and aromatic rings.
  • Cycloalkyl includes bicyclic molecules in which one, two or three or more atoms are shared between the two rings.
  • the term “fused cycloalkyl” refers to a bicyclic cycloalkyl in which each of the rings shares two adjacent atoms with the other ring.
  • the second ring of a fused bicyclic cycloalkyl may be selected from saturated, unsaturated and aromatic rings.
  • a “cycloalkenyl” group is a cyclic hydrocarbon containing one or more double bonds.
  • Carbocyclylalkyl refers to an alkyl group substituted with a carbocycle group.
  • carbonate is art-recognized and refers to a group -OCO2-R 30 , wherein R 30 represents a hydrocarbyl group.
  • carboxy refers to a group represented by the formula -CO2H.
  • esteer refers to a group -C(O)OR 30 wherein R 30 represents a hydrocarbyl group.
  • ether refers to a hydrocarbyl group linked through an oxygen to another hydrocarbyl group.
  • an ether substituent of a hydrocarbyl group may be hydrocarbyl-O-.
  • Ethers may be either symmetrical or unsymmetrical.
  • Examples of ethers include, but are not limited to, heterocycle-O-heterocycle and aryl-O- heterocycle.
  • Ethers include “alkoxyalkyl” groups, which may be represented by the general formula alkyl-O-alkyl.
  • halo and “halogen” as used herein means halogen and includes chloro, fluoro, bromo, and iodo.
  • heteroalkyl and “heteroaralkyl”, as used herein, refers to an alkyl group substituted with a hetaryl group.
  • heteroalkyl refers to a saturated or unsaturated chain of carbon atoms and at least one heteroatom, wherein no two heteroatoms are adjacent.
  • heteroaryl and heteroaryl include substituted or unsubstituted aromatic single ring structures, preferably 5- to 7-membered rings, more preferably 5- to 6-membered rings, whose ring structures include at least one heteroatom, preferably one to four heteroatoms, more preferably one or two heteroatoms.
  • heteroaryl and “hetaryl” also include polycyclic ring systems having two or more cyclic rings in which two or more carbons are common to two adjoining rings wherein at least one of the rings is heteroaromatic, e.g., the other cyclic rings can be cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls.
  • Heteroaryl groups include, for example, pyridyl, 2- oxo-pyridinyl, pyrimidinyl, pyridazinyl, pyrazinyl, triazinyl, furanyl, pyrrolyl, thiophenyl, pyrazolyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, triazolyl, oxadiazolyl, thiadiazolyl, tetrazolyl, indolyl, isoindolyl, benzofuranyl, benzothiophenyl, indolinyl, 2- oxoindolinyl, dihydrobenzofuranyl, dihydrobenzothiophenyl, indazolyl, benzimidazolyl, benzooxazolyl, benzothiazolyl, benzoisoxazolyl, benzoisothiazolyl
  • heteroatom as used herein means an atom of any element other than carbon or hydrogen.
  • exemplary heteroatoms are nitrogen, oxygen, and sulfur.
  • heterocyclyl refers to substituted or unsubstituted non-aromatic ring structures, preferably 3- to 10-membered rings, more preferably 3- to 7-membered rings, whose ring structures include at least one heteroatom, preferably one to four heteroatoms, more preferably one or two heteroatoms.
  • heterocyclyl and “heterocyclic” also include polycyclic ring systems having two or more cyclic rings in which two or more carbons are common to two adjoining rings wherein at least one of the rings is heterocyclic, e.g., the other cyclic rings can be cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls.
  • Heterocyclyl groups include, for example, azepinyl, azocanyl, pyranyl dioxanyl, dithianyl, 1,3-dioxolanyl, tetrahydrofuryl, dihydropyrrolidinyl, decahydroisoquinolyl, imidazolidinyl, isothiazolidinyl, isoxazolidinyl, morpholinyl, octahydroindolyl, octahydroisoindolyl, 2-oxopiperazinyl, 2- oxopiperidinyl, 2-oxopyrrolidinyl, 2-oxoazepinyl, oxazolidinyl, oxiranyl, piperidinyl, piperazinyl, 4-piperidonyl, pyrrolidinyl, pyrazolidinyl, thiazolidinyl, tetrahydropyranyl, thiamorph
  • heterocyclylalkyl refers to an alkyl group substituted with a heterocycle group.
  • Hydrocarbyl groups include, but are not limited to aryl, heteroaryl, carbocycle, heterocyclyl, alkyl, alkenyl, alkynyl, and combinations thereof.
  • hydroxyalkyl refers to an alkyl group substituted with a hydroxy group.
  • lower when used in conjunction with a chemical moiety, such as, acyl, acyloxy, alkyl, alkenyl, alkynyl, or alkoxy is meant to include groups where there are ten or fewer non-hydrogen atoms in the substituent, preferably six or fewer.
  • acyl, acyloxy, alkyl, alkenyl, alkynyl, or alkoxy substituents defined herein are respectively lower acyl, lower acyloxy, lower alkyl, lower alkenyl, lower alkynyl, or lower alkoxy, whether they appear alone or in combination with other substituents, such as in the recitations hydroxyalkyl and aralkyl (in which case, for example, the atoms within the aryl group are not counted when counting the carbon atoms in the alkyl substituent).
  • polycyclyl refers to two or more rings (e.g., cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls) in which two or more atoms are common to two adjoining rings, e.g., the rings are “fused rings”.
  • Each of the rings of the polycycle can be substituted or unsubstituted.
  • each ring of the polycycle contains from 3 to 10 atoms in the ring, preferably from 5 to 7.
  • sil refers to a silicon moiety with three hydrocarbyl moieties attached thereto.
  • substituted refers to moieties having substituents replacing a hydrogen on one or more carbons of the backbone. It will be understood that “substitution” or “substituted with” includes the implicit proviso that such substitution is in accordance with permitted valence of the substituted atom and the substituent, and that the substitution results in a stable compound, e.g., which does not spontaneously undergo transformation such as by rearrangement, cyclization, elimination, etc. As used herein, the term “substituted” is contemplated to include all permissible substituents of organic compounds.
  • the permissible substituents include acyclic and cyclic, branched and unbranched, carbocyclic and heterocyclic, aromatic and non-aromatic substituents of organic compounds.
  • the permissible substituents can be one or more and the same or different for appropriate organic compounds.
  • the heteroatoms such as nitrogen may have hydrogen substituents and/or any permissible substituents of organic compounds described herein which satisfy the valences of the heteroatoms.
  • Substituents can include any substituents described herein, for example, a halogen, a hydroxyl, a carbonyl (such as a carboxyl, an alkoxycarbonyl, a formyl, or an acyl), a thiocarbonyl (such as a thioester, a thioacetate, or a thioformate), an alkoxyl, a phosphoryl, a phosphate, a phosphonate, a phosphinate, an amino, an amido, an amidine, an imine, a cyano, a nitro, an azido, a sulfhydryl, an alkylthio, a sulfate, a sulfonate, a sulfamoyl, a sulfonamido, a sulfonyl, a heterocyclyl, an aralkyl, or an aromatic or heteroaromatic mo
  • sulfonamide is art-recognized and refers to the group represented by the general formulae wherein R 29 and R 30 independently represents hydrogen or hydrocarbyl, such as alkyl, or R 29 and R 30 taken together with the intervening atom(s) complete a heterocycle having from 4 to 8 atoms in the ring structure.
  • sulfoxide is art-recognized and refers to the group -S(O)-R 30 , wherein R 30 represents a hydrocarbyl.
  • sulfonate is art-recognized and refers to the group SO 3 H, or a pharmaceutically acceptable salt thereof.
  • sulfone is art-recognized and refers to the group -S(O) 2 -R 30 , wherein R 30 represents a hydrocarbyl.
  • thioalkyl refers to an alkyl group substituted with a thiol group.
  • thioester refers to a group -C(O)SR 30 or -SC(O)R 30 wherein R 30 represents a hydrocarbyl.
  • thioether is equivalent to an ether, wherein the oxygen is replaced with asulfur. “Unsubstituted” atoms bear all of the hydrogen atoms dictated by their valency.
  • urea is art-recognized and may be represented by the general formula wherein R 29 and R 30 independently represent hydrogen or a hydrocarbyl, such as alkyl, or either occurrence of R 29 taken together with R 30 and the intervening atom(s) complete a heterocycle having from 4 to 8 atoms in the ring structure.
  • Protecting group refers to a group of atoms that, when attached to a reactive functional group in a molecule, mask, reduce or prevent the reactivity of the functional group. Typically, a protecting group may be selectively removed as desired during the course of a synthesis. Examples of protecting groups can be found in Greene and Wuts, Protective Groups in Organic Chemistry, 3 rd Ed., 1999, John Wiley & Sons, NY and Harrison et al., Compendium of Synthetic Organic Methods, Vols.1-8, 1971-1996, John Wiley & Sons, NY.
  • nitrogen protecting groups include, but are not limited to, formyl, acetyl, trifluoroacetyl, benzyl, benzyloxycarbonyl (“CBZ”), tert-butoxycarbonyl (“Boc”), trimethylsilyl (“TMS”), 2-trimethylsilyl-ethanesulfonyl (“TES”), trityl and substituted trityl groups, allyloxycarbonyl, 9-fluorenylmethyloxycarbonyl (“FMOC”), nitro- veratryloxycarbonyl (“NVOC”) and the like.
  • hydroxylprotecting groups include, but are not limited to, those where the hydroxyl group is either acylated (esterified) or alkylated such as benzyl and trityl ethers, as well as alkyl ethers, tetrahydropyranyl ethers, trialkylsilyl ethers (e.g., TMS or TIPS groups), glycol ethers, such as ethylene glycol and propylene glycol derivatives and allyl ethers.
  • acylated esterified
  • alkylated such as benzyl and trityl ethers
  • alkyl ethers such as benzyl and trityl ethers
  • alkyl ethers such as benzyl and trityl ethers
  • alkyl ethers such as benzyl and trityl ethers
  • tetrahydropyranyl ethers e.g., TMS or TIPS groups
  • prodrugs examples include doctors, hospitals, continuing care retirement communities, skilled nursing facilities, subacute care facilities, clinics, multispecialty clinics, freestanding ambulatory centers, home health agencies, and HMO's.
  • the present application includes prodrugs of the compounds formula (I), or pharmaceutically acceptable salts thereof.
  • prodrug is intended to encompass compounds which, under physiologic conditions, are converted into the therapeutically active agents of the present application (e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof).
  • a common method for making a prodrug is to include one or more selected moieties which are hydrolyzed under physiologic conditions to yield the desired molecule.
  • the prodrug is converted by an enzymatic activity of the host animal.
  • a prodrug with a nitro group on an aromatic ring could be reduced by reductase to generate the desired amino group of the corresponding active compound in vivo.
  • functional groups such as a hydroxyl, carbonate, or carboxylic acid in the parent compound are presented as an ester, which could be cleaved by esterases.
  • amine groups in the parent compounds are presented in, but not limited to, carbamate, N-alkylated or N-acylated forms (Simpl ⁇ cio et al, “Prodrugs for Amines,” Molecules, (2008), 13:519-547).
  • some or all of the compounds of formula (I), or pharmaceutically acceptable salts thereof, in a formulation represented above can be replaced with the corresponding suitable prodrug.
  • the present application includes metabolites of the compounds of formula (I), or pharmaceutically acceptable salts thereof.
  • the term “metabolite” is intended to encompass compounds that are produced by metabolism/biochemical modification of the parent compound under physiological conditions, e.g. through certain enzymatic pathway.
  • an oxidative metabolite is formed by oxidation of the parent compound during metabolism, such as the oxidation of a pyridine ring to pyridine-N-oxide.
  • an oxidative metabolite is formed by demethylation of a methoxy group to result in a hydroxyl group.
  • compositions and methods of the present application may be utilized to treat an individual in need thereof.
  • the individual is a mammal such as a human, or a non-human mammal.
  • the composition or the compound When administered to an animal, such as a human, the composition or the compound is preferably administered as a pharmaceutical composition comprising, for example, a compound of the application and a pharmaceutically acceptable carrier.
  • Pharmaceutically acceptable carriers are well known in the art and include, for example, aqueous solutions such as water or physiologically buffered saline or other solvents or vehicles such as glycols, glycerol, oils such as olive oil, or injectable organic esters.
  • the aqueous solution is pyrogen-free, or substantially pyrogen-free.
  • the excipients can be chosen, for example, to effect delayed release of an agent or to selectively target one or more cells, tissues or organs.
  • the pharmaceutical composition can be in dosage unit form such as tablet, capsule (including sprinkle capsule and gelatin capsule), granule, lyophile for reconstitution, powder, solution, syrup, suppository, injection or the like.
  • the composition can also be present in a transdermal delivery system, e.g., a skin patch.
  • composition can also be present in a solution suitable for topical administration, such as an eye drop.
  • a pharmaceutically acceptable carrier can contain physiologically acceptable agents that act, for example, to stabilize, increase solubility or to increase the absorption of a compound such as a compound of the application.
  • physiologically acceptable agents include, for example, carbohydrates, such as glucose, sucrose or dextrans, antioxidants, such as ascorbic acid or glutathione, chelating agents, low molecular weight proteins or other stabilizers or excipients.
  • the choice of a pharmaceutically acceptable carrier, including a physiologically acceptable agent depends, for example, on the route of administration of the composition.
  • the preparation or pharmaceutical composition can be a self-emulsifying drug delivery system or a self-microemulsifying drug delivery system.
  • the pharmaceutical composition also can be a liposome or other polymer matrix, which can have incorporated therein, for example, a compound of the application.
  • Liposomes for example, which comprise phospholipids or other lipids, are nontoxic, physiologically acceptable and metabolizable carriers that are relatively simple to make and administer.
  • pharmaceutically acceptable is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.
  • pharmaceutically acceptable carrier means a pharmaceutically acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, solvent or encapsulating material. Each carrier must be “acceptable” in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient.
  • materials which can serve as pharmaceutically acceptable carriers include: (1) sugars, such as lactose, glucose and sucrose; (2) starches, such as corn starch and potato starch; (3) cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4) powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients, such as cocoa butter and suppository waxes; (9) oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil; (10) glycols, such as propylene glycol; (11) polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters, such as ethyl oleate and ethyl laurate; (13) agar; (14) buffering agents, such as magnesium hydroxide and aluminum hydroxide;
  • a pharmaceutical composition can be administered to a subject by any of a number of routes of administration including, for example, orally (for example, drenches as in aqueous or non-aqueous solutions or suspensions, tablets, capsules (including sprinkle capsules and gelatin capsules), boluses, powders, granules, pastes for application to the tongue); absorption through the oral mucosa (e.g., sublingually); anally, rectally or vaginally (for example, as a pessary, cream or foam); parenterally (including intramuscularly, intravenously, subcutaneously or intrathecally as, for example, a sterile solution or suspension); nasally; intraperitoneally; subcutaneously; transdermally (for example as a patch applied to the skin); and topically (for example, as a cream, ointment or spray applied to the skin, or as an eye drop).
  • routes of administration including, for example, orally (for example, drenches as in aqueous or
  • the compound may also be formulated for inhalation.
  • a compound may be simply dissolved or suspended in sterile water. Details of appropriate routes of administration and compositions suitable for same can be found in, for example, U.S. Pat. Nos.6,110,973, 5,763,493, 5,731,000, 5,541,231, 5,427,798, 5,358,970 and 4,172,896, as well as in patents cited therein.
  • the formulations may conveniently be presented in unit dosage form and may be prepared by any methods well known in the art of pharmacy.
  • the amount of active ingredient which can be combined with a carrier material to produce a single dosage form will vary depending upon the host being treated, the particular mode of administration.
  • the amount of active ingredient that can be combined with a carrier material to produce a single dosage form will generally be that amount of the compound which produces a therapeutic effect. Generally, out of one hundred percent, this amount will range from about 1 percent to about ninety-nine percent of active ingredient, preferably from about 5 percent to about 70 percent, most preferably from about 10 percent to about 30 percent.
  • Methods of preparing these formulations or compositions include the step of bringing into association an active compound, such as a compound of the application, with the carrier and, optionally, one or more accessory ingredients. In general, the formulations are prepared by uniformly and intimately bringing into association a compound of the present application with liquid carriers, or finely divided solid carriers, or both, and then, if necessary, shaping the product.
  • Formulations of the application suitable for oral administration may be in the form of capsules (including sprinkle capsules and gelatin capsules), cachets, pills, tablets, lozenges (using a flavored basis, usually sucrose and acacia or tragacanth), lyophile, powders, granules, or as a solution or a suspension in an aqueous or non-aqueous liquid, or as an oil-in- water or water-in-oil liquid emulsion, or as an elixir or syrup, or as pastilles (using an inert base, such as gelatin and glycerin, or sucrose and acacia) and/or as mouthwashes and the like, each containing a predetermined amount of a compound of the present application as an active ingredient.
  • capsules including sprinkle capsules and gelatin capsules
  • cachets pills, tablets, lozenges (using a flavored basis, usually sucrose and acacia or tragacanth)
  • lyophile powders,
  • compositions or compounds may also be administered as a bolus, electuary or paste.
  • solid dosage forms for oral administration capsules (including sprinkle capsules and gelatin capsules), tablets, pills, dragees, powders, granules and the like)
  • the active ingredient is mixed with one or more pharmaceutically acceptable carriers, such as sodium citrate or dicalcium phosphate, and/or any of the following: (1) fillers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; (2) binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; (3) humectants, such as glycerol; (4) disintegrating agents, such as agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; (5) solution retarding agents, such as paraffin; (6)
  • the pharmaceutical compositions may also comprise buffering agents.
  • Solid compositions of a similar type may also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugars, as well as high molecular weight polyethylene glycols and the like.
  • a tablet may be made by compression or molding, optionally with one or more accessory ingredients. Compressed tablets may be prepared using binder (for example, gelatin or hydroxypropylmethyl cellulose), lubricant, inert diluent, preservative, disintegrant (for example, sodium starch glycolate or cross-linked sodium carboxymethyl cellulose), surface-active or dispersing agent.
  • Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.
  • the tablets, and other solid dosage forms of the pharmaceutical compositions such as dragees, capsules (including sprinkle capsules and gelatin capsules), pills and granules, may optionally be scored or prepared with coatings and shells, such as enteric coatings and other coatings well known in the pharmaceutical-formulating art. They may also be formulated so as to provide slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethyl cellulose in varying proportions to provide the desired release profile, other polymer matrices, liposomes and/or microspheres.
  • compositions may be sterilized by, for example, filtration through a bacteria-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions that can be dissolved in sterile water, or some other sterile injectable medium immediately before use.
  • These compositions may also optionally contain opacifying agents and may be of a composition that releases the active ingredient(s) only, or preferentially, in a certain portion of the gastrointestinal tract, optionally, in a delayed manner.
  • embedding compositions that can be used include polymeric substances and waxes.
  • the active ingredient can also be in micro- encapsulated form, if appropriate, with one or more of the above-described excipients.
  • Liquid dosage forms useful for oral administration include pharmaceutically acceptable emulsions, lyophiles for reconstitution, microemulsions, solutions, suspensions, syrups and elixirs.
  • the liquid dosage forms may contain inert diluents commonly used in the art, such as, for example, water or other solvents, cyclodextrins and derivatives thereof, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.
  • inert diluents commonly used in the art, such
  • the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, coloring, perfuming and preservative agents.
  • Suspensions in addition to the active compounds, may contain suspending agents as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.
  • Formulations of the pharmaceutical compositions for rectal, vaginal, or urethral administration may be presented as a suppository, which may be prepared by mixing one or more active compounds with one or more suitable nonirritating excipients or carriers comprising, for example, cocoa butter, polyethylene glycol, a suppository wax or a salicylate, and which is solid at room temperature, but liquid at body temperature and, therefore, will melt in the rectum or vaginal cavity and release the active compound.
  • Formulations of the pharmaceutical compositions for administration to the mouth may be presented as a mouthwash, or an oral spray, or an oral ointment.
  • compositions can be formulated for delivery via a catheter, stent, wire, or other intraluminal device.
  • Formulations which are suitable for vaginal administration also include pessaries, tampons, creams, gels, pastes, foams or spray formulations containing such carriers as are known in the art to be appropriate.
  • Dosage forms for the topical or transdermal administration include powders, sprays, ointments, pastes, creams, lotions, gels, solutions, patches and inhalants.
  • the active compound may be mixed under sterile conditions with a pharmaceutically acceptable carrier, and with any preservatives, buffers, or propellants that may be required.
  • the ointments, pastes, creams and gels may contain, in addition to an active compound, excipients, such as animal and vegetable fats, oils, waxes, paraffins, starch, tragacanth, cellulose derivatives, polyethylene glycols, silicones, bentonites, silicic acid, talc and zinc oxide, or mixtures thereof.
  • Powders and sprays can contain, in addition to an active compound, excipients such as lactose, talc, silicic acid, aluminum hydroxide, calcium silicates and polyamide powder, or mixtures of these substances.
  • Sprays can additionally contain customary propellants, such as chlorofluorohydrocarbons and volatile unsubstituted hydrocarbons, such as butane and propane.
  • Transdermal patches have the added advantage of providing controlled delivery of a compound of the present application to the body.
  • dosage forms can be made by dissolving or dispersing the active compound in the proper medium.
  • Absorption enhancers can also be used to increase the flux of the compound across the skin. The rate of such flux can be controlled by either providing a rate controlling membrane or dispersing the compound in a polymer matrix or gel.
  • Ophthalmic formulations, eye ointments, powders, solutions and the like are also contemplated as being within the scope of this application. Exemplary ophthalmic formulations are described in U.S. Publication Nos.2005/0080056, 2005/0059744, 2005/0031697 and 2005/004074 and U.S.
  • liquid ophthalmic formulations have properties similar to that of lacrimal fluids, aqueous humor or vitreous humor or are compatible with such fluids.
  • a preferred route of administration is local administration (e.g., topical administration, such as eye drops, or administration via an implant).
  • parenteral administration and “administered parenterally” as used herein means modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal and intrasternal injection and infusion.
  • compositions suitable for parenteral administration comprise one or more active compounds in combination with one or more pharmaceutically acceptable sterile isotonic aqueous or nonaqueous solutions, dispersions, suspensions or emulsions, or sterile powders which may be reconstituted into sterile injectable solutions or dispersions just prior to use, which may contain antioxidants, buffers, bacteriostats, solutes which render the formulation isotonic with the blood of the intended recipient or suspending or thickening agents.
  • aqueous and nonaqueous carriers examples include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, vegetable oils, such as olive oil, and injectable organic esters, such as ethyl oleate.
  • polyols such as glycerol, propylene glycol, polyethylene glycol, and the like
  • vegetable oils such as olive oil
  • injectable organic esters such as ethyl oleate.
  • Proper fluidity can be maintained, for example, by the use of coating materials, such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants.
  • These compositions may also contain adjuvants such as preservatives, wetting agents, emulsifying agents and dispersing agents.
  • microorganisms Prevention of the action of microorganisms may be ensured by the inclusion of various antibacterial and antifungal agents, for example, paraben, chlorobutanol, phenol sorbic acid, and the like. It may also be desirable to include isotonic agents, such as sugars, sodium chloride, and the like into the compositions.
  • isotonic agents such as sugars, sodium chloride, and the like into the compositions.
  • prolonged absorption of the injectable pharmaceutical form may be brought about by the inclusion of agents that delay absorption such as aluminum monostearate and gelatin.
  • the rate of absorption of the drug then depends upon its rate of dissolution, which, in turn, may depend upon crystal size and crystalline form.
  • delayed absorption of a parenterally administered drug form is accomplished by dissolving or suspending the drug in an oil vehicle.
  • injectable depot forms are made by forming microencapsulated matrices of the subject compounds in biodegradable polymers such as polylactide-polyglycolide. Depending on the ratio of drug to polymer, and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly(anhydrides).
  • Depot injectable formulations are also prepared by entrapping the drug in liposomes or microemulsions that are compatible with body tissue.
  • active compounds can be given per se or as a pharmaceutical composition containing, for example, 0.1 to 99.5% (more preferably, 0.5 to 90%) of active ingredient in combination with a pharmaceutically acceptable carrier.
  • Methods of introduction may also be provided by rechargeable or biodegradable devices.
  • Various slow release polymeric devices have been developed and tested in vivo in recent years for the controlled delivery of drugs, including proteinaceous biopharmaceuticals.
  • biocompatible polymers including hydrogels
  • biodegradable and non-degradable polymers can be used to form an implant for the sustained release of a compound at a particular target site.
  • Actual dosage levels of the active ingredients in the pharmaceutical compositions may be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient.
  • the selected dosage level will depend upon a variety of factors including the activity of the particular compound or combination of compounds employed, or the ester, salt or amide thereof, the route of administration, the time of administration, the rate of excretion of the particular compounds) being employed, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular compound(s) employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well known in the medical arts.
  • a physician having ordinary skill in the art can readily determine and prescribe the therapeutically effective amount of the pharmaceutical composition required.
  • the physician could start doses of the pharmaceutical composition or compound at levels lower than that required in order to achieve the desired therapeutic effect and gradually increase the dosage until the desired effect is achieved.
  • therapeutically effective amount is meant the concentration of a compound that is sufficient to elicit the desired therapeutic effect. It is generally understood that the effective amount of the compound will vary according to the weight, sex, age, and medical history of the subject. Other factors which influence the effective amount may include, but are not limited to, the severity of the patient's condition, the disorder being treated, the stability of the compound, and, if desired, another type of therapeutic agent being administered with the compound of the application.
  • a larger total dose can be delivered by multiple administrations of the agent.
  • Methods to determine efficacy and dosage are known to those skilled in the art (Isselbacher et al. (1996) Harrison’s Principles of Internal Medicine 13 ed., 1814-1882, herein incorporated by reference).
  • a suitable daily dose of an active compound used in the compositions and methods of the application will be that amount of the compound that is the lowest dose effective to produce a therapeutic effect. Such an effective dose will generally depend upon the factors described above.
  • the effective daily dose of the active compound may be administered as one, two, three, four, five, six or more sub-doses administered separately at appropriate intervals throughout the day, optionally, in unit dosage forms.
  • the active compound may be administered two or three times daily. In preferred embodiments, the active compound will be administered once daily.
  • the patient receiving this treatment is any animal in need, including primates, in particular humans.
  • compositions and methods of the present application includes the use of pharmaceutically acceptable salts of compounds of the application in the compositions and methods of the present application.
  • pharmaceutically acceptable salts includes salts of the active compounds which are prepared with relatively nontoxic acids or bases, depending on the particular substituents found on the compounds described herein.
  • base addition salts can be obtained by contacting the neutral form of such compounds with a sufficient amount of the desired base, either neat or in a suitable inert solvent.
  • pharmaceutically acceptable base addition salts include sodium, potassium, calcium, ammonium, organic amino, or magnesium salt, or a similar salt.
  • acid addition salts can be obtained by contacting the neutral form of such compounds with a sufficient amount of the desired acid, either neat or in a suitable inert solvent.
  • pharmaceutically acceptable acid addition salts include those derived from inorganic acids like hydrochloric, hydrobromic, nitric, carbonic, monohydrogencarbonic, phosphoric, monohydrogenphosphoric, dihydrogenphosphoric, sulfuric, monohydrogensulfuric, hydriodic, or phosphorous acids and the like, as well as the salts derived from relatively nontoxic organic acids like acetic, trifluoroacetic, propionic, isobutyric, maleic, malonic, benzoic, succinic, suberic, fumaric, lactic, mandelic, phthalic, benzensulfonic, p-tolylsulfonic, citric, tartaric, methanesulfonic, camphorsulfonic and the like.
  • the pharmaceutically acceptable salt is a hydrochloride salt. In certain embodiments, the pharmaceutically acceptable salt is a camsylate salt. In certain embodiments, contemplated salts of the compounds include, but are not limited to, alkyl, dialkyl, trialkyl or tetra-alkyl ammonium salts.
  • contemplated salts of compounds include, but are not limited to, L-arginine, benenthamine, benzathine, betaine, calcium hydroxide, choline, deanol, diethanolamine, diethylamine, 2-(diethylamino)ethanol, ethanolamine, ethylenediamine, N-methylglucamine, hydrabamine, 1H-imidazole, lithium, L- lysine, magnesium, 4-(2-hydroxyethyl)morpholine, piperazine, potassium, 1-(2- hydroxyethyl)pyrrolidine, sodium, triethanolamine, tromethamine, and zinc salts.
  • contemplated salts of compounds include, but are not limited to, Li, Na, Ca, K, Mg, Zn or other metal salts. Also included are the salts of amino acids such as arginate and the like, and salts of organic acids like glucuronic or galactunoric acids and the like (see, for example, Berge et al., “Pharmaceutical Salts”, Journal of Pharmaceutical Science, 1977, 66, 1-19). Certain specific compounds of the present application may contain both basic and acidic functionalities that allow the compounds to be converted into either base or acid addition salts. The neutral forms of the compounds are preferably regenerated by contacting the salt with a base or acid and isolating the parent compound in the conventional manner.
  • the parent form of the compound differs from the various salt forms in certain physical properties, such as solubility in polar solvents, but otherwise the salts are equivalent to the parent form of the compound for the purposes of the present application.
  • the compounds of the application can also exist as various solvates, such as with water (also known as hydrates), methanol, ethanol, dimethylformamide, diethyl ether, acetamide, and the like. Mixtures of such solvates can also be prepared.
  • the source of such solvate can be from the solvent of crystallization, inherent in the solvent of preparation or crystallization, or adventitious to such solvent.
  • the compounds of the application can also exist as various polymorphs, pseudo-polymorphs, or in amorphous state.
  • polymorph refers to different crystalline forms of the same compound and other solid state molecular forms including pseudo-polymorphs, such as hydrates, solvates, or salts of the same compound.
  • pseudo-polymorphs such as hydrates, solvates, or salts of the same compound.
  • Different crystalline polymorphs have different crystal structures due to a different packing of molecules in the lattice, as a result of changes in temperature, pressure, or variations in the crystallization process. Polymorphs differ from each other in their physical properties, such as x-ray diffraction characteristics, stability, melting points, solubility, or rates of dissolution in certain solvents.
  • crystalline polymorphic forms are important aspects in the development of suitable dosage forms in pharmaceutical industry.
  • Wetting agents, emulsifiers and lubricants, such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, release agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the compositions.
  • antioxidants examples include: (1) water-soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal-chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like.
  • water-soluble antioxidants such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like
  • oil-soluble antioxidants such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), le
  • the application comprises a method for conducting a pharmaceutical business, by determining an appropriate formulation and dosage of a compound of the application for treating or preventing any of the diseases or conditions as described herein, conducting therapeutic profiling of identified formulations for efficacy and toxicity in animals, and providing a distribution network for selling an identified preparation as having an acceptable therapeutic profile.
  • the method further includes providing a sales group for marketing the preparation to healthcare providers.
  • the application relates to a method for conducting a pharmaceutical business by determining an appropriate formulation and dosage of a compound of the application for treating or preventing any of the disease or conditions as described herein, and licensing, to a third party, the rights for further development and sale of the formulation.
  • Example 1 Synthetic Protocols As depicted in the Examples below, in certain exemplary embodiments, compounds are prepared according to the following general procedures. It will be appreciated that, although the general methods depict the synthesis of certain compounds of the present application, the following general methods, and other methods known to one of ordinary skill in the art, can be applied to all compounds and subclasses and species of each of these compounds, as described herein.
  • General Modes of Preparation The general synthetic methods used in each General Procedure follow and include an illustration of a compound that was synthesized using the designated General Procedure. None of the specific conditions and reagents noted herein are to be construed as limiting the scope of the application and are provided for illustrative purposes only.
  • Purification includes purification by chromatographic techniques using reverse or normal phase HPLC using acetonitrile water, in case of reverse phase or a mixture of polar and nonpolar organic solvents in the case of normal phase chromatography.
  • the following abbreviations refer respectively to the definitions below:
  • the expressions, “ambient temperature,” “room temperature,” “RT,” and “r.t.” as used herein, are understood in the art, and generally refer to a temperature, e.g., a reaction temperature, that is about the temperature of the room in which the reaction is carried out, for example, a temperature from about 20 oC to about 30 oC.
  • MTBE methyl tert-butyl ether
  • reaction mixture was diluted with water (100 mL) and concentrated under reduced pressure to remove THF, then extracted with ethyl acetate (200 mL * 3), the organic layers were combined and washed with brine (200 mL), dried over Na 2 SO 4 , filtered, and concentrated under reduced pressure to give a residue.
  • the residue was triturated with MTBE (200 mL) for 30 mins to give compound c (17.0 g, 68.4 mmol, 49.6% yield, 87.8% purity) as a pale yellow solid.
  • Step 3 To a solution of compound c (41.0 g, 188 mmol) in THF (300 mL) was added compound ca (23.8 g, 209 mmol) and the solution of KOtBu (44.7 g, 398 mmol) in THF (300 mL) then was added dropwise over 0.5 hours.
  • Step 4 To a solution of compound d (24.0 g, 76.9 mmol) in DMF (240 mL) was added DIEA (24.8 g, 192 mmol, 33.5 mL) and compound A1 (15.8 g, 84.5 mmol), then the reaction was stirred for 10 mins. Then HATU (35.1 g, 92.2 mmol) was added portion-wise to the mixture. The mixture was stirred at 20 °C for 1 hour. LCMS showed that the reaction was complete.
  • reaction mixture was diluted with water (200 mL) and extracted with MTBE (250 mL *3), the organic layers were combined, washed with brine (250 mL), dried over MgSO 4 , filtered, and concentrated under reduced pressure to give a residue.
  • the residue was purified by flash silica gel chromatography (ISCO®; 440 g SepaFlash® Silica Flash Column, Eluent of 0 ⁇ 2% MeOH/DCM gradient @ 100 mL/min) to give compound A6 (31.0 g, 61.2 mmol, 79.6% yield, 94.8% purity) as a pale yellow solid.
  • Step 5 To a solution of compound A6 (16.0 g, 33.3 mmol) in dioxane (60 mL) was added HCl / dioxane (4 M, 100 mL). The mixture was stirred at 20 °C for 2 hours. LCMS showed that the reaction was complete. The reaction mixture was concentrated in vacuum to give compound A7’ (13.8 g, 31.3 mmol, 94.0% yield, 94.5% purity, HCl) as a pale yellow solid, which was used in the next step without further purification.
  • reaction mixture was stirred for overnight at room temperature under nitrogen atmosphere.
  • the reaction was quenched with water (300 mL) and extracted with ethyl acetate (3 x 500 mL).
  • the combined organic layers were washed with brine (3 x 500 mL), dried over anhydrous sodium sulfate, filtered and concentrated under reduced pressure.
  • the residue was chromatographed on a silica gel column with ethyl acetate/petroleum ether (1/99) to provide g, (4-bromo-3-fluorophenyl)(2,2- diethoxyethyl)sulfane (80g crude) as a colorless oil.
  • Example 2 Procedure for Assaying Compounds Test compounds were evaluated for their potential to inhibit PPIX accumulation in the K562-clone 10-9 EPP cells using flow cytometry.
  • the K562-EPP-clone 10-9 cells carry one FECH knockout allele in addition to a hypomorphic IVS 3-48C mutation on the FECH gene at both alleles. Briefly, the cells were maintained in culture incubator at 37 oC with 5% CO 2 and were sub-cultured routinely.
  • the cells growing in an exponential growth phase were counted and plated at 10000 cells per well in 96W plates (Costar® 96-wells Clear TC-treated Multiple Well Plates). Compounds were added to the cells in triplicates 1 day after seeding. PPIX levels were measured via flow cytometry before seeding and 4 day after compound treatment using Fortessa flow cytometry machine at wavelength Ex: 405/Em:603nm. Stock solution of compounds were initially prepared in DMSO and appropriate dilutions were made for screening and IC 50 determination (final DMSO conc in the assay was 0.1%).
  • IC 50 values were determined for the interested compounds with serial dilution from 3 ⁇ M to 0.46 nM. To determine IC 50 values, dose response curves were generated by plotting percentage inhibition as a function of inhibitor concentration and the data was fitted to sigmoidal non-linear regression equation (variable slope) using Graph Pad prism software V7. IC 50 values for certain compounds of the present application are provided in Table 2 below.
  • Example 3 A GlyT1 Inhibitor Reduces Phototoxicity in a Mouse Model of EPP
  • the recessive Fech m1Pas allele is an ethylnitrosourea (ENU)-induced missense mutation that retains approximately 5% residual ferrochelatase activity.
  • Fech m1Pas /Fech m1Pas homozygous mice develop protoporphyria characterized by elevated PPIX levels in red blood cells (RBCs) and liver, liver fibrosis, and cutaneous phototoxicity, which manifests as skin lesions when these mice are exposed to light with excitation wavelength of PPIX (395 to 410 nM).
  • GlyT1 Glycine transporter 1
  • Fech m1Pas /Fech m1Pas homozygous mice were administrated vehicle or compound 11 at 15mg/kg, p.o., twice per day, from day 0 to day 18. After removing the hairs on the back, all mice were exposed to light with wavelength of 395 nM, 588 ⁇ 10% lumens (lm)/m 2 for 30 minutes on day 14 under anesthesia. Images were taken on day 14 before light exposure and daily on days 15-18. Also, blood samples were collected on day 14 and day 18 to measure the PPIX levels by flow cytometry. Experiment procedures are illustrated in Figure 1.
  • mice The PPIX levels in RBCs, represented as the mean fluorescence intensity (MFI), reduced by 43% and 37%, on Day 14 and Day 18, respectively, in mice administrated compound 11 (“GlyT1 inhibitor”), compared with mice administrated vehicle ( Figure 2). Moreover, mice administered vehicle developed severe skin lesion over time, with the most severe lesions observed at 4 days after light exposure. Administration of compound 11 (“GlyT1 inhibitor”) significantly reduced skin lesion development ( Figure 3). To quantify the severity of phototoxicity, the area with skin lesion and the total exposed area were measured using Image J software, and the percentage of area with skin lesion within the total exposed area were calculated. Mice administrated vehicle developed skin lesion in an average of 51.2% of total exposed area ( Figure 4).
  • MFI mean fluorescence intensity
  • mice administrated compound 11 (“GlyT1 inhibitor”) developed skin lesion in only 9.2% of exposed area ( Figure 4), which was significantly lower than that in the vehicle administrated mice (p-value ⁇ 0.01).
  • the percentage of area with skin lesion correlates with the PPIX levels in RBCs ( Figure 5).
  • mice with lower PPIX levels in the RBCs were associated with reduction in severity of skin lesion development.
  • GlyT1 inhibitors have been developed for treatment of various disorders and conditions, including neurological disorders such as schizophrenia [see, e.g., Rosenbrock et al. Eur Arch Psychiatry Clin Neurosci.2023 Oct;273(7):1557-1566; Bugarski-Kirola et al. Lancet Psychiatry. 2016 Dec;3(12):1115-1128]. Therefore, some compounds within the GlyT1 inhibitor class have been characterized for their ability to penetrate the blood brain barrier and effects on the central nervous system (CNS).
  • CNS central nervous system
  • P-gp which was initially recognized for its ability to expel anticancer drugs from multidrug-resistant cancer cells, is strongly expressed in brain capillaries. Its expression in the blood-brain barrier limits the accumulation of many hydrophobic molecules and potentially toxic substances in the brain.
  • the transport buffer with or without inhibitor was also added to appropriate receiver wells.
  • the apical and basolateral sides were extracted with acetonitrile containing internal standards (100 nM alprazolam, 200 nM caffeine, and 100 nM tolbutamide) and analyzed to determine the P app and efflux ratio of the test compound or controls.
  • Lucifer yellow was used as a marker to confirm the integrity of the cell line after 2 hours incubation. UPLC-MS/MS was used for sample analysis, and peak areas were determined from extracted ion chromatograms. Results are presented in Table 3.
  • the Lucifer Yellow (LY) leakage of Caco-2 monolayers is calculated using the following equation: Where Iacceptor is the fluorescence intensity in the acceptor well (0.3 mL), and Idonor is the fluorescence intensity in the donor well (0.1 mL) and expressed as % leakage. Any monolayer that produces a Lucifer yellow leakage >1%, indicating poor monolayer formation, was excluded from the evaluation.
  • the efflux ratio was determined using the following equation: Where P app (A-B) indicates the apparent permeability coefficient in basolateral to apical direction, and P app (A-B) indicates the apparent permeability coefficient in apical to basolateral direction.
  • the recovery rate was determined using the following equation: Where V A is the volume (in mL) in the acceptor well (0.3 mL for Ap ⁇ B1 flux, and 0.1 mL for B1 ⁇ Ap), V D is the volume (in mL) in the donor well (0.1 mL for Ap ⁇ B1 flux, and 0.3 mL for B1 ⁇ Ap).
  • the Percentage Efflux Reduction was determined using the following equation: The efflux ratios, percentage recovery, and permeability results (with and without the P-gp inhibitor PSC833 or Zosuquidar) for test compounds and control compounds in Caco-2 cell monolayers are presented in Table3.
  • a compound is considered as a potential substrate of P-gp when the efflux ratio without inhibitor is greater than 2, and more than 50% reduction of the efflux ratio is observed in the presence of the corresponding inhibitor.
  • Functionality of the P-gp mediated efflux transport and permeability in the test system was confirmed using the positive control compound digoxin and negative control compound metoprolol.
  • the efflux ratios for digoxin incubated without and with the P-gp inhibitor PSC833 in Caco-2 monolayers were 64.3 and 0.941, respectively, with corresponding percentage reduction of 98.5%.
  • the efflux ratios for metoprolol incubated without and with the P-gp inhibitor PSC833 in Caco-2 monolayers were 0.954 and 0.926, respectively, with corresponding percentage reduction of 2.94%.
  • the efflux ratios of digoxin and metoprolol were within the historical range.
  • the efflux ratios for Compound 8 at 10 ⁇ M incubated without and with the P-gp inhibitor PSC833 in Caco-2 cell line were 0.778 and 0.476, respectively, with corresponding percentage reduction of 38.8%. See Table 3. Under the conditions of this study, Compound 8 had an efflux ratio ⁇ 2 in the absence of P-gp inhibitor, which was reduced by ⁇ 50% in the presence of PSC833.
  • Compound 8 may not be a substrate of human P-gp transporter.
  • Compound 8 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to have CNS penetration ability and therefore possible CNS pharmacodynamic/pharmacokinetic effects.
  • the efflux ratios for Compound 10 at 10 ⁇ M incubated without and with the P-gp inhibitor PSC833 in Caco-2 cell line were 2.95 and 1.18, respectively, with corresponding percentage reduction of 60.0%. See Table 3. Under the conditions of this study, Compound 10 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of PSC833.
  • Compound 10 is potentially a substrate of human P-gp transporter.
  • Compound 10 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP.
  • the efflux ratios for Compound 11 at 10 ⁇ M incubated without and with the P-gp inhibitor PSC833 in Caco-2 cell line were 20.8 and 0.972, respectively, with corresponding percentage reduction of 95.3%. See Table 3.
  • Compound 11 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of PSC833. Therefore, the results indicate that Compound 11 is potentially a substrate of human P-gp transporter. As such, Compound 11 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP.
  • porphyrias such as EPP, XLP, and/or CEP.
  • Compound 49 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP.
  • the efflux ratios for Compound 50 at 10 ⁇ M incubated without and with the P-gp inhibitor Zosuquidar in Caco-2 cell line were 29.4 and 0.955, respectively, with corresponding percentage reduction of 96.8%. See Table 3. Under the conditions of this study, Compound 50 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of Zosuquidar.
  • Compound 50 is potentially a substrate of human P-gp transporter.
  • Compound 50 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP.
  • the efflux ratios for Compound 52 at 10 ⁇ M incubated without and with the P-gp inhibitor Zosuquidar in Caco-2 cell line were 38.8 and 1.27, respectively, with corresponding percentage reduction of 96.7%. See Table 3.
  • Compound 52 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of Zosuquidar. Therefore, the results indicate that Compound 52 is potentially a substrate of human P-gp transporter. As such, Compound 52 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP.
  • porphyrias such as EPP, XLP, and/or CEP.

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Abstract

The present application relates to compounds of formula (I) and their pharmaceutical compositions/preparations. This application further relates to methods of treating or preventing hematological disorders.

Description

GLYT-1 INHIBITORS AND USES THEREOF Related Applications This application claims the benefit of priority to U.S. Provisional Patent Application No.63/538,539, filed September 15, 2023, and U.S. Provisional Patent Application No. 63/658,642, filed June 11, 2024, which applications are hereby incorporated by reference in their entirety. Background There are two main types of glycine transporters (GlyTs): glycine transporter-1 (GlyT-1) and glycine transporter-2 (GlyT-2). GlyT-1 shows a widespread distribution in the brain, erythrocytes, and peripheral tissues. In contrast, GlyT-2 is found primarily in the spinal cord and brainstem and is involved in the regulation of glycine. Glycine transporter-1 is the primary source of glycine for heme biosynthesis in developing red blood cells. Consequently, inhibition of glycine transporter-1 could potentially reduce heme synthesis leading to new treatments for conditions in which excess heme, the accumulation of toxic intermediates of heme biosynthesis, or pathological increases in erythropoiesis lead to disease. For example, inhibition of red cell glycine uptake could reduce the accumulation of protoporphyrin IX (PPIX), an intermediate in heme biosynthesis that accumulates and causes disease in erythropoietic protoporphyria and X-linked protoporphyria. The present application provides novel compounds that inhibit glycine transporter 1 and are amenable to treating various hematological conditions, particularly conditions in which excess heme, the accumulation of toxic intermediates of heme biosynthesis, or pathological increases in erythropoiesis lead to disease. Summary of Application The present application provides a compound of formula (I)
Figure imgf000003_0001
or a pharmaceutically acceptable salt thereof, wherein: A is an aryl or heteroaryl ring system wherein the aryl or heteroaryl ring system is optionally substitued one or more times with R1; B is a 4- to 8-membered non-aromatic carbocycle or a 4- to 8-membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R2; R1 is independently for each occurrence selected from the group consisting of OH, halogen, -CF3, - OCF3, -OCH2F, -OCHF2, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1-8alkyl, - SC1-8alkyl, -CN, =O, -C(O)H, -(CH2)nNRaRb, -(CH2)nNRaaC(O)Rbb, -C(O)NRaRb, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8alkyl, -NHC(O)OC1-8alkyl, -NRaRb, -(CH2)mC(O)OC1- 8alkyl, -S(O)2-NRaRb, -S(O)2-C1-8alkyl, -S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl, wherein -C1-8alkyl, -OC1-8alkyl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CN, -C1-8alkyl, -C1- 8alkylheterocyclyl, -C1-8alkylheteroaryl, -OC1-8alkyl, aryl, and monocyclic heteroaryl; R2 is independently for each occurrence selected from the group consisting of OH, halogen, -CF3, - OCF3, -OCH2F, -OCHF2, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1-8alkyl, - SC1-8alkyl, -CN, =O, -C(O)H, -(CH2)nNRaRb, -(CH2)nNRaaC(O)Rbb, -C(O)NRaRb, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8alkyl, -NHC(O)OC1-8alkyl, -NRaRb, -(CH2)mC(O)OC1- 8alkyl, -S(O)2-NRaRb, -S(O)2-C1-8alkyl, -S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl, wherein -C1-8alkyl, -OC1-8alkyl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CN, -C1-8alkyl, -C1- 8alkylheterocyclyl, -C1-8alkylheteroaryl, -OC1-8alkyl, aryl, and monocyclic heteroaryl; R3 is selected from the group consisting of OH, -C1-8alkyl, -OC1-8alkyl, -Oaryl, -Oheteroaryl, and – OC0-8alkylC3-8cycloalkyl, wherein -C1-8alkyl and -OC1-8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, haloalkyl (e.g., CH2F, CHF2, CF3), aryl, heterocyclyl, and –C3- 8cycloalkyl; R4 is H; or R3 and R4 together with the carbon atoms to which they are attached form cycloalkyl or heterocyclyl, wherein cycloalkyl and heterocyclyl can be optionally substituted 1 or 2 times with a substituent selected independently at each occurrence from the group consisting of CN, -C1-8alkyl, aryl, and heterocyclyl, wherein -C1-8alkyl, aryl, and heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen; R5 is selected from the group consisting of H, -OH, -C1-8alkyl, and NH2; R6 is selected from the group consisting of -C1-8alkyl, aryl, and heteroaryl, wherein -C1-8alkyl, aryl, and heteroaryl, can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of deuterium, H or -C1-8alkyl, wherein -C1-8alkyl can be optionally substituted with -CONH2, -S(O)2NH2, -S(O)2-C1-8alkyl, aryl, or heterocyclyl; or R5 and R6 together with the atoms to which they are attached form optionally substituted heterocyclyl; R7 is deuterium; Ra is H or -C1-8alkyl; Rb is H or -C1-8alkyl, wherein -C1-8alkyl can be optionally substituted with -CONH2, -S(O)2NH2, -S(O)2-C1-8alkyl, aryl, or heterocyclyl; or Ra and Rb together with the nitrogen atom to which they are attached form non-aromatic heterocyclyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of OH, =O, halogen, CF3, -OCF3, -OCH2F, -OCHF2, -C(O)H, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1-8alkyl, - SC1-8alkyl, -NRaRb, -CN, -C(O)OC1-8alkyl, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8 alkyl, -NHC(O)OC1-8alkyl, -(CH2)mC(O)OC1-8alkyl, -S(O)2-C1-8alkyl, -S(O)2-aryl, - S(O)2NRaRb, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl; Raa is H or -C1-8alkyl; Rbb is -C1- 8alkyl, -C4-8 cycloalkylmethyl, or monocyclic non-aromatic heterocyclyl, wherein -C1-8alkyl and -C4-8 cycloalkylmethyl can be optionally substituted with NH2, halogen, or CN; n is 0, 1, 2, 3, 4, 5, or 6; m is 0, 1, 2, 3, 4, 5, or 6; k is 0, 1, 2, 3, 4, 5, or 6; and l is 0, 1, 2, 3, 4, 5, 6, 7, or 8. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, A is selected from phenyl, pyrimidine, pyridine, and thiazole, wherein the phenyl, pyrimidine, pyridine, and thiazole, is optionally substituted one or more times with R1. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R1 is halogen. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 5-membered non-aromatic carbocycle optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 6-membered non-aromatic carbocycle optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 5-membered non-aromatic heterocyle comprising an oxygen atom wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 5-membered non-aromatic heterocyle comprising a sulfur atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 5-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom and an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 6-membered non-aromatic heterocyle comprising one nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, B is a 6-membered non-aromatic heterocyle comprising two nitrogen atoms, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R2 is independently selected from halogen, =O, -C1-8alkyl, C(O)OC1- 8alkyl, and -S(O)2-NRaRb. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R3 is -OC1-8alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CH2F, CHF2, CF3, aryl, heterocyclyl, and –C3-8cycloalkyl. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R3 is -OC1-8alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from halogen. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R3 is –OCH(CH3)CF3. In certain such embodiments, R3 has (S) configuration. In other such embodiments, R3 has (R) configuration. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R4 is H. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R5 is H. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R6 is C1-8alkyl. In certain embodiments of the compound of formula (I), or a pharmaceutically acceptable salt thereof, R6 is Me The present application provides a compound selected from any one of compounds 1- 60, and pharmaceutically acceptable salts thereof. In certain embodiments, the compound is compound (1), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (11), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (17), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (52), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (53), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (54), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (55), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (56), or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is compound (57), or a pharmaceutically acceptable salt thereof. The present application provides a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof; and (b) a pharmaceutically acceptable excipient. The present application provides a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof; and (b) a pharmaceutically acceptable excipient for use as a medicament. The present application provides a method of treating a hematological disorder in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of treating porphyria in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of treating a hepatic porphyria in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method treating one or more complications of a hepatic porphyria in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the one or more complications of hepatic porphyria is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, severe abdominal pain, neuropsychiatric symptoms, autonomic neuropathy, peripheral motor neuropathy, electrolyte disturbances, nausea, vomiting, constipation, diarrhea, difficulty urinating, ileus, paresthesia, insomnia, restlessness, agitation, anxiety, confusion, hallucinations, psychosis, convulsions, pain associated with neuropathy, muscle paralysis, tetraparesis, decreased breathing, respiratory arrest, hyponatremia, tachycardia, hypertension, increased heart rate, increased blood pressure, red urine, dark urine, hepatocellular carcinoma, hypertensive renal damage, chronic kidney disease, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholestasis, cytolysis, gallstones, cholestatic liver failure, cholelithiasis, mild liver disease, deteriorating liver disease, and terminal phase liver disease. In certain embodiments of the foregoing methods of treating a hepatic porphyria or treating one or more complications of a hepatic porphyria, the hepatic porphyria is an acute hepatic porphyria, acute intermittent porphyria (AIP), ALA dehydratase porphyria (ADP), variegate porphyria (VP), hereditary coproporphyria (HCP), or harderoporphyria. In certain embodiments of the foregoing methods, the hepatic porphyria is non-acute hepatic porphyria. In certain such embodiments, the non-acute hepatic porphyria is familial or sporadic porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP). The present application provides a method of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of treating one or more complications of EPP, XLPP, or CEP in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the one or more complications of EPP, XLPP, or CEP is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholestasis, cytolysis, gallstones, cholestatic liver failure, cholelithiasis, mild liver disease, deteriorating liver disease, terminal phase liver disease, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero. The present application provides a method of inhibiting protoporphyrin IX (PPIX) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of inhibiting 5-aminolevulinic acid (5- ALA) synthesis in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject The present application provides a method of inhibiting coproporphyrin III synthesis in vivo, comprising administering (1 a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject. The present application provides a method of inhibiting zinc-protoporphyrin IX (ZPPIX) synthesis in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of inhibiting porphobilinogen (PBG) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of inhibiting 5-aminolevulinic acid (5- ALA) and porphobilinogen (PBG) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject. The present application provides a method of inhibiting hydroxymethylbilane (HMB) synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject. The present application provides a method of inhibiting uroporphyrin III synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject. The present application provides a method of inhibiting heptacarboxyl-porphyrin synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject. The present application provides a method of inhibiting isocoproporphyrin synthesis in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject. The present application provides a method of inhibiting synthesis of a porphyrin or porphyrin precursor in vivo, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to a subject, wherein the porphyrin or porphyrin precursor is selected from the group consisting of: a. 5-ALA b. PBG c. Hydroxymethylbilane d. PPIX e. ZPPIX f. Uroporphyrinogen I g. Uroporphyrinogen III h. Heptacarboxyporphyrinogen I i. Heptacarboxyporphyrinogen III j. Hexacarboxyporphyrinogen I k. Hexacarboxyporphyrinogen III l. Pentacarboxyporphyrinogen I m. Pentacarboxyporphyrinogen III n. Coproporphyrinogen I o. Coproporphyrinogen III p. Isocoproporphyrin q. Porphobilinogen; and r. Protoporphyrinogen IX. In certain embodiments of the foregoing methods, accumulation of one or more heme intermediates is inhibited, and wherein the one or more heme intermediates are selected from the group consisting of 5-ALA, coproporphyrin III, zinc-protoporphyrin IX (ZPPIX), porphobilinogen, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin. In certain such embodiments, the accumulation of the one or more heme intermediates is inhibited in a dose dependent manner. In certain embodiments of the foregoing methods, the subject has EPP, XLPP, or CEP. In certain embodiments of the foregoing methods, the subject has hepatic porphyria. In certain embodiments of the foregoing methods, the subject has a mutation in UROS. In certain embodiments of the foregoing methods, the subject has a gene defect in GATA-1 erythroid-specific transcription factor. In certain embodiments of the foregoing methods, wherein the subject has liver disease associated with EPP, XLPP, or CEP. In certain embodiments of the foregoing methods, the method further comprises administering to the subject an additional active agent and/or supportive therapy. In certain such embodiments, the additional active agent and/or supportive therapy is selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse ®), bortezomib, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion. In certain embodiments, the additional active agent and/or supportive therapy is selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse®), bortezomib, heme infusions, sufficient caloric support, Givosiran, RNAi mediated silencing of various enzymes (e.g., ALA synthase), avoiding precipitating factors, 4-aminoquinolines, chloroquine, hydroxychloroquine, phlebotomy, intravenous magnesium, LH-RH agonists, enzyme replacement therapy (e.g., recombinant human PBGD), gene therapy (e.g., transfer of PBGD gene in liver cells by viral vectors), hemodialysis, pharmacologic chaperone treatment, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion. The present application provides a method of treating anemia associated with a ribosomal disorder in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of treating of one or more complications of anemia associated with a ribosomal disorder in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the one or more complications of anemia associated with a ribosomal disorder is selected from the group consisting of: thrombocytosis, megakaryotypic hyperplasia, infections, bleeding (e.g., from the nose or gums), bruising, splenomegaly, the need for more frequent blood transfusions, the need for increased glucocorticoid use, the need for allogenic hematopoietic stem cell transplantation, the need for autologous gene therapy, marrow failure, leukemia, and acute myelogenous leukemia. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the anemia associated with a ribosomal disorder is Diamond-Blackfan anemia. In certain such embodiments, the subject is haploinsufficient for a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein L5 (RPL5), 60S ribosomal protein L11 (RPL11), and 40S ribosomal protein S7 (RPS7). In other such embodiments, the subject is haploinsufficient for a ribosomal protein selected from the group consisting of 40S ribosomal protein S10 (RPS10), 40S ribosomal protein S26 (RPS26), 60S ribosomal protein L15 (RPL15), 60S ribosomal protein L17 (RPL17), 60S ribosomal protein L19 (RPL19), 60S ribosomal protein L26 (RPL26), 60S ribosomal protein L27 (RPL27), 60S ribosomal protein L31 (RPL31), 40S ribosomal protein S15a (RPS15a), 40S ribosomal protein S20 (RPS20), 40S ribosomal protein S27 (RPS27), 40S ribosomal protein S28 (RPS28), and 40S ribosomal protein S29 (RPS29). In other such embodiments, the subject has one or more mutations in a ribosomal protein gene. In other such embodiments, the subject has one or more mutations in a ribosomal protein gene selected from the group consisting of RPL5, RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19, RPS20, RPS24, RPS26, RPS27a, RPS27, RPS28, and RPS29. In other such embodiments, the subject has one or more mutations in a non-ribosomal protein gene selected from the group consisting of TSR2, GATA1, and EPO. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the anemia associated with a ribosomal disorder is Shwachman-Diamond syndrome. In certain such embodiments, the subject has one or more mutations in the SBDS gene. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the anemia associated with a ribosomal disorder is dyskeratosis congenita. In certain such embodiments, the dyskeratosis congenita is x-linked dyskeratosis congenita. In other such embodiments, the subject has one or more mutations in the DKC1 gene. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the method decreases the risk of bone marrow failure, pulmonary fibrosis, or liver fibrosis in the subject. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the anemia associated with a ribosomal disorder is cartilage hair hypoplasia. In certain such embodiments, the subject has one or more mutations in the RMRP gene. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the method reduces intracellular heme levels. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the method increases the subject’s red blood cell count. In certain embodiments of the foregoing methods of treating anemia associated with a ribosomal disorder or treating of one or more complications of anemia associated with a ribosomal disorder, the method further comprises administering to the subject an additional active agent and/or supportive therapy. In certain such embodiments, the additional active agent and/or supportive therapy is selected from the group consisting of: trifluoperazine, lenalidomide, HDAC inhibitors, glucocorticoids, sotatercept, luspatercept, iron chelators, blood transfusion, platelet transfusion, The present application provides a method of treating polycythemia in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. The present application provides a method of treating one or more complications of polycythemia in a subject in need thereof, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia. In certain embodiments of the foregoing methods of treating polycythemia or treating one or more complications of polycythemia, the polycythemia is primary polycythemia. In certain such embodiments, the primary polycythemia is polycythemia vera or pure erythrocytosis. In other such embodiments, the primary polycythemia is primary familial polycythemia. In certain embodiments of the foregoing methods of treating polycythemia or treating one or more complications of polycythemia, the polycythemia is secondary polycythemia. In certain such embodiments, the secondary polycythemia is associated with a disorder selected from the group consisting of hypoxia, central hypoxic process, lung disease, right-to-left cardiopulmonary vascular shunts (congenital or acquired), heart disease, heart failure, carbon monoxide poisoning, smoker’s erythrocytosis, high-altitude habitat, renal disease, kidney transplant, hemoglobinopathy with high-oxygen-affinity, decreased levels of erythrocyte 2,3,- DPG, bisphosphoglycerate mutase deficiency, methemoglobinemia, hereditary ATP increase, oxygen sensing pathway gene mutations, tumor, drug-induced secondary polycythemia, adrenal cortical hypersecretion, and idiopathic polycythemia. In certain embodiments of the foregoing methods of treating polycythemia or treating one or more complications of polycythemia, the polycythemia is relative polycythemia. In certain such embodiments, the relative polycythemia is selected from the group consisting of Gaisbock’s syndrome, spurious polycythemia, or stress erythrocytosis. In certain embodiments of the foregoing methods of treating polycythemia or treating one or more complications of polycythemia, the polycythemia is Chuvash polycythemia. The present application provides a method of inhibiting heme synthesis in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the heme synthesis is inhibited in a dose dependent manner. The present application provides a method of inhibiting hemoglobin synthesis in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the hemoglobin synthesis is inhibited in a dose dependent manner. The present application provides a method of inhibiting red blood cell synthesis in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, red blood cell synthesis is inhibited in a dose dependent manner. The present application provides a method of decreasing the red blood cell count in a subject with polycythemia, comprising administering (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or (2) a pharmaceutical composition comprising (a) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof and (b) a pharmaceutically acceptable excipient to the subject. In certain embodiments, the red blood cell count is decreased in a dose dependent manner. In certain embodiments of the foregoing methods, the method decreases the incidence of iron deficiency by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In certain embodiments of the foregoing methods, the method further comprises administering to the subject an additional active agent and/or supportive therapy. In certain such embodiments, the additional active agent and/or supportive therapy is selected from the group consisting of: Hydroxyruea (e.g., Droxia®, Hydrea®), Interferon alpha, Interferon alpha-2b (e.g., Intron® A), Ruxolitinib (e.g., Jakafi®), Busulfan (e.g., Busulfex®, Myleran®), radiation treatment, hepcidin mimetics (e.g., PTG-300), matriptase-2 inhibitors, ferroportin inhibitors, JAK inhibitors, BET inhibitors, MDM2 inhibitors, and HDAC inhibitors. Brief Description of the Drawings FIGURE 1 illustrates the study procedure to evaluate the efficacy of a GlyT1 inhibitor in EPP phototoxicity assay. FIGURE 2 shows compound 11 (“GlyT1 inhibitor”) reduces PPIX levels in RBCs in Fechm1Pas/Fechm1Pas homozygous mice as measured by flow cytometry on Day 14 and Day 18. FIGURE 3 shows compound 11 (“GlyT1 inhibitor”) treatment reduces skin lesions in Fechm1Pas/Fechm1Pas homozygous mice after light exposure. FIGURE 4 shows compound 11 (“GlyT1 inhibitor”) treatment reduces the percentage of area with skin lesions in Fechm1Pas/Fechm1Pas homozygous mice after light exposure. FIGURE 5 shows a correlation between the quantification of skin lesions and PPIX levels in Fechm1Pas/Fechm1Pas homozygous mice at day 14 treated with vehicle or compound 11 (“GlyT1 inhibitor”). Detailed Description of the Application Compounds of the present application, and pharmaceutical compositions thereof, are useful as inhibitors of GlyT-1, or a mutant thereof. Without wishing to be bound by any particular theory, it is believed that compounds of the present application, and pharmaceutical compositions thereof, may inhibit the activity GlyT-1, or a mutant thereof, and thus treat certain diseases, disorders, via GlyT-1 inhibition, such as various hematological disorders, particularly those caused by iron overload and/or regulate heme synthesis. Inhibition of heme synthesis via inhibition of PPIX synthesis could be used to treat numerous hematological disorders such as erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP). Inhibition of heme synthesis with glycine transporter inhibitors also has the potential in treatment of iron overload disorder and hemoglobinopathies such as polycythemia (e.g., primary polycythemia, polycythemia vera, pure erythrocytosis, primary familial polycythemia, relative polycythemia, secondary polycythemia, Gaisbock’s syndrome, spurious polycythemia, stress erythrocytosis, Chuvash polycythemia), anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia, Shwachman-Diamond syndrome, Cartilage-hair hypoplasia, and dyskeratosis congenita), hepatic porphyria (e.g., acute hepatic porphyria, acute intermittent porphyria, ALA dehydratase porphyria, variegate porphyria, hereditary coproporphyria, harderoporphyria, non-acute hepatic porphyria, familial or sporadic porphyria cutanea tarda, hepatoerythropoietic porphyria), thalassemia, and other blood related disorders. It has now been found that compounds of the present application, and pharmaceutically acceptable compositions thereof, are effective as GlyT-1inhibitors. The present application provides a compound of formula (I)
Figure imgf000018_0001
or a pharmaceutically acceptable salt thereof, wherein: A is an aryl or heteroaryl ring system wherein the aryl or heteroaryl ring system is optionally substitued one or more times with R1; B is a 4- to 8-membered non-aromatic carbocycle or a 4- to 8-membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R2; R1 is independently for each occurrence selected from the group consisting of OH, halogen, - CF3, -OCF3, -OCH2F, -OCHF2, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1- 8alkyl, -SC1-8alkyl, -CN, =O, -C(O)H, -(CH2)nNRaRb, -(CH2)nNRaaC(O)Rbb, -C(O)NRaRb, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8alkyl, -NHC(O)OC1-8alkyl, -NRaRb, - (CH2)mC(O)OC1-8alkyl, -S(O)2-NRaRb, -S(O)2-C1-8alkyl, -S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl, wherein -C1-8alkyl, -OC1-8alkyl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CN, -C1-8alkyl, -C1-8alkylheterocyclyl, -C1-8alkylheteroaryl, -OC1-8alkyl, aryl, and monocyclic heteroaryl; R2 is independently for each occurrence selected from the group consisting of OH, halogen, - CF3, -OCF3, -OCH2F, -OCHF2, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1- 8alkyl, -SC1-8alkyl, -CN, =O, -C(O)H, -(CH2)nNRaRb, -(CH2)nNRaaC(O)Rbb, -C(O)NRaRb, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8alkyl, -NHC(O)OC1-8alkyl, -NRaRb, - (CH2)mC(O)OC1-8alkyl, -S(O)2-NRaRb, -S(O)2-C1-8alkyl, -S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl, wherein -C1-8alkyl, -OC1-8alkyl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CN, -C1-8alkyl, -C1-8alkylheterocyclyl, -C1-8alkylheteroaryl, -OC1-8alkyl, aryl, and monocyclic heteroaryl; R3 is selected from the group consisting of OH, -C1-8alkyl, -OC1-8alkyl, -Oaryl, -Oheteroaryl, and – OC0-8alkylC3-8cycloalkyl, wherein -C1-8alkyl and -OC1-8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, haloalkyl (e.g., CH2F, CHF2, CF3), aryl, heterocyclyl, and –C3-8cycloalkyl; R4 is H; or R3 and R4 together with the carbon atoms to which they are attached form cycloalkyl or heterocyclyl, wherein cycloalkyl and heterocyclyl can be optionally substituted 1 or 2 times with a substituent selected independently at each occurrence from the group consisting of CN, -C1-8alkyl, aryl, and heterocyclyl, wherein -C1-8alkyl, aryl, and heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen; R5 is selected from the group consisting of H, -OH, -C1-8alkyl, and NH2; R6 is selected from the group consisting of -C1-8alkyl, aryl, and heteroaryl, wherein -C1-8alkyl, aryl, and heteroaryl, can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of deuterium, H or - C1-8alkyl, wherein -C1-8alkyl can be optionally substituted with -CONH2, -S(O)2NH2, - S(O)2-C1-8alkyl, aryl, or heterocyclyl; or R5 and R6 together with the atoms to which they are attached form optionally substituted heterocyclyl; R7 is deuterium; Ra is H or -C1-8alkyl; Rb is H or -C1-8alkyl, wherein -C1-8alkyl can be optionally substituted with -CONH2, - S(O)2NH2, -S(O)2-C1-8alkyl, aryl, or heterocyclyl; or Ra and Rb together with the nitrogen atom to which they are attached form non-aromatic heterocyclyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of OH, =O, halogen, CF3, - OCF3, -OCH2F, -OCHF2, -C(O)H, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, - OC1-8alkyl, -SC1-8alkyl, -NRaRb, -CN, -C(O)OC1-8alkyl, -C(O)OH, -(CH2)kCOC1-8alkyl, - (CH2)nOC1-8 alkyl, -NHC(O)OC1-8alkyl, -(CH2)mC(O)OC1-8alkyl, -S(O)2-C1-8alkyl, - S(O)2-aryl, -S(O)2NRaRb, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl; Raa is H or -C1-8alkyl; Rbb is -C1-8alkyl, -C4-8 cycloalkylmethyl, or monocyclic non-aromatic heterocyclyl, wherein - C1-8alkyl and -C4-8 cycloalkylmethyl can be optionally substituted with NH2, halogen, or CN; n is 0, 1, 2, 3, 4, 5, or 6; m is 0, 1, 2, 3, 4, 5, or 6; k is 0, 1, 2, 3, 4, 5, or 6; and l is 0, 1, 2, 3, 4, 5, 6, 7, or 8. It will be readily understood by those skilled in the art that
Figure imgf000021_0001
of formula I represents a ring system in which rings A and B are fused. It will be further understood by those skilled in the art that the foregoing ring system is bound to the adjacent piperizine ring system in Formula I through the A ring (i.e., the indicated nitrogen of the piperizine ring is bound directly to one of the atoms of the A ring). In certain embodiments, A is a monocyclic aryl or heteroaryl ring system wherein the monocyclic aryl or heteroaryl ring system is fused to ring B, and wherein the monocyclic aryl or heteroaryl ring system is optionally substitued one or more times with R1. In certain embodiments, A is selected from phenyl, pyrimidine, pyridine, and thiazole, wherein the phenyl, pyrimidine, pyridine, and thiazole, is optionally substituted one or more times with R1. In certain embodiments, R1 is halogen (e.g., fluoro or chloro) or -C1-8alkyl. In certain embodiments, R1 is halogen (e.g., fluoro or chloro). In certain embodiments, B is a 5- or 6-membered non-aromatic carbocycle or a 5- or 6- membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R2. In certain embodiments, B is a 5-membered non-aromatic carbocycle optionally substituted one or more times with R2. In certain embodiments, B is a 6-membered non-aromatic carbocycle optionally substituted one or more times with R2. In certain embodiments, B is a 5-membered non-aromatic heterocyle comprising an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments, B is a 5-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments, B is a 5-membered non-aromatic heterocyle comprising a sulfur atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2 (e.g., the sulfur is substituted two times with =O such that the 5-membered non-aromatic heterocyle comprises a sulfone). In certain embodiments, B is a 5-membered non-aromatic heterocyle comprising a nitrogen atom and a sulfur atom, wherein the non- aromatic heterocyle is optionally substituted one or more times with R2 (e.g., the sulfur is substituted two times with =O such that the 5-membered non-aromatic heterocyle comprises a sulfonamide). In certain embodiments, B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom, an oxygen atom, and a sulfur atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2 (e.g., the sulfur is substituted two times with =O such that the 6-membered non-aromatic heterocyle comprises a sulfone, an oxygen atom, and a nitrogen atom). In certain embodiments, B is a 6-membered non-aromatic heterocyle comprising an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments, B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom and an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments, B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments, B is a 6-membered non-aromatic heterocyle comprising two nitrogen atoms, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2. In certain embodiments, R2 is independently selected from =O, -C1-8alkyl (e.g., methyl), and C(O)OC1-8alkyl. In certain embodiments,
Figure imgf000022_0001
is selected from:
Figure imgf000022_0002
Figure imgf000022_0003
Figure imgf000023_0001
wherein the aryl or heteroaryl ring system of ring A is optionally substitued one or more times with R1 (e.g., halogen, such as fluorine or chlorine, or -C1-8alkyl, such as methyl), and the 5- or 6 -membered non-aromatic carbocycle or heterocyle of ring B is optionally further substituted one or more times with R2 (e.g., alkyl, such as methyl, or -(CH2)mC(O)OC1-8alkyl, such as C(O)OtBu). In certain embodiments,
Figure imgf000023_0002
wherein the aryl or heteroaryl ring system of ring A is optionally substitued one or more times with R1 (e.g., halogen, such as fluorine or chlorine, or -C1-8alkyl, such as methyl), and the 5- or 6 -membered non-aromatic carbocycle or heterocyle of ring B is optionally further substituted one or more times with R2 (e.g., alkyl, such as methyl, or -(CH2)mC(O)OC1-8alkyl, such as C(O)OtBu). In certain embodiments,
Figure imgf000023_0003
is selected from:
Figure imgf000023_0004
Figure imgf000024_0001
Figure imgf000025_0003
, , , , , and
Figure imgf000025_0004
In certain embodiments,
Figure imgf000025_0005
In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form an optionally substituted monocyclic non-aromatic heterocyclyl containing 3-9 atoms having 1-4 heteroatoms independently selected from nitrogen, oxygen, and sulfur. This monocyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of OH, =O, halogen, CF3, -OCF3, -OCH2F, -OCHF2, -C(O)H, -C1-8alkyl, –C3-8cycloalkyl, –C4- 16cycloalkylalkyl, -OC1-8alkyl, -SC1-8alkyl, -CN, -C(O)OC1-8alkyl, -C(O)OH, –(CH2)kCOC1- 8alkyl, -(CH2)nOC1-8 alkyl, -NHC(O)OC1-8alkyl, -(CH2)mC(O)OC1-8alkyl, –S(O)2-C1-8alkyl, - S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl. In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form morpholinyl, oxazolidinyl, thiazinyl, imidazolidinyl, piperidinyl, pyrrolidinyl, piperazinyl, or thiomorpholinyl group, wherein morpholinyl, oxazolidinyl, thiazinyl, imidazolidinyl, piperidinyl, pyrrolidinyl, piperazinyl, or thiomorpholinyl group can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of =O, -C1- 8alkyl, OH, and -C(O)OC1-8alkyl. In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form
Figure imgf000025_0006
, or
Figure imgf000025_0001
group, each of which can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of =O, -C1- 8alkyl, OH, and -C(O)OC1-8alkyl. In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form oxazolidinyl or oxazolidinyl group:
Figure imgf000025_0002
. In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form thiazinyl or thiazinyl group:
Figure imgf000026_0007
In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form imidazolidinyl or an imidazolidinyl group:
Figure imgf000026_0006
In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form piperazinyl or a piperazinyl group:
Figure imgf000026_0005
In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form pyrrolidinyl or a pyrrolidinyl group:
Figure imgf000026_0003
In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form thiomorpholinyl or a thiomorpholinyl group:
Figure imgf000026_0001
. In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form piperidinyl or a piperidinyl group:
Figure imgf000026_0002
. In certain embodiments, Ra and Rb together with the nitrogen atom to which they are attached form morpholinyl or a morpholinyl group:
Figure imgf000026_0004
In certain embodiments, R3 is selected from the group consisting of OH, -OC1-8alkyl, - Oaryl, -Oheteroaryl, and – OC0-8alkylC3-8cycloalkyl, wherein -C1-8alkyl and -OC1-8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, haloalkyl (e.g., CH2F, CHF2, CF3), aryl, heterocyclyl, and –C3-8cycloalkyl. In certain embodiments, R3 is -OC1-8alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CF3, aryl, heterocyclyl, and –C3-8cycloalkyl. In certain embodiments, R3 is -OC1-8alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from halogen (e.g., fluorine). In certain embodiments, R3 is –OCH(CH3)CF3. In certain embodiments, R4 is H. In certain embodiments, R3 and R4 together with the carbon atoms to which they are attached form a 4-8 membered heterocyclyl, wherein 4-8 membered heterocyclyl can be optionally substituted 1 or 2 times with -C1-8alkyl, aryl, and heterocyclyl, wherein -C1-8alkyl, aryl, and heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen. In certain embodiments, R3 and R4 together with the carbon atoms to which they are attached form tetrahydrofuranyl or dihydrofuranyl, wherein tetrahydrofuranyl and dihydrofuranyl can be optionally substituted 1 or 2 times with -C1-8alkyl, wherein -C1-8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen. In certain embodiments, R3 and R4 together with the atoms to which they are attached form an optionally substituted 4-8 membered heterocyclyl. In certain embodiments, R3 and R4 together with the atoms to which they are attached form tetrahydrothiophene 1,1-dioxide or dihydrothiophene 1,1-dioxide. In certain embodiments, R3 and R4 together with the carbon atoms to which they are attached form tetrahydrofuranyl optionally substituted 1 or 2 times with -C1-8alkyl, wherein - C1-8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen (e.g., Cl or F). Thus, the compound of Formula (I) has the following structure:
Figure imgf000027_0001
. In certain embodiments, R3 and R4 together with the carbon atoms to which they are attached form dihydrofuranyl optionally substituted 1 or 2 times with -C1-8alkyl, wherein -C1- 8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen (e.g., Cl or F). Thus, the compound of Formula (I) has the following structure:
Figure imgf000028_0004
In certain embodiments, R5 is H. In certain embodiments, R5 is selected from the group consisting of H and NH2. In certain embodiments, R6 is C1-8alkyl. In certain embodiments, R6 is Me. In certain embodiments, R5 and R6 together with the atoms to which they are attached form tetrahydrothiophene 1,1-dioxide. Thus, the compound of Formula (I) has the following structure:
Figure imgf000028_0001
. In certain embodiments, R5 and R6 with the atoms to which they are attached form dihydrothiophene 1,1-dioxide. Thus, the compound of Formula (I) has the following structure:
Figure imgf000028_0002
. In certain embodiments, l is 0. In certain embodiments, l is 8. The present application provides a compound selected from any one of compounds 1- 60, and pharmaceutically acceptable salts thereof:
Figure imgf000028_0003
Figure imgf000029_0001
Figure imgf000030_0001
Figure imgf000031_0001
Figure imgf000032_0001
Figure imgf000033_0001
Figure imgf000034_0001
Figure imgf000035_0001
Figure imgf000036_0001
Figure imgf000037_0001
Figure imgf000038_0001
Figure imgf000039_0001
In certain embodiments, the compound is selected from any one of compounds 1-51, and pharmaceutically acceptable salts thereof. In certain embodiments, the compound is selected from any one of compounds 1-57, and pharmaceutically acceptable salts thereof. In embodiments of the application wherein a compound (e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof, such as any one of compounds 1-60, and pharmaceutically acceptable salts thereof) is disclosed herein as a particular enantiomer, the application further contemplates the compound in its racemic or other enantiomeric form. For example, for any one of compounds 1-60 shown as the (S) enantiomer, the present application further provides the compound in its racemic or (R) enantiomeric form, and pharmaceutically acceptable salts thereof. Similarly, for any one of compounds 1-60 shown as the (R) enantiomer, the present application further provides the compound in its racemic or (S) enantiomeric form, and pharmaceutically acceptable salts thereof. In certain embodiments wherein alkyl, alkenyl, alkynyl, alkoxy, aryl, heteroaryl, cycloalkyl, heterocyclyl, or oxime are substituted, they are substituted, valency permitting, with one or more substituents selected from substituted or unsubstituted alkyl, such as perfluoroalkyl (e.g., trifluoromethyl), alkenyl, alkoxy, alkoxyalkyl, aryl, aralkyl, arylalkoxy, aryloxy, aryloxyalkyl, hydroxyl, halo, alkoxy, such as perfluoroalkoxy (e.g., trifluoromethoxy), alkoxyalkoxy, hydroxyalkyl, hydroxyalkylamino, hydroxyalkoxy, amino, aminoalkyl, alkylamino, aminoalkylalkoxy, aminoalkoxy, acylamino, acylaminoalkyl, such as perfluoro acylaminoalkyl (e.g., trifluoromethylacylaminoalkyl), acyloxy, cycloalkyl, cycloalkylalkyl, cycloalkylalkoxy, heterocyclyl, heterocyclylalkyl, heterocyclyloxy, heterocyclylalkoxy, heteroaryl, heteroarylalkyl, heteroarylalkoxy, heteroaryloxy, heteroaryloxyalkyl, heterocyclylaminoalkyl, heterocyclylaminoalkoxy, amido, amidoalkyl, amidine, imine, oxo, carbonyl (such as carboxyl, alkoxycarbonyl, formyl, or acyl, including perfluoroacyl (e.g., C(O)CF3)), carbonylalkyl (such as carboxyalkyl, alkoxycarbonylalkyl, formylalkyl, or acylalkyl, including perfluoroacylalkyl (e.g., -alkylC(O)CF3)), carbamate, carbamatealkyl, urea, ureaalkyl, sulfate, sulfonate, sulfamoyl, sulfone, sulfonamide, sulfonamidealkyl, cyano, nitro, azido, sulfhydryl, alkylthio, thiocarbonyl (such as thioester, thioacetate, or thioformate), phosphoryl, phosphate, phosphonate or phosphinate. When a bond to a substituent is shown to cross a bond connecting two atoms in a ring, then such substituent may be bonded to any atom on the ring. When a substituent is listed without indicating the atom via which such substituent is bonded to the rest of the compound of a given formula, then such substituent may be bonded via any atom in such substituent. Combinations of substituents, positions of substituents and/or variables are permissible only if such combinations result in chemically stable compounds. As used in this application, the term "optionally substituted" means that substitution is optional and therefore it is possible for the designated atom or moiety to be unsubstituted. Compounds of the present application containing one or multiple asymmetrically substituted atoms may be isolated in optically active or racemic forms. It is well known in the art how to prepare optically active forms, such as by resolution of racemic forms, by synthesis from optically active starting materials, or by synthesis using optically active reagents. In certain embodiments, compounds of the application may be racemic. For example, in embodiments of the application wherein a compound (e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof) is disclosed herein as a particular enantiomer, the application further contemplates the compound in its racemic form. In certain embodiments, compounds of the application may be enriched in one enantiomer. For example, a compound of the application may have greater than 30% ee, 40% ee, 50% ee, 60% ee, 70% ee, 80% ee, 90% ee, or even 95% or greater ee. In certain embodiments, the therapeutic preparation may be enriched to provide predominantly one enantiomer of a compound (e.g., of formula (I), or a pharmaceutically acceptable salt thereof). An enantiomerically enriched mixture may comprise, for example, at least 60 mol percent of one enantiomer, or more preferably at least 75, 90, 95, or even 99 mol percent. In certain embodiments, the compound enriched in one enantiomer is substantially free of the other enantiomer, wherein substantially free means that the substance in question makes up less than 10%, or less than 5%, or less than 4%, or less than 3%, or less than 2%, or less than 1% as compared to the amount of the other enantiomer, e.g., in the composition or compound mixture. For example, if a composition or compound mixture contains 98 grams of a first enantiomer and 2 grams of a second enantiomer, it would be said to contain 98 mol percent of the first enantiomer and only 2% of the second enantiomer. In certain embodiments, compounds of the application may have more than one stereocenter. In certain such embodiments, compounds of the application may be enriched in one or more diastereomer. For example, a compound of the application may have greater than 30% de, 40% de, 50% de, 60% de, 70% de, 80% de, 90% de, or even 95% or greater de. In certain embodiments, the therapeutic preparation may be enriched to provide predominantly one diastereomer of a compound (e.g., a compound of formula (I), or a pharmaceutically acceptable salt thereof). A diastereomerically enriched mixture may comprise, for example, at least 60 mol percent of one diastereomer, or more preferably at least 75, 90, 95, or even 99 mol percent. A variety of compounds in the present application may exist in particular geometric or stereoisomeric forms. The present application takes into account all such compounds, including tautomers, cis- and trans-isomers, R- and S-enantiomers, diastereomers, (D)- isomers, (L)-isomers, the racemic mixtures thereof, and other mixtures thereof, as being covered within the scope of this application. All tautomeric forms are encompassed in the present application. Additional asymmetric carbon atoms may be present in a substituent such as an alkyl group. All such isomers, as well as mixtures thereof, are intended to be included in this application, unless the stereochemistry or isomeric form is specifically indicated. The present application further includes all pharmaceutically acceptable isotopically labelled compounds (e.g., compounds of formula (I), or pharmaceutically acceptable salts thereof). An "isotopically" or "radio-labelled" compound is a compound where one or more atoms are replaced or substituted by an atom having an atomic mass or mass number different from the atomic mass or mass number typically found in nature (i.e., naturally occurring). For example, in certain embodiments, in compounds (e.g., compounds of formula (I), or pharmaceutically acceptable salts thereof), hydrogen atoms are replaced or substituted by one or more deuterium or tritium (e.g., hydrogen atoms on a C1-6 alkyl or a C1-6 alkoxy are replaced with deuterium, such as d3-methoxy or 1,1,2,2-d4-3-methylbutyl). Certain isotopically labelled compounds (e.g., of formula (I), or pharmaceutically acceptable salts thereof), in the application, for example, those incorporating a radioactive isotope, are useful in drug and/or substrate tissue distribution studies. The radioactive isotopes tritium, i.e.3H, and carbon 14, i.e., 14C, are particularly useful for this purpose in view of their ease of incorporation and ready means of detection. Substitution with heavier isotopes such as deuterium, i.e., 2H, may afford certain therapeutic advantages resulting from greater metabolic stability, for example, increased in vivo half-life or reduced dosage requirements, and hence may be preferred in some circumstances. Substitution with positron emitting isotopes, such as 11C, 18F, 15O, and 13N, can be useful in Positron Emission Topography (PET) studies for examining substrate receptor occupancy. Isotopically labelled compounds (e.g., of formula (I), or pharmaceutically acceptable salts thereof) can generally be prepared by conventional techniques known to those skilled in the art or by processes analogous to those described in the accompanying examples using an appropriate isotopically labelled reagent in place of the non-labelled reagent previously employed. Suitable isotopes that may be incorporated in compounds of the present application include but are not limited to 2H (also written as D for deuterium), 3H (also written as T for tritium), 11C, 13C,14C, 13N, 15N, 15O, 17O, 18O, 18F, 35S, 36Cl , 82B r, 75Br, 76B r, 77Br, 123I, 124I, 125I, and 131I. In certain embodiments, the present application provides a pharmaceutical preparation suitable for use in a human patient, comprising any of the compounds shown above (e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof) and one or more pharmaceutically acceptable excipients. In certain embodiments, the pharmaceutical preparations may be for use in treating or preventing a condition or disease as described herein. In certain embodiments, the pharmaceutical preparations have a low enough pyrogen activity to be suitable for use in a human patient. In certain embodiments, a compound as disclosed herein (e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof) demonstrates reduced brain pentration (e.g., as compared to compounds known to cross the blood brain barrier, such as metoprolol). In certain embodiments, a compound as disclosed herein (e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof) is not capable of crossing the blood brain barrier (i.e., the compound is peripherally restricted). In certain embodiments, a compound as disclosed herein (e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof) is a substrate for the human efflux transporter P- glycoprotein (P-gp). In certain embodiments, a compound as disclosed herein (e.g., a compound according to formula (I), or a pharmaceutically acceptable salt thereof) has an efflux ratio greater than about 1.75, 1.8, 1.9, 2.0, 5.0, 10, 15, 20, 25, 30, 35, or 40, wherein
Figure imgf000043_0001
and where Papp (A-B) indicates the apparent permeability coefficient in basolateral to apical direction, and Papp (A-B) indicates the apparent permeability coefficient in apical to basolateral direction. In certain such embodiments, the efflux ratio is determined in the absence of a P-gp inhibitor. In other such embodiments, at least a 50%, 60%, 70%, 80%, 90%, or 95% reduction of the efflux ratio is demonstrated when measured in the presence of a known P-gp inhibitor. Compounds of any of the above structures may be used in the manufacture of medicaments for the treatment of any diseases or conditions disclosed herein. Uses of the compounds Compounds of the present application may be administered orally, parenteral, buccal, vaginal, rectal, inhalation, insufflation, sublingually, intramuscularly, subcutaneously, topically, intranasally, intraperitoneally, intrathoracically, intravenously, epidurally, intrathecally, intracerebroventricularly and by injection into the joints. The dosage will depend on the route of administration, the severity of the disease, age and weight of the patient and other factors normally considered by the attending physician, when determining the individual regimen and dosage level as the most appropriate for a particular patient. The quantity of the compound to be administered will vary for the patient being treated and will vary from about 100 ng/kg of body weight to 100 mg/kg of body weight per day. For instance, dosages can be readily ascertained by those skilled in the art from this disclosure and the knowledge in the art. This, the skilled artisan can readily determine the amount of compound and optional additives, vehicles, and/or carrier in compositions and to be administered in methods of the application. In certain embodiments, the application relates to a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, for use as a medicament, e.g., for treatment of any of the disorders disclosed herein. In certain embodiments, compounds and compositions described herein are generally useful for the inhibition of GlyT-1, or a mutant thereof. The activity of a compound utilized in this disclosure as an inhibitor of GlyT-1, or a mutant thereof, may be assayed in vitro, in vivo or in a cell line. In vitro assays include assays that determine inhibition of GlyT-1, or a mutant thereof. Alternate in vitro assays quantitate the ability of the inhibitor to bind to GlyT-1, or a mutant thereof. Detailed conditions for assaying a compound utilized in this disclosure as an inhibitor of GlyT-1, or a mutant thereof, are set forth in the Examples below. In certain embodiments, the application relates to a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, for use as a medicament. The present application provides methods of preventing or treating disorders associated with conditions in which excess heme, the accumulation of toxic intermediates of heme biosynthesis, or pathological increases in erythropoiesis lead to disease in a subject, the method comprising administering to the subject one or more glycine transporter inhibitor or a pharmaceutically acceptable salt thereof, or a prodrug of the one or more glycine transporter inhibitor or its pharmaceutically acceptable salt. In certain aspects, the disorder is a porphyria (e.g., as erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP)), a hepatic porphyria (e.g., acute hepatic porphyria, acute intermittent porphyria, ALA dehydratase porphyria, variegate porphyria, hereditary coproporphyria, harderoporphyria, non-acute hepatic porphyria, familial or sporadic porphyria cutanea tarda, hepatoerythropoietic porphyria), anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia, Shwachman-Diamond syndrome, Cartilage-hair hypoplasia, and dyskeratosis congenita), polycythemia (e.g., primary polycythemia, polycythemia vera, pure erythrocytosis, primary familial polycythemia, relative polycythemia, secondary polycythemia, Gaisbock’s syndrome, spurious polycythemia, stress erythrocytosis, Chuvash polycythemia), thalassemia, or other blood related disorder. In certain embodiments, the glycine transporter inhibitor is a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. For example, the present application provides a method of preventing or treating disorders associated with accumulation of PPIX in a subject, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In the treatment of any of the disorders disclosed herein, different compounds of the application may be (e.g., conjointly) administered with one or more other compounds of the application (e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof). Moreover, any one or more of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be conjointly administered with other conventional therapeutic agents in treating one or more disease conditions referred to herein. In certain embodiments, compounds of the present application may be used alone or conjointly administered with another type of therapeutic agent. As used herein, the phrase “conjoint administration” refers to any form of administration of two or more different therapeutic compounds such that the second compound is administered while the previously administered therapeutic compound is still effective in the body (e.g., the two compounds are simultaneously effective in the patient, which may include synergistic effects of the two compounds). For example, the different therapeutic compounds can be administered either in the same formulation or in a separate formulation, either simultaneously, sequentially, or by separate dosing of the individual components of the treatment. In certain embodiments, the different therapeutic compounds can be administered within one hour, 12 hours, 24 hours, 36 hours, 48 hours, 72 hours, or a week of one another. Thus, an individual who receives such treatment can benefit from a combined effect of different therapeutic compounds. In certain embodiments, conjoint administration of compounds of the present application with one or more additional therapeutic agent(s) provides improved efficacy relative to each individual administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or the one or more additional therapeutic agent(s). In certain such embodiments, the conjoint administration provides an additive effect, wherein an additive effect refers to the sum of each of the effects of individual administration of the compound of the present application and the one or more additional therapeutic agent(s). Such combination products employ the compounds of this present application within the dosage range described herein and the other pharmaceutically active compound or compounds within approved dosage ranges and/or the dosage described in the publication reference. Porphyrias Porphyrias are a family of inherited or acquired disorders resulting from the deficient activity of specific enzymes in the heme biosynthetic pathway, also referred to herein as the porphyrin pathway. Porphyrins are the main precursors of heme. Porphyrins and porphyrin precursors include 5-aminolevulinic acid (ALA), porphopilinogen (PBG), hydroxymethylbilane (HMB), uroporphyrinogen I or III, coproporphyrinogen I or III, protoporphrinogen IX, and protoporphyrin IX. Heme is an essential part of hemoglobin, myoglobin, catalases, peroxidases, and cytochromes, the latter including the respiratory and P450 liver cytochromes. Heme is synthesized in most or all human cells. About 85% of heme is made in erythroid cells, primarily for hemoglobin. Most of the remaining heme is made in the liver, 80% of which is used for the synthesis of cytochromes. Deficiency of specific enzymes in the porphyrin pathway leads to insufficient heme production and also to an accumulation of porphyrin precursors and/or porphyrins, which can be toxic to cell or organ function in high concentrations. Porphyrias may be classified by the primary site of the overproduction and accumulation of porphyrins or their precursors. In hepatic porphyrias, porphyrins and porphyrin precursors are overproduced predominantly in the liver, whereas in erythropoietic porphyrias, porphyrins are overproduced in the erythroid cells in the bone. The acute or hepatic porphyrias lead to dysfunction of the nervous system and neurologic manifestations that can affect both the central and peripheral nervous system, resulting in symptoms such as, for example, pain (e.g., abdominal pain and/or chronic neuropathic pain), vomiting, neuropathy (e.g., acute neuropathy progressive neuropathy), muscle weakness, seizures, mental disturbances (e.g., hallucinations, depression anxiety, paranoia), cardiac arrhythmias, tachycardia, constipation, and diarrhea. The cutaneous or erythropoietic porphyrias primarily affect the skin, causing symptoms such as photosensitivity that can be painful, blisters, necrosis, itching, swelling, and increased hair growth on areas such as the forehead. Subsequent infection of skin lesions can lead to bone and tissue loss, as well as scarring, disfigurement, and loss of digits (e.g., fingers, toes). Most porphyrias are caused by mutations that encode enzymes in the heme biosynthetic pathway. However, not all porphyrias are genetic. For example, patients with liver disease may develop porphyria as a result of liver dysfunction. Patients with PCT can acquire the deficient activity of uroporphyrinogen decarboxylase (URO-D), due to the formation of a ORO-D enzyme with lower than normal enzymatic activity. Acute Hepatic Porphyrias Porphyrias comprise eight inherited metabolic disorders of heme biosynthesis in which various enzymes in the complex heme biosynthetic pathway are disrupted. Porphyrias are broadly classified as acute vs non-acute or hepatic vs erythropoietic porphyrias, based on their clinical presentation. Acute hepatic porphyrias include acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), and aminolevulinic acid dehydratase deficient porphyria (ADP), and often lead to serious abdominal, psychiatric, neurologic, or cardiovascular symptoms. Each acute hepatic porphyria results from a genetic defect leading to deficiency in one of the enzymes of the heme synthesis pathway in the liver. AIP, HCP, and VP are autosomal dominant porphyrias and ADP is autosomal recessive porphyria. In rare cases, AIP, HCP, and VP occur as homozygous dominant forms. Porphyria cutanea tarda (PCT) is a non-acute hepatic porphyria in which patients often present with blisters, bullae, milia, and hypertrichosis on cheeks, temples, and eyebrows. In addition, there is a rare homozygous recessive form of PCT known as hepatoerythropoietic porphyria (HEP). The clinical and laboratory features of these porphyrias are described in Table 1 below. Table 1: Symptoms and Diagnostic Strategy in Hepatic Porphyrias and Lead Poisoning
Figure imgf000047_0001
Figure imgf000048_0001
Acute intermittent porphyria (AIP) (also be referred to as porphobilinogen (PBG) deaminase deficiency, or hydroxymethylbilane synthase (HMBS) deficiency), is the most common type of acute hepatic porphyria. Other types of acute hepatic porphyrias include hereditary coproporphyria (HCP), variegate porphyria (VP), and ALA deyhdratase deficiency porphyria (ADP). Non-acute hepatic porphyrias include porphyria cutanea tarda (PCT), a disease in which patients often present with blisters, bullae, milia, and hypertrichosis on cheeks, temples, and eyebrows. In addition, there is a rare homozygous recessive form of PCT known as hepatoerythropoietic porphyria (HEP). The clinical and laboratory features of these porphyrias are described in Table 1. AIP has been found to have a prevalence as high as 1 in 10,000 in certain populations (e.g., in Northern Sweden). The prevalence of mutations in the general population in United States and Europe, excluding the U.K., is estimated to be about 1 in 10,000 to 1 in 20,000. Clinical disease manifests itself in only approximately 10-15% of individuals who carry mutations that are known to be associated with AIP. However, the penetrance is as high as 40% in individuals with certain mutations (e.g., the W198X mutation). AIP is typically latent prior to puberty. Symptoms are more common in females than in males. The prevalence of the disease is probably underestimated due to its incomplete penetrance and long periods of latency. In the United States, it is estimated that there are about 2000 patients who have suffered at least one attack. It is estimated that there are about 150 active recurrent cases in France, Sweden, the U.K., and Poland; these patients are predominantly young women, with a median age of 30. AIP affects, for example, the visceral, peripheral, autonomic, and central nervous systems. Symptoms of AIP are variable and include gastrointestinal symptoms (e.g., severe and poorly localized abdominal pain, nausea/vomiting, constipation, diarrhea, ileus), urinary symptoms (dysuria, urinary retention/incontinence, or dark urine), neurologic symptoms (e.g., sensory neuropathy, motor neuropathy (e.g., affecting the cranial nerves and/or leading to weakness in the arms or legs), seizures, neuropathic pain (e.g., pain associated with progressive neuropathy, e.g., chronic neuropathic pain), neuropsychiatric symptoms (e.g., mental confusion, anxiety, agitation, hallucination, hysteria, delirium, apathy, depression, phobias, psychosis, insomnia, somnolence, coma), autonomic nervous system involvement (resulting e.g., in cardiovascular symptoms such as tachycardia, hypertension, and/or arrhythmias, as well as other symptoms, such as, e.g., increased circulating catecholamine levels, sweating, restlessness, and/or tremor), dehydration, and electrolyte abnormalities. The most common symptoms are abdominal pain and tachycardia. In addition, patients frequently have chronic neuropathic pain and develop a progressive neuropathy. Patients with recurring attacks often have a prodrome. Permanent paralysis may occur after a severe attack. Recovery from severe attacks that are not promptly treated may take weeks or months. An acute attack may be fatal, for example, due to paralysis of respiratory muscles or cardiovascular failure from electrolyte imbalance. Prior to the availability of Hemin treatments, up to 20% of patients with AIP died from the disease. In individuals who carry genes for AIP, the risk of hepatocellular cancer is increased. In those with recurrent attacks, the risk of hepatocellular cancer is particularly grave: after the age of 50, the risk is nearly 100-fold greater than in the general population. Attacks of acute porphyria may be precipitated by endogenous or exogenous factors. The mechanisms by which such factors induce attacks may include, for example, increased demand for hepatic P450 enzymes and/or induction of ALAS1 activity in the liver. Increased demand for hepatic P450 enzymes results in decreased hepatic free heme, thereby inducing the synthesis of hepatic ALAS1. Precipitating factors include fasting (or other forms of reduced or inadequate caloric intake, due to crash diets, long-distance athletics, etc.), metabolic stresses (e.g., infections, surgery, international air travel, and psychological stress), endogenous hormones (e.g., progesterone), cigarette smoking, lipid-soluble foreign chemicals (including, e.g., chemicals present in tobacco smoke, certain prescription drugs, organic solvents, biocides, components in alcoholic beverages), endocrine factors (e.g., reproductive hormones (women may experience exacerbations during the premenstrual period), synthetic estrogens, progesterones, ovulation stimulants, and hormone replacement therapy). Over 1000 drugs are contraindicated in the acute hepatic porphyrias (e.g., AIP, HCP, ADP, and VP) including, for example, alcohol, barbiturates, Carbamazepine, Carisoprodol, Clonazepam (high doses), Danazol, Diclofenac and possibly other NSAIDS, Ergots, estrogens, Ethyclorvynol, Glutethimide, Griseofulvin, Mephenytoin, Meprobamate (also mebutamate and tybutamate), Methyprylon, Metodopramide, Phenytoin, Primidone, progesterone and synthetic progestins, Pyrazinamide, Pyrazolones (aminopyrine and antipyrine), Rifampin, Succinimides (ethosuximide and methsuximide), sulfonamide antibiotics, and Valproic acid. Objective signs of AIP include discoloration of the urine during an acute attack (the urine may appear red or red-brown), and increased concentrations of PBG and ALA in urine during an acute attack. Molecular genetic testing identifies mutations in the PBG deaminase (also known as HMBS) gene in more than 98% of affected individuals. The differential diagnosis of porphyrias may involve determining the type of porphyria by measuring individual levels of porphyrins or porphyrin precursors (e.g., ALA, PBG) in the urine, feces, and/or plasma (e.g., by chromatography and fluorometry) during an attack. The diagnosis of AIP can be confirmed by establishing that erythrocyte PBG deaminase activity is at 50% or less of the normal level. DNA testing for mutations may be carried out in patients and at-risk family members. The diagnosis of AIP is typically confirmed by DNA testing to identify a specific causative gene mutation (e.g., an HMBS mutation). Treatment of acute attacks typically requires hospitalization to control and treat acute symptoms, including, e.g., abdominal pain, seizures, dehydration/hyponatremia, nausea/vomiting, tachycardia/hypertension, urinary retention/ileus. For example, abdominal pain may be treated, e.g., with narcotic analgesics, seizures may be treated with seizure precautions and possibly medications (although many anti-seizure medications are contraindicated), nausea/vomiting may be treated, e.g., with phenothiazines, and tachycardia/hypertension may be treated, e.g., with beta blockers. Treatment may include withdrawal of unsafe medications, monitoring of respiratory function, as well as muscle strength and neurological status. Mild attacks (e.g., those with no paresis or hyponatremia) may be treated with at least 300 g intravenous 10% glucose per day, although increasingly hemin is provided immediately. Severe attacks should be treated as soon as possible with intravenous hemin (3-4 mg/kg daily for 4-14 days) and with IV glucose while waiting for the IV hemin to take effect. Typically, attacks are treated with IV hemin for 4 days and with IV glucose while waiting for administration of the IV hemin. Hemin (Panhematin® or hemin for injection, previously known as hematin) is the only heme product approved for use in the United States and was the first drug approved under the Orphan Drug Act. Panhematin ® is hemin derived from processed red blood cells (PRBCs), and is Protoporphyrin IX containing a ferric iron ion (Heme B) with a chloride ligand. Heme acts to limit the hepatic and/or marrow synthesis of porphyrin. The exact mechanism by which hemin produces symptomatic improvement in patients with acute episodes of the hepatic porphyrias has not been elucidated; however, its action is likely due to the (feedback) inhibition of δ-aminolevulinic acid (ALA) synthase, the enzyme which limits the rate of the porphyrin/heme biosynthetic pathway. Inhibition of ALA synthase should result in reduced production of ALA and PBG as well as porphyrins and porphyrin intermediates.
Drawbacks of hemin include its delayed impact on clinical symptoms and its failure to prevent the recurrence of attacks. Adverse reactions associated with hemin administration may include thrombophlebitis, anticoagulation, thrombocytopenia, renal shut down, or iron overload, which is particularly likely in patients requiring multiple courses of hemin treatment for recurrent attacks. To prevent phlebitis, an indwelling venous catheter is needed for access in patients with recurrent attacks. Uncommonly reported side effects include fever, aching, malaise, hemolysis, anaphalaxis, and circulatory collapse.
Heme is difficult to prepare in a stable form for intravenous administration. It is insoluble at neutral pH but can be prepared as heme hydroxide at pH 8 or higher. Panhematin® is a lyophilized hemin preparation. When lyophilized hemin is solubilized for intravenous administration, degradation products form rapidly; these degradation products are responsible for a transient anticoagulant effect and for phlebitis at the site of infusion. Heme albumin and heme arginate (Normosang, the European version of hemin) are more stable and may potentially cause less thrombophlebitis. However, heme arginate is not approved for use in the United States. Panhemin® may be stabilized by solubilizing it for infusion in 30% human albumin rather than in sterile water; however, albumin adds intravascular volumeexpanding effects and increases the cost of treatment as well as risk of pathogens since it is isolated from human blood.
The successful treatment of an acute attack does not prevent or delay recurrence.
There is a question of whether hemin itself can trigger recurring attacks due to induction of heme oxygenase. Nonetheless, in some areas (especially France), young women with multiply recurrent attacks are being treated with weekly hemin with the goal of achieving prophylaxis.
The current therapy for acute neurological attacks includes the intravenous administration of hemin (Panhematin®, Lundbeck or Normosang ®, Orphan Europe), which provides exogenous heme for the negative feedback inhibition of ALAS1, and thereby, decreases production of ALA and PBG. Hemin is used for the treatment during an acute attack and for prevention of attacks, particularly in women having an acute porphyria who experience frequent attacks due to hormonal changes during their menstrual cycles. While patients generally respond well, its effect is slow, typically taking two to four days or longer for urinary ALA and PBG concentrations to trend towards normal levels. As the intravenous hemin is rapidly metabolized, three to four infusions are usually necessary to effectively treat or prevent an acute attack. In addition, repeated infusions may cause iron overload and phlebitis, which may compromise peripheral venous access. Givosiran (Givlaari ®), an aminolevulinate synthase 1-directed small interfering ribonucleic acid (siRNA) is also used to treat patients with acute hepatic porphyrias by targeting and degrading ALAS1 mRNA in hepatocytes using RNA interference. The concerned risks associated with the use of givosiran include anaphylactic reactions, liver toxicity, and renal toxicity. For example, 15% patients in givosiran clinical trials showed transaminase (ALT) elevations 3 times the upper limit of normal. Additionally, 15% of patients receiving givosiran have renal-related adverse reactions including elevated serum creatinine levels and decreased estimated glomerular filtration rate. One final treatment is orthotrophic liver transplantation. While orthotrophic liver transplantation is curative, this procedure has significant morbidity and mortality and the availability of liver donors is limited. Accordingly, there is a need for new methods and compositions for treating and/or preventing hepatic porphyrias. The methods and use of glycine transporter inhibitors, such as, but not limited to, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, fulfill these needs as well as others. Limited experience with liver transplantation suggests that if successful, it is an effective treatment for AIP. There have been approximately 12 transplants in Europe in human patients, with curative or varying effects. Liver transplantation can restore normal excretion of ALA and PBG and prevent acute attacks. Furthermore, if the liver of a patient with AP is transplanted into another patient ("domino transplant"), the patient receiving the transplant may develop AIP. While orthotrophic liver transplantation is curative, this procedure has significant morbidity and mortality, and the availability of liver donors is limited. Among the long-term clinical effects of acute porphyrias is chronic neuropathic pain that may result from a progressive neuropathy due to neurotoxic effects, e.g., of elevated porphyrin precursors (e.g., ALA and/or PBG). Patients may suffer from neuropathic pain prior to or during an acute attack. Older patients may experience increased neuropathic pain with age for which various narcotic drugs are typically prescribed. Electromyogram abnormalities and decreased conduction times have been documented in patients with acute hepatic porphyrias. In patients with acute porphyria (e.g., ADP, AIP, HCP, or VP), levels of porphyrin precursors (ALA & PBG) are often elevated in asymptomatic patients and in symptomatic patients between attacks. Thus, reduction of the porphyrin precursors and resumption of normal heme biosynthesis by reducing the level of ALAS1 expression and/or activity is expected to prevent and/or minimize development of chronic and progressive neuropathy. Treatment, e.g., chronic treatment (e.g., periodic treatment with iRNA as described herein, e.g., treatment according to a dosing regimen as described herein, e.g., weekly or biweekly treatment) can continuously reduce the ALAS1 expression in acute porphyria patients who have elevated levels of porphyrin precursors, porphyrins, porphyrin products or their metabolites. Such treatment may be provided as needed to prevent or reduce the frequency or severity of an individual patient's symptoms (e.g., pain and/or neuropathy) and/or to reduce a level of a porphyrin precursor, porphyrin, porphyrin product or metabolite. The need exists for identifying novel therapeutics that can be used for the treatment of porphyrias. As discussed above, existing treatments such as hemin, givosiran, and liver transplant have numerous drawbacks. For example, the impact of hemin on clinical symptoms is delayed, it is expensive, and it may have side effects (e.g., thrombophlebitis, anticoagulation, thrombocytopenia, iron overload, renal shutdown). In certain aspects, the present application provides the use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a pharmaceutical composition for the treatment of a hepatic porphyria in a subject in need thereof. In some embodiments, the disclosure provides methods of preventing or treating a hepatic porphyria in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. For example, the present application provides a method of preventing, treating, or reducing the progression rate and/or severity of a hepatic porphyria in a subject, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. Optionally, methods disclosed herein for preventing, treating, or reducing the progression rate and/or severity of one or more complications of a hepatic porphyria (e.g., AIP, HCP, VP, HARPO, ADP, PCT, and HEP) in a subject, may further comprise administering to the patient one or more supportive therapies or additional active agents for treating porphyria (e.g., AIP, HCP, VP, HARPO, ADP, PCT, and HEP). For example, the patient also may be administered one or more supportive therapies or active agents selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse®), bortezomib, heme infusions, sufficient caloric support, Givosiran, RNAi mediated silencing of various enzymes (e.g., ALA synthase), avoiding precipitating factors, 4-aminoquinolines, chloroquine, hydroxychloroquine, phlebotomy, intravenous magnesium, LH-RH agonists, enzyme replacement therapy (e.g., recombinant human PBGD), gene therapy (e.g., transfer of PBGD gene in liver cells by viral vectors), hemodialysis, pharmacologic chaperone treatment, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion. In some embodiments, the subject is administered a combination treatment, e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and one or more additional treatments known to be effective against AIP, HCP, VP, HARPO, ADP, PCT, and HEP (e.g., glucose and/or a heme product such as hemin, as described herein) or its associated symptoms. In one embodiment, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with glucose or dextrose. For example, 10-20% dextrose in normal saline may be provided intravenously. Typically, when glucose is administered, at least 300 g of 10% glucose is administered intravenously daily. The compound selected from a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may also be administered intravenously, as part of the same infusion that is used to administer the glucose or dextrose, or as a separate infusion that is administered before, concurrently, or after the administration of the glucose or dextrose. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered via a different route of administration (e.g., subcutaneously). In yet another embodiment, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with total parenteral nutrition. The compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be administered before, concurrent with, or after the administration of total parenteral nutrition. In certain embodiments, a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered in combination with one or more additional treatments, e.g., another treatment known to be effective in treating a hepatic porphyria or symptoms of a hepatic porphyria. In one embodiment, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product (e.g., hemin, heme arginate, or heme albumin). In a further embodiment, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product and glucose, a heme product and dextrose, or a heme product and total parenteral nutrition. The additional treatment(s) may be administered before, after, or concurrent with the administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. The compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and an additional therapeutic agent can be administered in combination in the same composition, e.g., intravenously, or the additional therapeutic agent can be administered as part of a separate composition or by another method described herein. In some embodiments, the subject has previously been treated with a heme product (e.g., hemin, heme arginate, or heme albumin), as described herein. In some embodiments, administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in combination one or more additional treatments (e.g., glucose, dextrose), decreases the frequency of acute attacks (e.g., by preventing acute attacks so that they no longer occur, or by reducing the number of attacks that occur in a certain time period, e.g., fewer attacks occur per year). In some such embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered according to a regular dosing regimen, e.g., b.i.d., daily, weekly, biweekly, or monthly. In some embodiments, the subject has or is at risk for developing a hepatic porphyria (e.g., AIP, HCP, VP, ADP, PCT, HARPO, and HEP). In some embodiments, the hepatic porphyria is an acute hepatic porphyria (e.g., AIP, HCP, VP, and ADP). In some embodiments, the hepatic porphyria is a non-acute hepatic porphyria (e.g., PCT and HEP). In some embodiments, the hepatic porphyria is a dual hepatic porphyria, e.g., at least two hepatic porphyrias. In some embodiments, the dual hepatic porphyria comprises two or more hepatic porphyrias selected from the group consisting of AIP, HCP, VP, ADP, HARPO, PCT, and HEP. In some embodiments, the hepatic porphyria is a caused by a heterozygous mutation resulting in reduced enzymatic activity. In some embodiments, the hepatic porphyria is a caused by a homozygous mutation resulting in reduced enzymatic activity. In some embodiments, the hepatic porphyria is an autosomal recessive diseases (e.g., ADP). In some embodiments, the subject carries a genetic alteration (e.g., a mutation) as described herein but is otherwise asymptomatic. A mutation associated with a hepatic porphyria includes mutations in a gene encoding certain enzymes in the heme biosynthetic pathway (porphyrin pathway) or a gene which alters the expression of a gene in the heme biosynthetic pathway (e.g., ALAD, HMBS, UROD, UROS, CPOX, and PPOX). In many embodiments, the subject carries one or more mutations in an enzyme of the porphyrin pathway (e.g., ALA-dehydratase, PBG deaminase, uroporphyrinogen III synthase, uroporphyrinogen III synthase, uroporphyrinogen decarboxylase, coproporphyrinogen oxidase, and protoporphyrinogen oxidase). In some embodiments, the hepatic porphyria is acute hepatic porphyria. In some embodiments, the hepatic porphyria is non-acute hepatic porphyria. In some embodiments, the hepatic porphyria is acute intermittent porphyria (AIP). In some embodiments, the hepatic porphyria is ALA dehydratase porphyria (ADP). In some embodiments, the hepatic porphyria is variegate porphyria (VP). In some embodiments, the hepatic porphyria is hereditary coproporphyria (HCP). In some embodiments, the hepatic porphyria is harderoporphyria (HARPO). In some embodiments, the hepatic porphyria is porphyria cutanea tarda (PCT). In some embodiments, the PCT is familial or sporadic PCT. In some embodiments, the hepatic porphyria is hepatoerythropoietic porphyria (HEP). In some embodiments, patients with an acute hepatic porphyria (e.g., AIP), or patients who carry mutations associated with an acute hepatic porphyria (e.g., AIP) but who are asymptomatic, have elevated ALA and/or PBG levels compared with healthy individuals. In such cases, the level of ALA and/or PBG can be elevated even when the patient is not having, or has never had, an attack. In some such cases, the patient is otherwise completely asymptomatic. In some such cases, the patient suffers from pain, e.g., neuropathic pain, which can be chronic pain (e.g., chronic neuropathic pain). In some cases, the patient has a neuropathy. In some cases, the patient has a progressive neuropathy. In some embodiments, the subject has an acute attack of hepatic porphyria. In some embodiments, the subject has a non-acute attack of hepatic porphyria. In some embodiments, the subject has never experienced an acute attack of hepatic porphyria. In some embodiments, the subject suffers from chronic pain. In some embodiments, the subject has nerve damage. In some embodiments, the subject has EMG changes and/or changes in nerve conduction velocity. In some embodiments, the subject is asymptomatic. In some embodiments, the subject is at risk for developing a hepatic porphyria (e.g., carries a gene mutation associated with a hepatic porphyria) and is asymptomatic. In some embodiments, the subject has previously had an acute attack of hepatic porphyria but is asymptomatic at the time of treatment. In some embodiments, the subject is at risk for developing a hepatic porphyria and is treated prophylactically to prevent the development of a hepatic porphyria. In some embodiments the subject has an elevated level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG). In some embodiments, the prophylactic treatment begins at puberty. In some embodiments the treatment lowers the level (e.g., the plasma level or the urine level) of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG). In some embodiments, the treatment prevents the development of an elevated level of a porphyrin or a porphyrin precursor, (e.g., ALA and/or PBG). In some embodiments, the treatment prevents the development of, or decreases the frequency or severity of, a symptom associated with a hepatic porphyria (e.g., pain or nerve damage). The present application further provides use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of a hepatic porphyria in a subject. In some embodiments, the subject to be treated according to the methods described suffers from pain, e.g., chronic pain. In some embodiments, the method is effective to treat the pain (e.g., by reducing the severity of the pain or curing the pain). In some embodiments, the method is effective to decrease or prevent nerve damage. In some embodiments, the subject to be treated according to the methods described herein (a) has an elevated level of ALA and/or PBG and (b) suffers from pain (e.g., chronic pain). In some embodiments, the method is effective to decrease an elevated level of ALA and/or PBG and/or to treat the pain (e.g., by reducing the severity of the pain or curing the pain). In some embodiments, the subject is a subject who has suffered one or more acute attacks of one or more hepatic porphyric symptoms. In other embodiments, the subject is a subject who has suffered chronically from one or more symptoms of hepatic porphyria (e.g., pain, e.g., neuropathic pain and or neuropathy, e.g., progressive neuropathy). In some embodiments, the subject to be treated according to the methods described herein has recently experienced or is currently experiencing a prodrome. A “prodrome,” as used herein, includes any symptom that the individual subject has previously experienced immediately prior to developing an acute attack. Typical symptoms of a prodrome include, e.g., abdominal pain, nausea, headaches, psychological symptoms (e.g., anxiety), restlessness and/or insomnia. In some embodiments, the subject experiences pain (e.g., abdominal pain and/or a headache) during the prodrome. In some embodiments, the subject experiences nausea during the prodrome. In some embodiments, the subject experiences psychological symptoms (e.g., anxiety) during the prodrome. In some embodiments, the subject becomes restless and/or suffers from insomnia during the prodrome. An acute “attack” of hepatic porphyria involves the onset of one or more symptoms of hepatic porphyria, typically in a patient who carries a mutation associated with hepatic porphyria (e.g., a mutation in a gene that encodes an enzyme in the porphyrin pathway). In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered after an acute attack of a hepatic porphyria. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered during an acute attack of a hepatic porphyria. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to lessen the severity of the attack (e.g., by ameliorating one or more signs or symptoms associated with the attack). In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to shorten the duration of an attack. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to stop an attack. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered prophylactically to prevent an acute attack of hepatic porphyria. In some embodiments, the prophylactic administration is before, during, or after exposure to or occurrence of a precipitating factor. In some embodiments, the subject is at risk of developing porphyria. A “precipitating factor” as used herein, refers to an endogenous or exogenous factor that may induce an acute attack of one or more symptoms associated with porphyria. Precipitating factors include fasting (or other forms of reduced or inadequate caloric intake, due to crash diets, long-distance athletics, etc.), metabolic stresses (e.g., infections, surgery, international air travel, and psychological stress), endogenous hormones (e.g., progesterone), cigarette smoking, lipid-soluble foreign chemicals (including, e.g., chemicals present in tobacco smoke, certain prescription drugs, organic solvents, biocides, components in alcoholic beverages), endocrine factors (e.g., reproductive hormones (women may experience exacerbations during the premenstrual period), synthetic estrogens, progesterones, ovulation stimulants, and hormone replacement therapy), and lead. Other common precipitating factors include cytochrome P450 inducing drugs and phenobarbitol. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered during a prodrome. In some embodiments, the prodrome is characterized by pain (e.g., headache and/or abdominal pain), nausea, psychological symptoms (e.g., anxiety), restlessness and/or insomnia. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered during a particular phase of the menstrual cycle, e.g., during the luteal phase. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to prevent attacks (e.g., recurrent attacks that are associated with a prodrome and/or with a precipitating factor, e.g., with a particular phase of the menstrual cycle, e.g., the luteal phase). In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is effective to reduce the frequency of attacks. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to lessen the severity of the attack (e.g., by ameliorating one or more signs or symptoms associated with the attack). In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to shorten the duration of an attack. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to stop an attack. In some embodiments administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to prevent or decrease the frequency or severity of pain, e.g., neuropathic pain. In some embodiments administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to prevent or decrease the frequency or severity of neuropathy. In some embodiments, the subject has or is at risk for developing a hepatic porphyria and suffers from pain (e.g., neuropathic pain, e.g., chronic neuropathic pain) or neuropathy (e.g., progressive neuropathy). In some embodiments, the subject has an elevated level of ALA and/or PBG and suffers from chronic pain. Effects of administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, can be established, for example, by comparison with an appropriate control. For example, a decrease in the frequency of acute attacks, as well as a decrease in the level of one or more porphyrins or porphyrin precursors, may be established, for example, in a group of patients with AIP, as a decreased frequency compared with an appropriate control group. A control group (e.g., a group of similar individuals or the same group of individuals in a crossover design) may include, for example, an untreated population, a population that has been treated with a conventional treatment for hepatic porphyria (e.g., a conventional treatment for AIP may include glucose, hemin, or both); a population that has been treated with placebo, or a GlyT1 inhibitor, optionally in combination with one or more conventional treatments for hepatic porphyria (e.g., glucose, e.g., IV glucose). A subject “at risk” of developing hepatic porphyria, as used herein, includes a subject with a family history of hepatic porphyria and/or a history of one or more recurring or chronic hepatic porphyria symptoms, and/or a subject who carries a genetic alteration (e.g., a mutation) in a gene encoding an enzyme of the heme biosynthetic pathway, and a subject who carries a genetic alteration, e.g., a mutation known to be associated with hepatic porphyria. In some embodiments, the alteration, e.g., the mutation, makes an individual susceptible to an acute attack (e.g., upon exposure to a precipitating factor, e.g., a drug, dieting or other precipitating factor, e.g., a precipitating factor as disclosed herein). In some embodiments, the alteration, e.g., the mutation, is associated with elevated levels of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG). In some embodiments, the alteration, e.g., the mutation, is associated with chronic pain (e.g., chronic neuropathic pain) and/or neuropathy (e.g., progressive neuropathy). In some embodiments, the alteration, e.g., the mutation, is associated with changes in EMG and/or nerve conduction velocities. In some embodiments, the alteration is a mutation in a gene selected from the group consisting of ALAD, HMBS, UROD, CPOX, and PPOX. In some embodiments, the alteration is an alteration, e.g., a mutation, in a gene that encodes an enzyme in the heme biosynthetic pathway. In some embodiments, the subject has a genetic alteration but does not suffer from acute attacks. In some embodiments, the subject has a mutation associated with AIP, HCP, VP, ADP, PCT, or HEP. In some embodiments, the hepatic porphyria is AIP. In some such embodiments, the subject has an alteration, e.g., at least one mutation, in PBGD (gene encoding PBG deaminase). Many PBGD mutations are known in the art. In some embodiments, the subject is heterozygous for a PBGD mutation. In other embodiments, the subject is homozygous for a PBGD mutation. A homozygous subject may carry two identical mutations or two different mutations in the PBGD gene. In some embodiments, the hepatic porphyria is HCP. In some embodiments, the subject has an alteration, e.g., at least one mutation, in CPOX (i.e, gene that encodes the enzyme coproporphyrinogen III oxidase). In some embodiments, the hepatic porphyria is VP. In some embodiments, the subject has an alteration, e.g., at least one mutation, in PPOX (i.e., gene that encodes protoporphrinogen oxidase). In some embodiments, the hepatic porphyria is ADP (e.g., autosomal recessive ADP). In some embodiments, the subject has an alteration, e.g., at least one mutation, in ALAD (gene that encodes ALA dehydratase). In some embodiments, the hepatic porphyria is PCT. In some embodiments, the subject has an alteration, e.g., at least one mutation, in UROD (gene that encodes uro-decarboxylase). In some embodiments, the hepatic porphyria is CEP. In some embodiments, the subject has an alteration, e.g., at least one mutation, in UROS (gene that encodes uroporphyrinogen III synthase). In some embodiments, the increased levels of porphyrin precursors are due to lead poisoning. Lead poisoning inhibits the activity of each of ALAD, CPOX, and FECH, enzymes which are involved in heme biosynthesis. Patients with lead poisoning are frequently misdiagnosed with ADP or other acute porphyrias. In some embodiments, a subject with lead poisoning has decreased enzymatic activity of ALAD. In some embodiments, a subject with lead poisoning has decreased enzymatic activity of CPOX. In some embodiments, a subject with lead poisoning has decreased enzymatic activity of FECH. In some embodiments, a subject with lead poisoning has increased levels of lead in the blood and/or urine. In some embodiments, a subject with lead poisoning has increased levels of ALA. In some embodiments, a subject with lead poisoning has increased levels of ALA and PBG. In some embodiments, a subject with lead poisoning has ALA levels which are increased by at least 10 fold over a reference value. In some embodiments, a subject with lead poisoning has ALA levels which are increased by at least 5 fold over a reference value. In some embodiments, the disclosure relates to methods of treating lead poisoning in a subject, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject is further administered a chelating agent. In some embodiments the chelating agent is 2,3- dimercaptosuccinic acid. In some embodiments, the chelating agent is calcium disodium ethylenediamine-tetraacetate. Porphyrins (e.g., 5-ALA, PBG, uroporphyrin, and coproporphyrin) can be found in various biological samples including the skin, urine, stool, plasma, and erythrocytes. In some embodiments, the porphyrins may be extracted from the biological sample (e.g., plasma) into a solution for fluorescence analysis. Porphyrins can be detected in these biological samples by direct inspection using long wavelength ultraviolet light (e.g., 400-420 nm light). Porphyrins have the greatest absorption wavelengths near 400-420 nm, with their highest absorption peak occurring at 415 nm. The emission maxima of porphyrins is typically around 600 nm and varies slightly based on the type of porphyrins and the solvent used for analysis. In some embodiments, diagnosis of a hepatic porphyria may be made using fluorescence analysis. In some embodiments, skin porphyrin levels can be measured by calculating the difference before and after complete photobleaching of the skin porphyrin using controlled illumination. See, e.g., Heerfordt IM. Br J Dermatol.2016;175(6):1284-1289. In some embodiments, the subject’s plasma porphyrin fluoresces at a peak of 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s plasma porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak of 632 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, a sample from the subject (e.g., plasma or skin) containing a porphyrin or porphyrin precursor fluoresces at a peak between 615 nm and 620 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, a sample from the subject (e.g., plasma or skin) containing a porphyrin or porphyrin precursor fluoresces at a peak between 624 nm and 627 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s plasma is excited using a 405 nm laser. In some embodiments, the subject has red fluorescent urine. Erythropoietic Protoporphyria, X-linked Protoporphyria, and Congenital Erythropoietic Porphyria Erythropoietic protoporphyria (EPP) is prevalent globally and affects about 5,000- 10,000 individuals worldwide (Michaels et al.2010). EPP is considered the most common form of porphyria in children. Erythropoietic protoporphyria is a form of porphyria, which varies in severity and can be very painful. It arises from a deficiency in the enzyme ferrochelatase, leading to abnormally high levels of protoporphyrin IX in red blood cells (erythrocytes), plasma, skin, and liver. Erythropoietic protoporphyria is due to an inherited or acquired deficiency in the activity of the enzyme ferrochelatase. X-linked protoporphyria (XLPP) is due to an inherited increase in the activity of delta-aminolevulinic acid synthase-2 (ALAS2). Enzymes that cause both EPP and XLPP are in the heme biosynthetic pathway. EPP and XLPP are nearly identical clinically. Congenital erythropoietic porphyria (CEP), also known as Gunther disease, caused by mutations in the gene for uroporphyrinogen synthase resulting in reduced activity of this enzyme and accumulation of the upstream metabolite coproporphyrin I. Current treatments for erythropoietic protoporphyria (EPP), X- linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) are limited. Thus, there is a need for new methods and compositions for treating and/or preventing erythropoietic protoporphyria, X-linked protoporphyria, and congenital erythropoietic porphyria. The methods and use of glycine transporter inhibitors, such as, but not limited to, GlyT1 inhibitors (e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof) fulfill these needs as well as others. The present application provides methods of preventing or treating disorders associated with accumulation of PPIX in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In part, the present application relates to methods of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain embodiments, the present application provides methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. These methods are particularly aimed at therapeutic and prophylactic treatments of animals, and more particularly, humans. The terms "subject," an "individual," or a "patient" are interchangeable throughout the specification and refer to either a human or a non-human animal. These terms include mammals, such as humans, non-human primates, laboratory animals, livestock animals (including bovines, porcines, camels, etc.), companion animals (e.g., canines, felines, other domesticated animals, etc.) and rodents (e.g., mice and rats). In particular embodiments, the patient, subject or individual is a human. The present application provides methods of preventing or treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP), or related syndrome (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) thereof in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. The present application further provides methods of preventing or treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. For example, the present application provides methods of treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. The present application further provides methods of preventing or treating EPP, XLPP, or CEP, or related syndrome thereof (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. The present application further provides methods of preventing or treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain embodiments of the foregoing, the pharmaceutical composition further comprises a pharmaceutically acceptable carrier. Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLPP) are erythropoietic cutaneous porphyrias characterized by acute non-blistering photosensitivity, intolerance to sunlight, and significantly reduced quality of life. EPP is caused by a partial deficiency in ferrochelatase (FECH), which catalyzes the final step in the heme biosynthesis pathway. FECH deficiency increases levels of metal-free erythrocyte PPIX (also referred to herein as “free-protoporphyrin IX” and “PPIX”). XLPP is typically caused by C-terminal deletions in the ALAS2 gene which result in a gain-of-function mutation. These gain-of- function mutations increase the enzymatic activity of ALAS2 and cause an accumulation of both metal-free and zinc-bound PPIX. Both EPP and XLPP result in an accumulation of PPIX in erythrocytes and other tissues or biological fluids (e.g., skin, liver, bile, or stool). PPIX, which is lipophilic and eliminated via bile, is hepatotoxic at high concentrations. Patients with EPP or XLPP usually develop photosensitivity during early childhood. Patients frequently present with symptoms of burning, itching, pain erythema, and edema on sun-exposed areas. Cutaneous symptoms are sometimes associated with abnormal liver enzyme activities, hepatobiliary injury, such as jaundice and liver cirrhosis, iron deficiency, and corresponding microcytic anemia. The diagnosis of EPP and XLPP can be determined by measuring the levels of total erythrocyte, free-protoporphyrin IX, and zinc-protoporphyrin IX in hemolyzed anticoagulated whole blood. A diagnosis of EPP and/or XLPP can be made based on increased levels of free-protoporphyrin IX in blood. Patients with XLPP have a significantly higher proportion of zinc-protoporphyrin IX to free-protoporphyrin IX (e.g., >25%) as compared to those with EPP (e.g., ≤15%). The diagnosis of EPP can also be determined by measuring the level of ferrocheletase activity in a subject. Ferrocheletase is a mitochondrial enzyme that catalyzes the insertion of ferrous iron into PPIX to form heme. Ferrocheletase also catalyzes the insertion of zinc, to form zinc protoporphyrin IX (ZPPIX) from any PPIX that remains after completion of heme synthesis. In EPP, free PPIX accumulates in bone marrow reticulocytes, since formation of both heme and ZPPIX is impaired. In some embodiments, the disclosure relates to methods of a treating a subject whose ferrochelatase activity level is reduced to between 10 to 35% of the ferrocheletase activity level observed in normal subjects. In some embodiments, the disclosure relates to methods of a treating a subject whose ferrochelatase activity level is reduced to less than 50% of the ferrocheletase activity level observed in normal subjects. XLPP has a similar phenotype to EPP, and can be differentiated based on genetic analysis of ALAS2 or by determining the enzymatic activity level of ALAS2. In some embodiments, the disclosure relates to methods of a treating a subject having a gain-of- function mutation in ALAS2. In some embodiments, the subject’s ALAS2 enzyme activity is increased. Since ferrocheletase is not deficient in XLPP, some of the excess PPIX measured in erythrocytes is ZPPIX and a lower percentage (e.g., 50-85%) is metal-free. In some embodiments, the subject has increased zinc-protoporphyrin IX levels in erythrocytes. In some embodiments, the method decreases zinc-protoporphyrin IX levels in the subject’s erythrocytes. In some embodiments, method decreases zinc-protoporphyrin IX levels in the subject’s erythrocytes by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In certain aspects, the disclosure relates to methods of treating erythropoietic protoporphyria (EPP) and/or X-linked protoporphyria (XLPP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased PPIX levels. In some embodiments, the method relates to subjects having PPIX levels that are at least 10%, 20%, 30%, 40%, or 50% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 10% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 20% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 30% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 40% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having PPIX levels that are at least 50% more than PPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has increased protoporphyrin IX levels in the stool. In some embodiments, the subject has increased protoporphyrin IX levels in the skin. In some embodiments, the subject has increased free-protoporphyrin IX levels in erythrocytes. In some embodiments, the subject has greater than 31 µmol L-1 protoporphyrin IX levels in the erythrocytes. In some embodiments, the subject has between 31 µmol L-1 and 53 µmol L-1 protoporphyrin IX levels in the erythrocytes. In some embodiments, the subject has greater than 53 µmol L-1 protoporphyrin IX levels in the erythrocytes. The present application further provides methods of inhibiting PPIX synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of inhibiting PPIX synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting PPIX synthesis in vivo by at least 100%. The present application further provides methods of decreasing the rate of PPIX synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain embodiments of the methods and uses as disclosed herein inhibit PPIX accumulation directly or indirectly. In certain such embodiments, PPIX accumulation is inhibited in a dose dependent manner.
In some embodiments, the method relates to methods of decreasing free- protoporphyrin IX levels in the subject. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject’s erythrocytes. In some embodiments, the method decreases protoporphyrin IX levels in the erythrocytes of the subject to levels less than 53 μmol L-l. In some embodiments, the method decreases protoporphyrin IX levels in the erythrocytes of the subject to levels less than 31 μmol L- 1. In some embodiments, the method decreases protoporphyrin IX levels in the erythrocytes of the subject to levels less than 15 μmol L-l. In some embodiments, the method relates to decreasing protoporphyrin IX levels in the stool of the subject. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 15%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 20%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 25%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 30%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 35%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 40%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 45%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 50%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 55%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 60%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 65%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 70%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 75%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 80%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 85%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 90%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 95%. In some embodiments, the method relates to methods of decreasing free-protoporphyrin IX levels in the subject by at least 100%. In certain aspects, the disclosure relates to methods of treating X-linked protoporphyria (XLPP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased zinc-protoporphyrin IX (ZPPIX) levels. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 10%, 20%, 30%, 40%, or 50% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 10% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 20% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 30% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 40% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having ZPPIX levels that are at least 50% more than ZPPIX levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has increased ZPPIX levels in erythrocytes. In certain aspects, the disclosure relates to methods of treating X-linked protoporphyria (XLPP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased proportion of zinc-protoporphyrin IX (ZPPIX) to free-protoporphyrin IX (ZPPIX/PPIX ratio) as compared to those with EPP. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 15% (e.g., 15%, 20%, 25%, 30%, 35%, 40%, or 45%). In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 20%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 25%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 30%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 35%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 40%. In some embodiments, the method relates to subjects having a ZPPIX/PPIX ratio that is at least 45%. In certain aspects, the disclosure relates to methods of inhibiting zinc protoporphyrin IX (ZPPIX) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting ZPPIX synthesis in vivo by at least 100%. In certain aspects, the disclosure relates to methods of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased 5-aminolevulinic acid (5-ALA) levels. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 10%, 20%, 30%, 40%, or 50% more than 5- ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 10% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 20% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 30% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 40% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having 5-ALA levels that are at least 50% more than 5-ALA levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of inhibiting 5-aminolevulinic acid (5-ALA) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting 5-ALA synthesis in vivo by at least 100%. The present application further provides use of one or more compound selected from a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of EPP, XLPP, CEP or related syndrome thereof (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) in a subject. In some embodiments, the present application provides use of one or more compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of EPP, XLPP, or CEP in a subject. The present application provides the use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a pharmaceutical composition for the treatment of EPP, XLPP, or CEP, or related syndrome thereof (e.g., EPP-related syndrome, XLPP-related syndrome, or CEP-related syndrome) in a subject. In certain embodiments of the foregoing, the pharmaceutical composition further comprises a pharmaceutically acceptable carrier. Congenital erythropoietic porphyria (CEP) is an erythropoietic cutaneous porphyria characterized by blistering cutaneous photosensitivity. Severe cases of CEP can present in utero with hydrops fetalis, or shortly after birth with severe blistering photosensitivity, red urine, splenomegaly, hemolysis, and transfusion dependence. Milder cases and later onset forms typically present with red urine, severe blistering, and hemolytic anemia. CEP individuals are often homozygous or compound heterozygous for UROS mutations. Some cases of CEP are due to mutations in the gene encoding the transcriptional regulator GATA1. These mutations result in reduced enzyme activity of uroporphyrinogen III synthase (UROIII-S), the fourth enzyme in the heme biosynthetic pathway. The decreased activity of UROIII-S leads to an accumulation of hydroxymethylbilane which spontaneously forms uroporphyrinogen I, which is further metabolized to coproporphyrinogen I. Uroporphyrinogen I and coproporphyrinogen I accumulate in the tissues. The diagnosis of CEP can be determined by analyzing the enzyme activity of uroporphyrinogen III synthase (UROIII-S), by evaluating mutations in the UROS gene, by evaluating the function of GATA-1 erythroid-specific transcription factor, by evaluating mutations in GATA1, and by determining the levels of uroporphyrin I and coproporphyrin I in the subject. In some embodiments, the subject has a mutation in UROS. In some embodiments, the subject has a gene defect in GATA-1 erythroid-specific transcription factor. In some embodiments, the method relates to methods of treating a subject, wherein the subject has decreased activity of uroporphyrinogen III synthase. In some embodiments, the increased levels of uroporphyrin I and/or coproporphyrin I are measured in the subject’s urine or red blood cells. In some embodiments, the increased levels of coproporphyrin I are measured in the subject’s stool. In certain aspects, the disclosure relates to methods of treating congenital erythropoietic porphyria (CEP) in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has increased uroporphyrin I and/or coproporphyrin I levels. In some embodiments, the subject has increased levels of uroporphyrin I and/or coproporphyrin I. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 10%, 20%, 30%, 40%, or 50% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 10% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 20% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 30% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 40% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having uroporphyrin I levels that are at least 50% more than uroporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of treating subjects having coproporphyrin I levels that are at least 10%, 20%, 30%, 40%, or 50% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 10% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 20% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 30% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 40% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method relates to subjects having coproporphyrin I levels that are at least 50% more than coproporphyrin I levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of treating EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels. In some embodiments, the patient’s PPIX levels decrease by at least 50% (e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the patient’s PPIX levels decrease by at least 55%. In some embodiments, the patient’s PPIX levels decrease by at least 60%. In some embodiments, the patient’s PPIX levels decrease by at least 65%. In some embodiments, the patient’s PPIX levels decrease by at least 70%. In some embodiments, the patient’s PPIX levels decrease by at least 75%. In some embodiments, the patient’s PPIX levels decrease by at least 80%. In some embodiments, the patient’s PPIX levels decrease by at least 85%. In some embodiments, the patient’s PPIX levels decrease by at least 90%. In some embodiments, the patient’s PPIX levels decrease by at least 95%. In some embodiments, the patient’s PPIX levels decrease by at least 100%. In some embodiments, the patient’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%). In some embodiments, the patient’s heme levels decrease no more than 15%. In some embodiments, the patient’s heme levels decrease no more than 20%. In some embodiments, the patient’s heme levels decrease no more than 25%. In some embodiments, the patient’s heme levels decrease no more than 30%. In some embodiments, the accumulation of one or more of the following heme intermediates is inhibited, wherein the one or more heme intermediates is selected from the group consisting of PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of PPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of ZPPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of uroporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of coproporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of 5-ALA, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the accumulation of the one or more heme intermediates (e.g., PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA) is inhibited in a dose dependent manner.
Protoporphyrin accumulation in EPP, XLPP, and CEP can cause liver damage when the hepatic load exceeds the canalicular excretion capacity. The accumulation of PPIX in hepatocytes and bile canaliculi may result in cell damage, cholestasis, cytolysis and further retention of protoporphyrin. Excess protoporphyrin can exert cholestatic effects leading to changes in the hepatobiliary system which can range from mild inflammation to fibrosis and cirrhosis (e.g., cholelithiasis, mild liver disease, deteriorating liver disease, and terminal phase liver disease). Between 3-5% of patients with EPP or XLPP develop protoporphyria hepatopathy, a severe liver disease that can progress rapidly and require liver transplantation. Approximately 2% of patients will develop severe liver disease.
In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of liver disease associated with EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the liver disease associated with EPP, XLPP, or CEP is cholelithiasis. In some embodiments, the liver disease associated with EPP, XLPP, or CEP is mild liver disease. In some embodiments, the liver disease associated with EPP, XLPP, or CEP is deteriorating liver disease. In some embodiments, the liver disease associated with EPP, XLPP, or CEP is terminal phase liver disease.
Liver function in patients with EPP, XLPP, and CEP can be assessed using various known clinical assays. In some embodiments, liver function tests can be used to determine the level of various biochemical parameters (e.g., raised aspartate transaminase levels, alkaline phosphatase, or γ-glutamyl transferase levels). In some embodiments, histopathology of liver biopsies may be used to assess one or more parameters (e.g., protoporphyrin deposition, fibrosis, infiltrates, portal fibrosis, and periportal fibrosis) in the subject. In some embodiments, ultrastructural studies of biopsy specimen can be used to determine if crystal containing vacuoles are present in the subject. With deterioration of liver function, urinary coproporphyrin excretion increases. In some embodiments, coproporphyrin excretion in the urine may be analyzed to assess liver function in the subject. In some embodiments, ultrasound, or magnetic resonance elastography may be used to measure liver stiffness in the subject. In certain embodiments of the methods and uses as disclosed herein, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 500 nM, less than 400 nM, less than 300 nM, less than 200 nM, or less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 50 nM. In certain such embodiments, the EC50 is measured in a flow cytometry assay. In certain embodiments of the methods and uses as disclosed herein, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 500 nM, less than 400 nM, less than 300 nM, less than 200 nM, or less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates PPIX inhibition with an EC50 of less than 50 nM. In certain such embodiments, the EC50 is measured in a flow cytometry assay. In certain embodiments of the methods and uses as disclosed herein, at least 50%, at least 60%, at least 70%, at least 80%, at least 85%, at least 90%, or at least 95% cell viability is maintained. In certain such embodiments, at least 90% cell viability is maintained. Heme and Heme Intermediates Glycine is one of the key initial substrates for heme and globin synthesis. As such, decreased levels of glycine due to GlyT1 inhibition could lead to a decrease in heme synthesis. In certain aspects, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%). In some embodiments, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 15%. In some embodiments, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 20%. In some embodiments, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 25%. In some embodiments, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, wherein the subject’s heme levels decrease no more than 30%. In certain aspects, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels. In some embodiments, the synthesis of one or more of the following heme intermediates (e.g., porphyrin precursors) is inhibited, wherein the one or more heme intermediates is selected from the group consisting of 5-ALA, PBG, hydroxymethylbilane, ZPPIX, uroporphyrinogen I, uroporphyrinogen III, heptacarboxyporphyrinogen I, heptacarboxyporphyrinogen III, hexacarboxyporphyrinogen I, hexacarboxyporphyrinogen III, pentacarboxyporphyrinogen I, pentacarboxyporphyrinogen III, coproporphyrinogen I, coproporphyrinogen III, isocoproporphyrin, porphobilinogen; and protoporphyrinogen IX. In some embodiments, the disclosure relates to methods of inhibiting 5-aminolevulinic acid (5- ALA) synthesis in a subject, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has a hepatic porphyria, EPP, XLPP, or CEP. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin III synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting zinc-protoporphyrin IX (ZPPIX) synthesis in a subject, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has ALA dehydratase porphyria (ADP). In some embodiments, the disclosure relates to methods of inhibiting porphobilinogen (PBG) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting 5- aminolevulinic acid (5-ALA) and porphobilinogen (PBG) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting hydroxymethylbilane (HMB) synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin III synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting heptacarboxyl-porphyrin synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting isocoproporphyrin synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the synthesis of the one or more heme intermediates (e.g., 5-ALA, coproporphyrin III, ZPPIX, PBG, HMB, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin) is inhibited in a dose dependent manner. In some embodiments, the accumulation of one or more of the following heme intermediates (e.g., porphyrin precursors) is inhibited, wherein the one or more heme intermediates is selected from the group consisting of 5-ALA, PBG, hydroxymethylbilane, ZPPIX, uroporphyrinogen I, uroporphyrinogen III, heptacarboxyporphyrinogen I, heptacarboxyporphyrinogen III, hexacarboxyporphyrinogen I, hexacarboxyporphyrinogen III, pentacarboxyporphyrinogen I, pentacarboxyporphyrinogen III, coproporphyrinogen I, coproporphyrinogen III, isocoproporphyrin, porphobilinogen; and protoporphyrinogen IX. In some embodiments, the accumulation of the one or more heme intermediates (e.g., 5-ALA, coproporphyrin III, ZPPIX, PBG, HMB, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin) is inhibited in a dose dependent manner. In some embodiments, the subject to be treated according to the methods described herein has an elevated level of a porphyrin or a porphyrin precursor, e.g., ALA and/or PBG. In some embodiments, the subject has porphyrin precursor level that is at least 10%, 20%, 30%, 40%, or 50% more than porphyrin precursor level in a healthy subject prior to administration of the v. In some embodiments, the subject has increased levels of a porphyrin precursor. In some embodiments, the porphyrin precursor is selected from the group consisting of 5-ALA, HMB, coproporphyrin III, ZPPIX, porphobilinogen, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin. In some embodiments, the subject has increased uroporphyrin III levels (e.g., increased uroporphyrin III levels in the urine). In some embodiments, the subject has increased levels of 5-ALA (e.g., increased levels of 5- ALA in the urine or plasma). In some embodiments, the subject has increased levels of HMB. In some embodiments, the subject has increased levels of coproporphyrin III (e.g., increased levels of coproporphyrin III in the urine and stool). In some embodiments, the subject has increased levels of PBG (e.g., increased levels of PBG in the urine). In some embodiments, the subject has an increased proportion of protoporphyrin to coproporphyrin in the stool. In some embodiments, the subject has increased heptacarboxyl-porphyrin levels (e.g., increased heptacarboxyl-porphyrin levels in the urine or stool). In some embodiments, the subject has increased isocoproporphyrin levels (e.g., increased isocoproporphyrin levels in the stool). In some embodiments, the subject has increased ZPPIX levels in erythrocytes. Levels of a porphyrin or a porphyrin precursor can be assessed using methods known in the art or methods described herein. In some embodiments, the level of a porphyrin or a porphyrin precursor (e.g., ALA or PBG) in the subject is assessed based on the absolute level of the porphyrin or the porphyrin precursor, e.g., ALA or PBG in a sample from the subject. In some embodiments, the level of a porphyrin or a porphyrin precursor (e.g., ALA or PBG) in the subject is assessed based on the relative level of the porphyrin or porphyrin precursor (e.g., ALA or PBG) in a sample from the subject. In some embodiments, the relative level is relative to the level of another protein or compound, e.g., the level of creatinine, in a sample from the subject. In some embodiments, the sample is a urine sample. In some embodiments, the sample is a plasma sample. In some embodiments, the sample is a stool sample. An elevated level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) can be established by showing that the subject has a level of a porphyrin or a porphyrin precursor (e.g., a plasma or urine level of ALA and/or PBG) that is greater than, or greater than or equal to, a reference value. A physician with expertise in the treatment of porphyrias would be able to determine whether the level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) is elevated, e.g., for the purpose of diagnosing a hepaticporphyria, EPP, XLPP, or CEP or for determining whether a subject is at risk for developing a hepatic porphyria, EPP, XLPP, or CEP, e.g., a subject may be predisposed to an acute attack or to pathology associated with a porphyria, such as, e.g., chronic pain (e.g., neuropathic pain) and neuropathy (e.g., progressive neuropathy). As used herein, a “reference value” refers to a value from the subject when the subject is not in a disease state, or a value from a normal or healthy subject, or a value from a reference sample or population, e.g., a group of normal or healthy subjects (e.g., a group of subjects that does not carry a mutation associated with a hepatic porphyria, EPP, XLPP, or CEP and/or a group of subjects that does not suffer from symptoms associated with a hepatic porphyria, EPP, XLPP, or CEP). In some embodiments, the reference value is a pre-disease level in the same individual. In some embodiments, the reference value is a level in a reference sample or population. In some embodiments, the reference value is the mean or median value in a reference sample or population. In some embodiments, the reference value the value that is two standard deviations above the mean in a reference sample or population. In some embodiments, the reference value is the value that is 2.5, 3, 3.5, 4, 4.5, or 5 standard deviations above the mean in a reference sample or population. In some embodiments, the subject has a plasma level or a urine level of ALA or PBG that is greater than a reference value. In some embodiments, wherein the subject has an elevated level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) the subject has a level of ALA and/or PBG that is at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% higher than a reference value. In some embodiments, the subject has a level of a porphyrin or a porphyrin precursor (e.g., ALA and/or PBG) that is at least 2, 3, 4, 5, 6, 7, 8, 9, or 10 fold higher than a reference value. In some embodiments, the reference value is an upper reference limit. As used herein, an “upper reference limit” refers to a level that is the upper limit of the 95% confidence interval for a reference sample or population, e.g., a group of normal (e.g., wild type) or healthy individuals, e.g., individuals who do not carry a genetic mutation associated with a porphyria and/or individuals who do not suffer from a hepatic porphyria, EPP, XLPP, or CEP. Accordingly, a lower reference limit refers to a level that is the lower limit of the same 95% confidence interval. In some embodiments, the subject has an elevated level (e.g., a plasma level or a urine level) of a porphyrin or a porphyrin precursor that is greater than or equal to 2 times, 3 times, 4 times, or 5 times that of a reference value (e.g., an upper reference limit). In some embodiments, the subject has a urine level of a porphyrin or a porphyrin precursor that is greater than 4 times that of an upper reference limit. In some embodiments, the subject has a urine level of PBG that is greater than or equal to 1.4 mmol/mol creatinine. In some embodiments, the subject has a urine level of PBG that is greater than or equal to 4.8 mmol/mol creatinine. In certain embodiments, the subject has a urine level of PBG that is greater than, or greater than or equal to, about 3, 4, 5, 6, 7, or 8 mmol/mol creatinine.
In some embodiments, the reference value for plasma PBG is 0.12 μmol/L. In some embodiments, the subject has a plasma PBG level that is greater than, or greater than or equal to 0.10 μmol/L, 0.12 μmol/L, 0.24 μmol/L, 0.36 μmol/L, 0.48 μmol/L, or 0.60 μmol/L. In some embodiments, the subject has a plasma level of PBG that is greater than, or greater than or equal to 0.48 μmol/L.
In some embodiments, the reference value for urine PBG is 1.2 mmol/mol creatinine. In some embodiments, the reference value for urine PBG is 1.4 mmol/mol creatinine. In some embodiments, the subject has a urine PBG level that is greater than, or greater than or equal to 1.0 mmol/mol creatinine, 1.2 mmol/mol creatinine, 2.4 mmol/mol creatinine, 3.6 mmol/mol creatinine, 4.8 mmol/mol creatinine, or 6.0 mmol/mol creatinine. In some embodiments, the subject has a urine level of PBG that is greater than, or greater than or equal to 4.8 mmol/mol creatinine.
In some embodiments, the reference value for plasma ALA is 0.12 μmol/L. In some embodiments, the subject has a plasma ALA level that is greater than, or greater than or equal to 0.10 μmol/L, 0.12 μmol/L, 0.24 μmol/L, 0.36 μmol/L, 0.48 μmol/L, or 0.60 μmol/L. In some embodiments, the subject has a plasma ALA level that is greater than, or greater than or equal to 0.48 μmol/L.
In some embodiments, the reference value for urine ALA is 3.1 mmol/mol creatinine. In some embodiments, the reference value for urine ALA is 6.3 mmol/mol creatinine. In some embodiments, the subject has a urine ALA level that is greater than, or greater than or equal to 2.5 mmol/mol creatinine, 3.1 mmol/mol creatinine, 6.2 mmol/mol creatinine, 6.3 mmol/mol creatinine, 9.3 mmol/mol creatinine, 12.4 mmol/mol creatinine, or 15.5 mmol/mol creatinine.
In some embodiments, the reference value for urine uroporphyrin is less than 4.5 μmol/mol creatinine. In some embodiments, the subject has a urine uroporphyrin level that is greater than, or greater than or equal to 4.5 μmol/mol creatinine, 9.0 μmol /mol creatinine, 13.5 μmol/mol creatinine, 18.0 μmol/mol creatinine, 22.5 μmol/mol creatinine, 27 μmol/mol creatinine, or 31.5 μmol/mol creatinine. In some embodiments, the reference value for urine coproporphyrin is less than 20.7 μmol/mol creatinine. In some embodiments, the subject has a urine coproporphyrin level that is greater than, or greater than or equal to 20.7 μmol /mol creatinine, 41.4 μmol /mol creatinine, 62.1 μmol /mol creatinine, 82.8 μmol /mol creatinine, 103.5 μmol /mol creatinine, 124.2 μmol /mol creatinine, or 144.9 μmol /mol creatinine.
In some embodiments, the reference value for plasma porphyrin is 10 nmol/L. In some embodiments, the subject has a plasma porphyrin level that is greater than, or greater than or equal to 10 nmol/L. In some embodiments, the subject has a plasma porphyrin level that is greater than, or greater than or equal to 8, 10, 15, 20, 25, 30, 35, 40, 45, or 50 nmol/L. In some embodiments, he subject has a plasma porphyrin level that is greater than, or greater than or equal to 40 nmol/L.
In some embodiments, the reference value for urine porphyrin is 25 μmol/mol creatinine. In some embodiments, the reference value for urine porphyrin is less than 28.4 μmol/mol creatinine. In some embodiments, the subject has a urine porphyrin level that is greater than, or greater than or equal to 25 μmol/mol creatinine. In some embodiments, the subject has a urine porphyrin level that is greater than, or equal to 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 μmol/mol creatinine.
In some embodiments, the subject has a level (e.g. , a plasma level or a urine level) of a porphyrin or a porphyrin precursor that is greater than that of 99% of individuals in a sample of healthy individuals.
In some embodiments, the subject has a level (e.g., a plasma level or a urine level) of ALA or PBG that is greater than two standard deviations above the mean level in a sample of healthy individuals.
In some embodiments, the subject has a urine level of ALA that is 1.6 or more times that of the mean level in a normal subject (e.g., a subject that does not carry a mutation associated with a porphyria). In some embodiments, the subject has a plasma level of ALA that is 2 or 3 times that of the mean level in a normal subject. In some embodiments, the subject has a urine level of PBG that is four or more times that of the mean level in a normal subject. In some embodiments, the subject has a plasma level of PBG that is four or more times that of the mean level in a normal subject.
In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, results in a decrease in the level of one or more porphyrins or porphyrin precursors, as described herein (e.g., ALA and/or PBG). The decrease may be measured relative to any appropriate control or reference value. For example, the decrease in the level of one or more porphyrins or porphyrin precursors may be established in an individual subject, e.g., as a decrease of at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50% or more compared with the level prior to treatment (e.g., immediately prior to treatment). A decrease in the level of a porphyrin precursor, a porphyrin, or a porphyrin metabolite may be measured using any method known in the art. In some embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is effective to reduce the level of ALA and/or PBG in the subject. The level of ALA or PBG in the subject can be assessed, e.g., based on the absolute level of ALA or PBG, or based on the relative level of ALA or PBG (e.g., relative to the level of another protein or compound, e.g., the level of creatinine) in a sample from the subject. In some embodiments, the sample is a urine sample. In some embodiments, the sample is a plasma sample. In some embodiments, the method decreases 5-ALA levels in the subject. In some embodiments, the method decreases 5-ALA levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases HMB levels in the subject. In some embodiments, the method decreases HMB levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases coproporphyrin III levels in the subject. In some embodiments, the method decreases coproporphyrin III levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases PBG levels in the subject. In some embodiments, the method decreases PBG levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases uroporphyrin III levels in the subject. In some embodiments, the method decreases uroporphyrin III levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the proportion of protoporphyrin to coproporphyrin in the subject. In some embodiments, the method decreases the proportion of protoporphyrin to coproporphyrin in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases heptacarboxyl-porphyrin levels in the subject. In some embodiments, the method decreases heptacarboxyl-porphyrin levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases isocoproporphyrin levels in the subject. In some embodiments, the method decreases isocoproporphyrin levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases ZPPIX levels in the subject. In some embodiments, the method decreases ZPPIX levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases porphyrin or porphyrin precursor (e.g., ALA or PBG) levels in the subject to a normal level. In some embodiments, the normal level is a reference value for a porphyrin or porphyrin precursor (e.g., urine ALA levels <6.3 mmol/mol creatine and urine PBG levels <1.4 mmol/mol creatine) as described herein. In certain aspects, the disclosure relates to methods of inhibiting uroporphyrin I and/or coproporphyrin I synthesis in vivo, comprising administering to a subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting uroporphyrin I synthesis in vivo by at least 100%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 10% (e.g., 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or at least 100%). In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 20%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 30%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 40%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 50%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 60%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 70%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 80%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 90%. In some embodiments, the disclosure relates to methods of inhibiting coproporphyrin I synthesis in vivo by at least 100%. Porphyrins (e.g., PPIX, ZPPIX, uroporphyrin I, and coproporphyrin I) can be found in various biological samples including the skin, urine, stool, plasma, and erythrocytes. In some embodiments, the porphyrins may be extracted from the biological sample into a solution for fluorescence analysis. Porphyrins can be detected in these biological samples by direct inspection using long wavelength ultraviolet light (e.g., 400-420 nm light). Porphyrins have the greatest absorption wavelengths near 400-420 nm, with their highest absorption peak occurring at 415 nm. The emission maxima of porphyrins is typically around 600 nm and varies slightly based on the type of porphyrins and the solvent used for analysis. In some embodiments, diagnosis of a hepatic porphyria, EPP, XLPP, and CEP may be made using fluorescence analysis. In some embodiments, skin porphyrin levels (e.g., PPIX levels) can be measured by calculating the difference before and after complete photobleaching of PPIX using controlled illumination. See, e.g., Heerfordt IM. Br J Dermatol.2016;175(6):1284- 1289. In some embodiments, the subject’s plasma porphyrin fluoresces at a peak of 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s plasma porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak of 632 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject’s skin porphyrin fluoresces at a peak between 626 nm and 634 nm when illuminated with blue light (e.g., 400-420 nm light). In some embodiments, the subject has greater than 0.2 FluoDerm Units (FDU) of protoporphyrin IX levels in the skin. In some embodiments, the subject has greater than 1.0 FDU of protoporphyrin IX levels in the skin. In some embodiments, the subject has between 1.0 FDU and 2.5 FDU of protoporphyrin IX levels in the skin. In some embodiments, the subject has greater than 2.5 FDU of protoporphyrin IX levels in the skin. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 0.5 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 1.0 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 1.5 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 2.0 FDU. In some embodiments, the method decreases protoporphyrin IX levels in the skin of the subject to less than 2.5 FDU. In some embodiments, the subject has red fluorescent urine. In some embodiments, the subject has a peak between 615 nm and 620 nm using plasma porphyrin fluorescence analysis. In certain aspects, the methods provided herein comprise administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject’s PPIX levels decrease while the patient’s heme levels are substantially maintained. In some embodiments, the patients PPIX levels decrease by at least 50% (e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%) and the patient’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%). In some embodiments, the patient’s PPIX levels decrease by at least 85% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 80% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 75% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 70% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 65% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 60% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 55% and the patient’s heme levels decrease no more than 15%. In some embodiments, the patients PPIX levels decrease by at least 50% and the patient’s heme levels decrease no more than 15%. In certain aspects, the disclosure relates to methods of treating a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the dosage of the pharmaceutical composition does not cause a substantial reduction in heme levels. In some embodiments, the patient’s PPIX levels decrease by at least 50% (e.g., 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the patient’s PPIX levels decrease by at least 55%. In some embodiments, the patient’s PPIX levels decrease by at least 60%. In some embodiments, the patient’s PPIX levels decrease by at least 65%. In some embodiments, the patient’s PPIX levels decrease by at least 70%. In some embodiments, the patient’s PPIX levels decrease by at least 75%. In some embodiments, the patient’s PPIX levels decrease by at least 80%. In some embodiments, the patient’s PPIX levels decrease by at least 85%. In some embodiments, the patient’s PPIX levels decrease by at least 90%. In some embodiments, the patient’s PPIX levels decrease by at least 95%. In some embodiments, the patient’s PPIX levels decrease by at least 100%. In some embodiments, the patient’s heme levels decrease no more than 10% (e.g., 10%, 15%, 20%, 25%, and 30%). In some embodiments, the patient’s heme levels decrease no more than 15%. In some embodiments, the patient’s heme levels decrease no more than 20%. In some embodiments, the patient’s heme levels decrease no more than 25%. In some embodiments, the patient’s heme levels decrease no more than 30%. In some embodiments, the accumulation of one or more of the following heme intermediates is inhibited, wherein the one or more heme intermediates is selected from the group consisting of PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of PPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of ZPPIX, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of uroporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of coproporphyrin I, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of inhibiting the accumulation of 5-ALA, the method comprising administering to the subject a pharmaceutical composition comprising a v. In some embodiments, the accumulation of the one or more heme intermediates (e.g., PPIX, ZPPIX, uroporphyrin I, coproporphyrin I, and/or 5-ALA) is inhibited in a dose dependent manner. Complications of Porphyrias In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of a hepatic porphyria, EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the one or more complications of a hepatic porphyria is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, severe abdominal pain, neuropsychiatric symptoms, autonomic neuropathy, peripheral motor neuropathy, electrolyte disturbances, nausea, vomiting, constipation, diarrhea, difficulty urinating, ileus, paresthesia, insomnia, restlessness, agitation, anxiety, confusion, hallucinations, psychosis, convulsions, pain associated with neuropathy, muscle paralysis, tetraparesis, decreased breathing, respiratory arrest, hyponatremia, tachycardia, hypertension, increased heart rate, increased blood pressure, red urine, dark urine, hepatocellular carcinoma, hypertensive renal damage, chronic kidney disease, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholestasis, cytolysis, gallstones, cholestatic liver failure, cholelithiasis, mild liver disease, deteriorating liver disease, and terminal phase liver disease. In some embodiments, the one or more complications are improved indirectly. In some embodiments, the one or more complications of EPP, XLPP, or CEP is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholelithiasis, cholestasis, cytolysis, gallstones, cholestatic liver failure, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero. In some embodiments, the disclosure contemplates methods of treating one or more complications of EPP, XLPP, or CEP (e.g., acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholelithiasis, cholestasis, cytolysis, gallstones, cholestatic liver failure, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero) comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the one or more complications are improved indirectly. In some embodiments, the disclosure contemplates methods of preventing one or more complications of a hepatic porphyria, EPP, XLPP, or CEP comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure contemplates methods of reducing the progression rate of one or more complications of a hepatic porphyria, EPP, XLPP, or CEP comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure contemplates methods of reducing the severity of one or more complications of a hepatic porphyria, EPP, XLPP, or CEP comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. Methods of treatment provided herein may serve to ameliorate one or more symptoms associated with a hepatic porphyria or to reduce the risk of developing conditions associated with porphyria (e.g., neuropathy (e.g., progressive neuropathy), hepatocellular cancer). Symptoms associated with a hepatic porphyria may include abdominal pain or cramping, headaches, effects caused by nervous system abnormalities, and light sensitivity, causing rashes, blistering, and scarring of the skin (photodermatitis). In certain embodiments, the hepatic porphyria is AIP. Symptoms of AIP include gastrointestinal symptoms (e.g., severe and poorly localized abdominal pain, nausea/vomiting, constipation, diarrhea, ileus), urinary symptoms (dysuria, urinary retention/incontinence, or dark urine), neurologic symptoms (e.g., sensory neuropathy, motor neuropathy (e.g., affecting the cranial nerves and/or leading to weakness in the arms or legs), seizures, neuropathic pain, progressive neuropathy, headaches, neuropsychiatric symptoms (e.g., mental confusion, anxiety, agitation, hallucination, hysteria, delirium, apathy, depression, phobias, psychosis, insomnia, somnolence, coma), autonomic nervous system involvement (resulting e.g., in cardiovascular symptoms such as tachycardia, hypertension, and/or arrhythmias, as well as other symptoms, such as, e.g., increased circulating catecholamine levels, sweating, restlessness, and/or tremor), dehydration, and electrolyte abnormalities. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered together with (e.g., before, after, or concurrent with) another treatment that may serve to alleviate one or more of the above symptoms. For example, abdominal pain may be treated, e.g., with narcotic analgesics, seizures may be treated, e.g., with anti-seizure medications, nausea/vomiting may be treated, e.g., with phenothiazines, and tachycardia/hypertension may be treated, e.g., with beta blockers. Optionally, methods disclosed herein for preventing, treating, or reducing the progression rate and/or severity of one or more complications of EPP, XLPP, or CEP in a subject, may further comprise administering to the patient one or more supportive therapies or additional active agents for treating EPP, XLPP, or CEP. For example, the patient also may be administered one or more supportive therapies or active agents selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse ®), bortezomib, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion. In some embodiments, the methods described herein may further comprise administering to the patient Afamelanotide (Scenesse ®). Porphyrin photosensitization in certain hepatic porphyrias (e.g., VP, HCP, PCT, and HEP), EPP, XLPP, and CEP produces two distinct clinical syndromes: (1) acute photosensitivity on exposure to sunlight with erythema and edema and (2) a syndrome wherein subepidermal bullae occur in sun-exposed areas of the skin. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of EPP, XLPP, or CEP in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases pain free light exposure in the subject. In some embodiments, the method increases pain free light exposure in the subject by at least 10%, 20%, 30%, 40%, or 50% more as compared to pain free light exposure prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method decreases light sensitivity in the subject. In some embodiments, the method decreases light sensitivity in the subject by at least 10%, 20%, 30%, 40%, or 50% more as compared to light sensitivity prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a history of phototoxic reactions from EPP. In some embodiments, the subject is an adult, child, infant, or pregnant woman. EC50 and Administration In certain embodiments of the methods and uses as disclosed herein, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates inhibition of a porphyrin precursor (e.g., 5-ALA or PBG) with an EC50 of less than 500 nM, less than 400 nM, less than 300 nM, less than 200 nM, or less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates inhibition of a porphyrin precursor (e.g., 5-ALA or PBG) with an EC50 of less than 100 nM. In certain embodiments of the present application, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, demonstrates inhibition of a porphyrin precursor (e.g., 5-ALA or PBG) with an EC50 of less than 50 nM. In certain embodiments, the EC50 is measured in a flow cytometry assay. In certain embodiments, the EC50 is measured in a LC-MS/MS assay. In certain embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof is administered to prevent or reduce the severity or frequency of recurring attacks, e.g., cyclical attacks associated with a precipitating factor. In some embodiments, the precipitating factor is the menstrual cycle. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered repeatedly, e.g., at regular intervals to prevent or reduce the severity or frequency of recurring attacks, e.g., cyclical attacks associated with a precipitating factor, e.g., the menstrual cycle, e.g., a particular phase of the menstrual cycle, e.g., the luteal phase. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof is administered during a particular phase of the menstrual cycle or based on hormone levels of the patient being treated (e.g., based on hormone levels that are associated with a particular phase of the menstrual cycle). In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered on one or more particular days of the menstrual cycle, e.g., on day 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, or on day 28 (or later day for subjects who have a longer menstrual cycle). In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered during the luteal phase, e.g., on one or more days between days 14-28 of the menstrual cycle (or later, in subjects who have a menstrual cycle longer than 28 days). In some embodiments, ovulation of the subject is assessed (e.g., using a blood or urine test that detects a hormone associated with ovulation, e.g., LH) and the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered at a predetermined interval after ovulation. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered immediately after ovulation. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, or 18 days after ovulation. Any of these schedules may optionally be repeated for one or more iterations. The number of iterations may depend on the achievement of a desired effect, e.g., the achievement of a therapeutic or prophylactic effect, e.g., reduce or prevent one or more symptoms associated with a hepatic porphyria, EPP, XLPP, or CEP, to reduce the frequency of attacks associated with hepatic porphyria, EPP, XLPP, or CEP. In some embodiments, an initial dose of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered and the level of ALA or PBG is tested, e.g., 1-48 hours, e.g., 2, 4, 8, 12, or 24 hours following administration of the initial dose. In some embodiments, if the level of ALA and/or PBG has decreased (e.g., to achieve a predetermined reduction, e.g., a normalization), and/or if the symptoms associated with a hepatic porphyria, EPP, XLPP, or CEP (e.g., pain) have improved (e.g., such that the patient is asymptomatic), no further dose is administered, whereas if the level of ALA and/or PBG has not decreased (e.g., has not achieved a predetermined reduction, e.g., has not normalized), a further dose of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered. In some embodiments, the further dose is administered 12, 24, 36, 48, 60, or 72 hours after the initial dose. In some embodiments, if the initial dose is not effective to decrease the level of ALA and/or PBG, the further dose is modified, e.g., increased to achieve a desired decrease (e.g., a predetermined reduction, e.g., a normalization) in ALA or PBG levels. In some embodiments, the predetermined reduction is a decrease of at least 10%, 20%, 30%, 40%, or 50%. In some embodiments, the predetermined reduction is a reduction that is effective to prevent or ameliorate symptoms, e.g., pain, prodromal symptoms, or recurring attacks. In some embodiments, the predetermined reduction is a reduction of at least 1, 2, 3, or more standard deviations, wherein the standard deviation is determined based on the values from a reference sample, e.g., a reference sample as described herein. In some embodiments, the predetermined reduction is a reduction that brings the level of the porphyrin or porphyrin precursor to a level that is less than, or to a level that is less than or equal to, a reference value (e.g., a reference value as described herein). As used herein, a “normalization” in ALA or PBG levels (or a “normal” or “normalized” level) refers to a level (e.g., a urine and/or plasma level) of either ALA, or PBG, or both, that is within the expected range for a healthy individual, an individual who is asymptomatic (e.g., an individual who does not experience pain and/or suffer from neuropathy), or an individual who does not have a mutation associated with a porphyria. For example, in some embodiments, a normalized level is within two standard deviations of the normal mean. In some embodiments, a normalized level is within normal reference limits, e.g., within the 95% confidence interval for an appropriate control sample, e.g., a sample of healthy individuals or individuals who do not carry a gene mutation associated with a porphyria. In some embodiments, the ALA and/or PBG level of the subject (e.g., the urine and/or plasma ALA and/or PBG level) is monitored at intervals, a further dose of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered when the level increases above the reference value. Administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may reduce porphyrin or porphyrin precursor levels, e.g., in a cell, tissue, blood, urine or other compartment of the patient by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80% or at least 90% or more. Administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may also decrease porphyrin or porphyrin precursor levels during an acute attack of AIP. Combination Therapies Optionally, methods disclosed herein for preventing, treating, or reducing the progression rate and/or severity of one or more complications of a porphyria (e.g., hepatic porphyria, EPP, XLPP, or CEP) in a subject, may further comprise administering to the patient one or more supportive therapies or additional active agents for treating porphyria (e.g., hepatic porphyria, EPP, XLPP, or CEP). For example, the patient also may be administered one or more supportive therapies or active agents selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse®), bortezomib, heme infusions, sufficient caloric support, Givosiran, RNAi mediated silencing of various enzymes (e.g., ALA synthase), avoiding precipitating factors, 4-aminoquinolines, chloroquine, hydroxychloroquine, phlebotomy, intravenous magnesium, LH-RH agonists, enzyme replacement therapy (e.g., recombinant human PBGD), gene therapy (e.g., transfer of PBGD gene in liver cells by viral vectors), hemodialysis, pharmacologic chaperone treatment, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion. In some embodiments, the subject is administered a combination treatment, e.g., a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and one or more additional treatments known to be effective against hepatic porphyria, EPP, XLPP, or CEP (e.g., glucose and/or a heme product such as hemin, as described herein) or its associated symptoms. In one embodiment, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with glucose or dextrose. For example, 10-20% dextrose in normal saline may be provided intravenously. Typically, when glucose is administered, at least 300 g of 10% glucose is administered intravenously daily. The compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may also be administered intravenously, as part of the same infusion that is used to administer the glucose or dextrose, or as a separate infusion that is administered before, concurrently, or after the administration of the glucose or dextrose. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered via a different route of administration (e.g., subcutaneously). In yet another embodiment, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with total parenteral nutrition. The compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be administered before, concurrent with, or after the administration of total parenteral nutrition. In certain embodiments, a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, is administered in combination with one or more additional treatments, e.g., another treatment known to be effective in treating porphyria or symptoms of porphyria. In one embodiment, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product (e.g., hemin, heme arginate, or heme albumin). In a further embodiment, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered in combination with a heme product and glucose, a heme product and dextrose, or a heme product and total parenteral nutrition. The additional treatment(s) may be administered before, after, or concurrent with the administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. The compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and an additional therapeutic agent can be administered in combination in the same composition, e.g., intravenously, or the additional therapeutic agent can be administered as part of a separate composition or by another method described herein. In some embodiments, the subject has previously been treated with a heme product (e.g., hemin, heme arginate, or heme albumin), as described herein. In some embodiments, administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, or administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in combination one or more additional treatments (e.g., glucose, dextrose), decreases the frequency of acute attacks (e.g., by preventing acute attacks so that they no longer occur, or by reducing the number of attacks that occur in a certain time period, e.g., fewer attacks occur per year). In some such embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is administered according to a regular dosing regimen, e.g., b.i.d., daily, weekly, biweekly, or monthly. Anemias associated with ribosomal disorders Mutations in ribosomal protein (RP) genes or other transcription factors (e.g., GATA1) can result in the loss of erythrocyte progenitor cells and cause anemia associated with a ribosomal disorder. One example of an anemia associated with a ribosomal disorder is Diamond-Blackfan anemia (DBA), a rare blood disorder that is almost exclusively linked to RP gene haploinsufficiency. DBA affects approximately seven per million live births and is usually diagnosed during the first year of life. Classic diagnostic criteria includes: (1) macrocytic, normochromic, anemia; (2) reticulocytopenia; (3) bone marrow erythroid hypoplasia; and (4) early onset of anemia (90% present before age one year). In DBA patients, erythrocyte precursors do not mature sufficiently leading to congenital erythroid aplasia and developmental defects. Affected individuals may have physical abnormalities, such as craniofacial malformations, thumb or upper limb abnormalities, cleft palate, as well as defects of the genitalia, urinary tract, eyes and heart. In some cases, low birth weight and short stature are observed. DBA patients are also at a modest risk of developing leukemia and other malignancies. The current treatment options for DBA includes corticosteroids, blood transfusion, and bone marrow transplantation. Approximately 80% of DBA patients respond to an initial course of corticosteroids. However, the efficacy of corticosteroids can wane over time in many patients. These patients and the 20% who do not respond initially to such therapy must be maintained on a chronic blood transfusion with iron chelation. Chronic transfusions are known to cause iron overload in various organs including the liver, heart, and endocrine system. Other therapies such as interleukin-3, high dose corticosteroids, cyclosporine, anti- thymocyte globulin, immunoglobulin, and metoclopramide, are either of unproved benefit and/or seem to benefit relatively few people. Pharmacological doses of Erythropoietin (EPO) are also ineffective. Bone marrow transplantation is the sole cure for the hematologic manifestation of DBA-related anemia, but is usually only considered in corticosteroid- resistant persons because of substantial morbidity and mortality. Typically, only transplants from human leukocyte antigen (HLA)-identical sibling were considered. For many patients, the lack of a suitable donor excludes bone marrow transplantation as a therapeutic option. As such, there is a high, unmet need for effective therapies for treating anemias associated with ribosomal disorders. Accordingly, it is an object of the present application to provide methods for treating, preventing, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder. The methods and use of glycine transporter inhibitors, such as, but not limited to, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, these needs as well as others. In certain aspects, the present application provides the use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a pharmaceutical composition for the treatment of an anemia associated with a ribosomal disorder in a subject in need thereof. The present application provides methods of preventing or treating anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In part, the present application relates to methods of treating anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the ribosomal disorder is Diamond-Blackfan anemia. In some embodiments, the ribosomal disorder is Shwachman- Diamond syndrome. In some embodiments, the ribosomal disorder is x-linked dyskeratosis congenital. In some embodiments, the ribosomal disorder is cartilage hair hypoplasia. In particular embodiments, the patient, subject or individual is a human. The present application provides methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain embodiments of the foregoing, the pharmaceutical composition further comprises a pharmaceutically acceptable carrier. The present application further provides use of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in the manufacture of a formulation for the treatment of anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia) in a subject. Diamond-Blackfan anemia Diamond-Blackfan anemia (DBA) is a congenital erythroid aplasia that usually develops during the neonatal period. DBA is characterized by low red blood cell counts (anemia) with decreased erythroid progenitors in the bone marrow. In DBA patients, levels of other blood components such as platelets and the white blood cells are normal. This is in contrast to Shwachman-Diamond syndrome, in which the bone marrow defect results primarily in low neutrophil counts (neutropenia). Ribosomal protein mutations have been implicated in the pathophysiology of DBA. The first gene, mutated in approximately 25% of DBA patients, was identified as RPS19 (ribosomal protein S19) (Gustavsson et ah, Nat Genet.1997 Aug;l6(4):368-7l; Draptchinskaia et al, Nat Genet.1999 Feb;2l(2): 169-75). Sequencing of patient samples has identified mutations of either large (60s) or small (40s) subunit ribosomal proteins in over 50% of patients (Vlachos et al, Br J Haematol.2008 Sep; 142(6): 859-876). Identified genes include but are not limited to RPL5, RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19, RPS20, RPS24, RPS26, RPS27a, RPS27, RPS28, and RPS29, as well as three other non-RP genes, TSR2, GATA1, and EPO (Da Costa L, et al. F1000Res. 2018;7). All patients identified to date are heterozygous for these mutations, always maintaining a wildtype copy of the affected RP gene. However, approximately 30% of people with DBA have no detectable RP mutation. Some phenotype/genotype correlations are known, relating to congenital abnormalities. Id. There are numerous subtypes of DBA, each of which are caused by different mutations in various genes. For instance, Diamond-Blackfan anemia-l (DBA1, OMIM #105650) is caused by heterozygous mutations in the RPS19 gene on chromosome l9ql3. Other forms of DBA include DBA2 (OMIM #606129), caused by mutations on chromosome 8p23-p22; DBA3 (OMIM #610629), caused by mutation in the RPS24 gene on l0q22; DBA4 (OMIM #612527), caused by mutation in the RPS17 gene on 15q; DBA5 (OMIM #612528), caused by mutation in the RPL35A gene on 3q29; DBA6 (OMIM #612561), caused by mutation in the RPL5 gene on lp22. l; DBA7 (OMIM #612562), caused by mutation in the RPL11 gene on lp36; DBA8 (OMIM #612563), caused by mutation in the RPS7 gene on 2p25; DBA9 (OMIM #613308), caused by mutation in the RPS10 gene on 6p; DBA10 (OMIM #613309), caused by mutation in the RPS26 gene on l2q; DBA11 (OMIM #614900), caused by mutation in the RPL26 gene on 17r13; DBA12 (OMIM #615550), caused by mutation in the RPL15 gene on 3p24; DBA13 (OMIM #615909), caused by mutation in the RPS29 gene on l4q; DBA 14 (OMIM #300946), caused by mutation in the /'SR 2 gene on Xpl 1; DBA 15 (OMIM #606164), caused by mutation in the RPS28 gene on 19p 13 ; DBA 16 (OMIM #617408), caused by mutation in the RPL27 gene on chromosome 17q21; and DBA17 (OMIM #617409), caused by mutation in the RPS27 gene on chromosome lq2l . Mutations in ribosomal proteins impact ribosomal protein function, leading to ribosomal insufficiency and increased stress. Impaired ribosome biogenesis has been linked to p53 induction and cell-cycle arrest. Ribosomal protein knockdown leads to an increase of free ribosomal proteins. Some ribosomal proteins, including RPL11, RPL5, and RPL13, bind to MDM2 and block MDM2 -mediated p53 ubiquitination and degradation (Lindstrom et al, Cell Cycle 6:4, 434-437, 15 February 2007; Fumagalli et al, Nat Cell Biol.2009 Apr; l l(4):50l-8). Other ribosomal proteins may activate p53 by different mechanisms. For example, RPL26 has been found to increase the translation rate of p53 mRNA by binding to its 5’ untranslated region (Tagaki et al., Cell.2005 Oct 7; l23(l):49-63). The negative impact of DBA on ribosomal protein function results in decreased globin synthesis, which is required to produce hemoglobin. Heme synthesis does not appear to be impacted. The imbalance between heme synthesis and globin leads to the accumulation of free heme in DBA erythroid cells (Rio S, et al. Blood.2019;133(12):1358-1370). Heme is toxic for the cells by increasing reactive oxygen species production, lipid peroxidation, and apoptosis. As a consequence, excess heme levels resulting from the heme/globin imbalance leads to deleterious effects on erythroipoiesis. Typically, a diagnosis of DBA is made through a blood count and a bone marrow biopsy. A diagnosis of DBA is made on the basis of anemia, low reticulocyte (immature red blood cells) counts, and diminished erythroid precursors in bone marrow. Features that support a diagnosis of DBA include the presence of congenital abnormalities, macrocytosis, elevated fetal hemoglobin, and elevated adenosine deaminase levels in red blood cells. Most patients are diagnosed in the first two years of life. However, some mildly affected individuals only receive attention after a more severely affected family member is identified. Genetic testing is frequently used to identify mutations in ribosomal protein genes as well as some other non-ribosomal protein genes. About 20-25% of DBA patients may be identified with a genetic test for mutations in the RPS19 gene. Approximately 10-25% of DBA cases have a family history of disease, and most pedigrees suggest an autosomal dominant mode of inheritance. In certain aspects, the disclosure relates to methods of treating anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the anemia associated with a ribosomal disorder is Diamond Blackfan anemia (DBA). In some embodiments, the DBA is caused by haploinsufficiency for a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein L5 (RPL5), 60S ribosomal protein L11 (RPL11), and 40S ribosomal protein S7 (RPS7). ). In some embodiments, the DBA is caused by haploinsufficiency for a ribosomal protein selected from the group consisting of 40S ribosomal protein S10 (RPS10), 40S ribosomal protein S26 (RPS26), 60S ribosomal protein L15 (RPL15), 60S ribosomal protein L17 (RPL17), 60S ribosomal protein L19 (RPL19), 60S ribosomal protein L26 (RPL26), 60S ribosomal protein L27 (RPL27), 60S ribosomal protein L31 (RPL31), 40S ribosomal protein S15a (RPS15a), 40S ribosomal protein S20 (RPS20), 40S ribosomal protein S27 (RPS27), 40S ribosomal protein S28 (RPS28), and 40S ribosomal protein S29 (RPS29). In some embodiments, the patient has one or more mutations in a ribosomal protein gene. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, can be used in a method of treating anemia associated with a ribosomal disorder, wherein the subject has a mutation in ribosomal protein 19 (RPS19). The phenotype of DBA patients indicates a hematological stem cell defect specifically affecting the erythroid progenitor population. The RPS19 protein is involved in the production of ribosomes. Disease features may be related to the nature of RPS19 mutations. The disease is characterized by dominant inheritance, and therefore arises due to a partial loss of RPS19 protein function. In alternative embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, can be used in a method of treating anemia associated with a ribosomal disorder, wherein the subject has a mutation in ribosomal protein from at least one of, but not limited to RPL5, RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19, RPS20, RPS24, RPS26, RPS27a, RPS27, RPS28, and RPS29. For example, a mutation or variant in RPS19 causes DBA1, and a mutation or variant in RPS24 causes DBA3, a mutation or variant in RPS17 causes DBA4, a mutation or variant in RPS34A causes DBA5, a mutation or variant in RPLS causes DBA6, a mutation or variant in RPL11 causes DBA7, and a mutation or variant in RPS7 causes DBA8. In some embodiments, the subject with a ribosomal disorder has a mutation in a non-ribosomal protein selected from the group consisting of TSR2, GATA1, and EPO. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the one or more complications of anemia associated with a ribosomal disorder is selected from the group consisting of: thrombocytosis, megakaryotypic hyperplasia, infections, bleeding (e.g., from the nose or gums), bruising, splenomegaly, the need for more frequent blood transfusions, the need for increased glucocorticoid use, the need for allogenic hematopoietic stem cell transplantation, the need for autologous gene therapy, marrow failure, leukemia, and acute myelogenous leukemia. In certain aspects, the disclosure relates to methods of treating splenomegaly associated with anemia associated with a ribosomal disorder in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has an increased spleen size (e.g., splenomegaly). In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce splenomegaly in a subject with anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia). In some embodiments, the method reduces the subject’s spleen size. In some embodiments, the method reduces the subject’s spleen size by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the subject’s spleen size by at least 15%. In some embodiments, the method reduces the subject’s spleen size by at least 20%. In some embodiments, the method reduces the subject’s spleen size by at least 25%. In some embodiments, the method reduces the subject’s spleen size by at least 30%. In some embodiments, the method reduces the subject’s spleen size by at least 35%. In some embodiments, the method reduces the subject’s spleen size by at least 40%. In some embodiments, the method reduces the subject’s spleen size by at least 45%. In some embodiments, the method reduces the subject’s spleen size by at least 50%. In some embodiments, the method reduces the subject’s spleen size by at least 55%. In some embodiments, the method reduces the subject’s spleen size by at least 60%. In some embodiments, the method reduces the subject’s spleen size by at least 65%. In some embodiments, the method reduces the subject’s spleen size by at least 70%. In some embodiments, the method reduces the subject’s spleen size by at least 75%. In some embodiments, the method reduces the subject’s spleen size by at least 80%. In some embodiments, the method reduces the subject’s spleen size by at least 85%. In some embodiments, the method reduces the subject’s spleen size by at least 90%. In some embodiments, the method reduces the subject’s spleen size by at least 95%. In some embodiments, the method reduces the subject’s spleen size by at least 100%. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, can be used to treat a subject with a ribosomal disorder, such as DBA, wherein the subject has a symptom of macrocytic anemia and/or craniofacial abnormalities. Shwachman-Diamond syndrome Shwachman-Diamond syndrome (SDS) or Shwachman-Bodian-Diamond syndrome is a rare genetic disorder that that affects many parts of the body, particularly the pancreas, bone marrow, and skeletal system. Shwachman-Diamond syndrome is inheritated in an autosomal recessive pattern. Most cases of SDS are caused by mutations in the SBDS gene, which lies on the long arm of chromosome 7 at cytogenetic position 7ql 1. The protein encoded by SBDS is thought to play a role in RNA processing and ribosome biogenesis, although the exact mechanism of how SBDS mutations lead to the major signs and symptoms of Shwachman- Diamond syndrome is still unclear. Typical symptoms of Shwachman-Diamond syndrome include exocrine pancreatic insufficiency, decreased muscle tone, low blood neutrophil count (neutropenia), anemia, and abnormal bone development affecting the rib cage and/or bones in the arms and/or legs (metaphyseal dysostosis). Diagnosis of Shwachman-Diamond syndrome can be made based on clinical findings, including pancreatic dysfunction and characteristic hematologic abnormalities (e.g., neutropenia and thrombocytopenia). Genetic testing may be used to confirm the diagnosis. SBDS gene mutations are known to cause about 90% of cases of Shwachman-Diamond syndrome. The remaining 10% cases have unknown genetic cause, and hence genetic testing is not an option for these cases. There is no cure for Shwachman-Diamond syndrome. Treatment usually include oral pancreatic enzyme replacement, vitamin supplementation, blood and/or platelet transfusion, administration of granulocyte-colony stimulating factor (G-CSF), and/or hematopoietic stem cell transplantation. The shortage of neutrophils in subjects with Shwachman-Diamond syndrome can lead to neutropenia, which makes them more vulnerable to infections such as pneumonia. Patients with Shwachman-Diamond syndrome also have a higher than average chance of developing aplastic anemia, and leukemia (e.g., acute myeloid leukemia). In certain aspects, the disclosure relates to methods of treating Shwachman-Diamond syndrome in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of Shwachman- Diamond syndrome in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has one or more mutations in the SBDS gene. In some embodiments, the method decreases the need for hematopoietic stem cell transplant in the subject. In some embodiments, the method decreases neutropenia in the subject. In some embodiments, the method decreases thrombocytopenia in the subject. In some embodiments, the method decreases the subject’s risk of developing leukemia. In some embodiments, the method decreases the subject’s risk of developing an infection. In some embodiments, the method decreases the subject’s risk of developing pneumonia. In some embodiments, the subject has low neutrophil levels. Dyskeratosis congenita Dyskeratosis congenita, also known as Zinsser-Engman-Cole syndrome, is a rare genetic form of bone marrow failure which is classically associated with oral leukoplakia, nail dystrophy, and reticular hyperpigmentation. Inheritance is most commonly x-linked recessive. As such, males are three times more likely to be affected than females. Symptoms vary widely and may include atrophic wrinkled skin, eye disease, and bone marrow failure. Dyskeratosis congenita patients are at increased risk of developing leukemia and other cancers (e.g., cancers of the head, neck, anus, or genitals) as well as fibrosis (e.g., pulmonary fibrosis and liver fibrosis). The majority of patients have mutations in dyskerin gene (DKC1), a protein which is directly involved in stabilizing an enzyme called telomerase that is responsible for catalyzing a reaction that sustains the length of telomeres. Without proteins like dyskerin, the telomeres progressively shorten casing the cells to undergo apoptosis or senescence. Other genes including TINF2, TERC, TERT, C16orf57, NOLA2, NOLA3, WRAP53/TCAB1, and RTEL1 have been shown to be mutated in dyskeratosis congenita. Treatment options for patients with dyskeratosis congenita are limited. The only long-term treatment option for bone failure in dyskeratosis congenita patients is hematopoietic stem cell transplantation. However, long-term outcomes remain poor, with an estimated 10-year survival rate of 23%. Short-term treatment options include anabolic steroids (e.g., oxymetholone), granulocyte macrophage colony-stimulating factor, granulocyte colony-stimulating factor, and erythropoietin. In certain aspects, the disclosure relates to methods of treating dyskeratosis congenita in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of dyskeratosis congenita in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has dyskeratosis congenita. In some embodiments, the dyskeratosis congenita is x-linked dyskeratosis congenita. In some embodiments, the subject has one or more mutations in the DKC1 gene. In some embodiments, the subject has one or more mutations in a gene selected from the group consisting of TINF2, TERC, TERT, C16orf57, NOLA2, NOLA3, WRAP53/TCAB1, PARN, CTC1, and RTEL1. In some embodiments, the method decreases the risk of bone marrow failure in the subject. In some embodiments, the method decreases the risk of pulmonary fibrosis in the subject. In some embodiments, the method decreases the risk of liver fibrosis in the subject. Cartilage-hair hypoplasia Cartilage-hair hypoplasia, also known as McKusick type metaphyseal chondrodysplasia, is a disorder of bone growth characterized by short stature (dwarfism) with other skeletal abnormalities; fine, sparse hair; joint hypermobility; anemia; increased risk for malignancy; gastrointestinal dysfunction; impaired spermatogenesis; and abnormal immune system function which often leads to recurrent infections. Patients with cartilage-hair hypoplasia. Most patients with cartilage-hair hypoplasia have a mutation in the RMRP gene (OMIM no.157660), with a 70A#G transition mutation commonly present. The RMRP gene encodes the untranslated RNA component of the mitochondrial RNA–processing ribonuclease, RNase MRP. Diagnosis of cartilage-hair hypoplasia is based primarily on clinical findings, characteristic radiographic findings, and in some cases, evidence of immune dysfunction, macrocytic anemia, and/or gastrointestinal problems. Molecular genetic testing can be used in patients to identify pathogenic variants by RMRP. Treatment of patients often incudes repeated blood transfusions and surgeries to fuse unstable vertebrae or to treat progressive kyphoscoliosis which compromises lung function. Corrective osteotomies may also be required to treat progressive varus deformity associated with ligament laxity in the knees. For patients with immunodeficiency, frequent treatments of underlying infections is required. Prophylatic antibiotic therapy and/or immunoglobulin replacement therapy is often required. Recurrent severe infections and/or the presence of severe combined immunodeficiency (SCID) and/or severely depressed erythropoiesis may warrant bone marrow transplantation. In certain aspects, the disclosure relates to methods of treating cartilage-hair hypoplasia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of cartilage-hair hypoplasia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has one or more mutations in the RMRP gene. In some embodiments, the method reduces the need for bone marrow transplantation in the subject. Defects in erythropoiesis Erythropoiesis refers generally to the process by which red blood cells (erythrocytes) are produced from HSCs, and includes the formation of erythroid progenitor cells. Erythropoiesis is a carefully ordered sequence of events. Initially occurring in fetal hepatocytes, the process is taken over by the bone marrow in the child and adult. Although multiple cytokines and growth factors are dedicated to the proliferation of the red blood cell, the primary regulator is erythropoietin (EPO). Red blood cell development is initially regulated by stem cell factor (SCF), which commits hematopoietic stem cells to develop into erythroid progenitors. Subsequently, EPO continues to stimulate the development and terminal differentiation of these progenitors. In the fetus, EPO is produced by monocytes and macrophages found in the liver. After birth, EPO is produced in the kidneys; however, Epo messenger RNA (mRNA) and EPO protein are also found in the brain and in red blood cells (RBCs), suggesting the presence of paracrine and autocrine functions. Erythropoiesis escalates as increased expression of the EPO gene produces higher levels of circulating EPO. EPO gene expression is known to be affected by multiple factors, including hypoxemia, transition metals (Co2+, Ni2+, Mn2+), and iron chelators. However, the major influence is hypoxia, including factors of decreased oxygen tension, red blood cell loss, and increased oxygen affinity of hemoglobin. For instance, EPO production may increase as much as 1000-fold in severe hypoxia. Erythropoiesis requires the proper biosynthesis of heme and as erythroblasts mature, their demand for heme and iron dramatically increase. Erythroid cells synthesize large amounts of heme and hemoglobin while simultaneously absorbing lots of iron into the cell. A disequilibrium between the globin chain and the heme synthesis is known to occur in the erythroid cells of Diamond-Blackfan anemia patients. This imbalance leads to the accumulation of excess free heme and increased reactive oxygen species production. Blockade of erythroid differentiation and proliferation in Diamond-Blackfan anemia have been shown to affect immature progenitor cells or erythroid-Burst-Forming Unit (BFU- e) resulting in impaired hematopoiesis. Circulating EPO levels are increased in Diamond- Blackfan anemia patients, indicating the unresponsiveness of the bone marrow to anemia related EPO stimulation. An increased propensity of erythroid progenitors to apoptosis during in vitro EPO deprivation and in RPS19 deficiency has also been reported. Glycine is one of the key initial substrates for heme synthesis. As such, decreased levels of glycine due to GlyT1 inhibition could lead to a decrease in heme synthesis. In certain aspects, the disclosure relates to methods of inhibiting heme synthesis in a subject with anemia associated with a ribosomal disorder, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the heme synthesis is inhibited in a dose dependent manner. In some embodiments, the subject with anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia) has elevated heme levels. In some embodiments, the subject has heme levels that are at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or 100% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 10% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 20% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 30% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 40% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 50% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 60% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 70% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 80% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 90% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has heme levels that are at least 100% more than heme levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the method reduces the heme levels in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the heme levels in the subject by at least 15%. In some embodiments, the method reduces the heme levels in the subject by at least 20%. In some embodiments, the method reduces the heme levels in the subject by at least 25%. In some embodiments, the method reduces the heme levels in the subject by at least 30%. In some embodiments, the method reduces the heme levels in the subject by at least 35%. In some embodiments, the method reduces the heme levels in the subject by at least 40%. In some embodiments, the method reduces the heme levels in the subject by at least 45%. In some embodiments, the method reduces the heme levels in the subject by at least 50%. In some embodiments, the method reduces the heme levels in the subject by at least 55%. In some embodiments, the method reduces the heme levels in the subject by at least 60%. In some embodiments, the method reduces the heme levels in the subject by at least 65%. In some embodiments, the method reduces the heme levels in the subject by at least 70%. In some embodiments, the method reduces the heme levels in the subject by at least 75%. In some embodiments, the method reduces the heme levels in the subject by at least 80%. In some embodiments, the method reduces the heme levels in the subject by at least 85%. In some embodiments, the method reduces the heme levels in the subject by at least 90%. In some embodiments, the method reduces the heme levels in the subject by at least 95%. In some embodiments, the method reduces the heme levels in the subject by at least 100%. In some embodiments, the method reduces heme synthesis in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces heme synthesis in the subject by at least 15%. In some embodiments, the method reduces heme synthesis in the subject by at least 20%. In some embodiments, the method reduces heme synthesis in the subject by at least 25%. In some embodiments, the method reduces heme synthesis in the subject by at least 30%. In some embodiments, the method reduces heme synthesis in the subject by at least 35%. In some embodiments, the method reduces heme synthesis in the subject by at least 40%. In some embodiments, the method reduces heme synthesis in the subject by at least 45%. In some embodiments, the method reduces heme synthesis in the subject by at least 50%. In some embodiments, the method reduces heme synthesis in the subject by at least 55%. In some embodiments, the method reduces heme synthesis in the subject by at least 60%. In some embodiments, the method reduces heme synthesis in the subject by at least 65%. In some embodiments, the method reduces heme synthesis in the subject by at least 70%. In some embodiments, the method reduces heme synthesis in the subject by at least 75%. In some embodiments, the method reduces heme synthesis in the subject by at least 80%. In some embodiments, the method reduces heme synthesis in the subject by at least 85%. In some embodiments, the method reduces heme synthesis in the subject by at least 90%. In some embodiments, the method reduces heme synthesis in the subject by at least 95%. In some embodiments, the method reduces heme synthesis in the subject by at least 100%. In some embodiments, the method reduces intracellular heme levels. In some embodiments, the method reduces intracellular heme levels in erythroid precursors. In some embodiments, the method reduces the risk of heme toxicity in the subject. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 15%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 20%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 25%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 30%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 35%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 40%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 45%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 50%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 55%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 60%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 65%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 70%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 75%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 80%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 85%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 90%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 95%. In some embodiments, the method reduces the risk of heme toxicity in the subject by at least 100%. In some embodiments, the subject has liver iron overload. In some embodiments, the method reduces the risk of liver iron overload. In some embodiments, the method reduces the levels of iron in the liver. In some embodiments, the method reduces the levels of iron in the liver by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the levels of iron in the liver by at least 15%. In some embodiments, the method reduces the levels of iron in the liver by at least 20%. In some embodiments, the method reduces the levels of iron in the liver by at least 25%. In some embodiments, the method reduces the levels of iron in the liver by at least 30%. In some embodiments, the method reduces the levels of iron in the liver by at least 35%. In some embodiments, the method reduces the levels of iron in the liver by at least 40%. In some embodiments, the method reduces the levels of iron in the liver by at least 45%. In some embodiments, the method reduces the levels of iron in the liver by at least 50%. In some embodiments, the method reduces the levels of iron in the liver by at least 55%. In some embodiments, the method reduces the levels of iron in the liver by at least 60%. In some embodiments, the method reduces the levels of iron in the liver by at least 65%. In some embodiments, the method reduces the levels of iron in the liver by at least 70%. In some embodiments, the method reduces the levels of iron in the liver by at least 75%. In some embodiments, the method reduces the levels of iron in the liver by at least 80%. In some embodiments, the method reduces the levels of iron in the liver by at least 85%. In some embodiments, the method reduces the levels of iron in the liver by at least 90%. In some embodiments, the method reduces the levels of iron in the liver by at least 95%. In some embodiments, the method reduces the levels of iron in the liver by at least 100%. In some embodiments, the subject has cardiac iron overload. In some embodiments, the method reduces the risk of cardiac iron overload. In some embodiments, the method reduces the level of iron in the heart. In some embodiments, the method reduces the levels of iron in the heart by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the levels of iron in the heart by at least 15%. In some embodiments, the method reduces the levels of iron in the heart by at least 20%. In some embodiments, the method reduces the levels of iron in the heart by at least 25%. In some embodiments, the method reduces the levels of iron in the heart by at least 30%. In some embodiments, the method reduces the levels of iron in the heart by at least 35%. In some embodiments, the method reduces the levels of iron in the heart by at least 40%. In some embodiments, the method reduces the levels of iron in the heart by at least 45%. In some embodiments, the method reduces the levels of iron in the heart by at least 50%. In some embodiments, the method reduces the levels of iron in the heart by at least 55%. In some embodiments, the method reduces the levels of iron in the heart by at least 60%. In some embodiments, the method reduces the levels of iron in the heart by at least 65%. In some embodiments, the method reduces the levels of iron in the heart by at least 70%. In some embodiments, the method reduces the levels of iron in the heart by at least 75%. In some embodiments, the method reduces the levels of iron in the heart by at least 80%. In some embodiments, the method reduces the levels of iron in the heart by at least 85%. In some embodiments, the method reduces the levels of iron in the heart by at least 90%. In some embodiments, the method reduces the levels of iron in the heart by at least 95%. In some embodiments, the method reduces the levels of iron in the heart by at least 100%. In some embodiments, the subject has decreased erythroid precursor survival as compared to a healthy subject. In some embodiments, the subject has decreased erythroid precursor differentiation into mature red blood cells as compared to a healthy subject. In some embodiments, the subject has impaired hematopoiesis. In some embodiments, the method increases the subject’s erythroid precursor survival. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s erythroid precursor survival by at least 15%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 20%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 25%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 30%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 35%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 40%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 45%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 50%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 55%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 60%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 65%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 70%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 75%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 80%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 85%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 90%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 95%. In some embodiments, the method increases the subject’s erythroid precursor survival by at least 100%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells in the subject. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 15%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 20%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 25%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 30%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 35%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 40%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 45%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 50%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 55%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 60%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 65%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 70%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 75%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 80%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 85%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 90%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 95%. In some embodiments, the method increases erythroid precursor differentiation into mature red blood cells by at least 100%. In some embodiments, the subject has elevated erythrocyte adenosine deaminase activity. In some embodiments, the subject has normal marrow cellularity with a paucity of red cell precursors. In some embodiments, the subject has normal neutrophil and/or platelet counts. In some embodiments, the anemia is due to a failure in erythropoiesis. In some embodiments, the method reduces anemia in the subject. In some embodiments, the method reduces anemia in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces anemia in the subject by at least 15%. In some embodiments, the method reduces anemia in the subject by at least 20%. In some embodiments, the method reduces anemia in the subject by at least 25%. In some embodiments, the method reduces anemia in the subject by at least 30%. In some embodiments, the method reduces anemia in the subject by at least 35%. In some embodiments, the method reduces anemia in the subject by at least 40%. In some embodiments, the method reduces anemia in the subject by at least 45%. In some embodiments, the method reduces anemia in the subject by at least 50%. In some embodiments, the method reduces anemia in the subject by at least 55%. In some embodiments, the method reduces anemia in the subject by at least 60%. In some embodiments, the method reduces anemia in the subject by at least 65%. In some embodiments, the method reduces anemia in the subject by at least 70%. In some embodiments, the method reduces anemia in the subject by at least 75%. In some embodiments, the method reduces anemia in the subject by at least 80%. In some embodiments, the method reduces anemia in the subject by at least 85%. In some embodiments, the method reduces anemia in the subject by at least 90%. In some embodiments, the method reduces anemia in the subject by at least 95%. In some embodiments, the method reduces anemia in the subject by at least 100%. In some embodiments, the subject has macrocytic anemia. In some embodiments, the method reduces anemia in the subject by reducing free heme toxicity.
In some embodiments, the method increases red cell mass. In some embodiments, the method decreases the mean corpuscular volume of red cells. In some embodiments, the method decreases red cell adenosine deaminase. In some embodiments, the method decreases red cell adenosine deaminase in a subject with DBA. In some embodiments, the method decreases fetal hemoglobin content in red cells.
Red blood cell count and hematocrit
Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an low red blood cell count (e.g, less than about 4.5 million red blood cells per μl of blood for men and about 4.1 million red blood cells per μl of blood for women, often by a clinically or statistically significant amount), or a low hematocrit (e.g, greater than about 38% for men or about 35% for women, often by a clinically or statistically significant amount). In some embodiments, the subject has hematocrit levels that are less than 38%. In some embodiments, the subject has hematocrit levels that are less than 35%.
In some embodiments, the subject’s hematocrit levels are at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 10% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 20% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 30% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 40% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 50% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 60% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 70% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 80% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 90% less than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 10% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 20% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 30% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 40% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 50% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 60% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 70% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 80% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 90% less than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count less than 4.5 x1012/L. In some embodiments, the subject has a red blood cell count less than 4.1 x1012/L. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, increase red blood cell synthesis (also known as erythropoiesis), and may be used to treat a condition associated with decreased red blood cells. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof may modulate red blood cell synthesis by reducing the formation of heme. In some embodiments, the disclosure relates to methods of increasing red blood cell synthesis in a subject with anemia associated with a ribosomal disorder, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the red blood cell synthesis is increased in a dose dependent manner. In some embodiments, the red blood cell count is increased in a dose dependent manner. In some embodiments, merely by way of non-limiting example, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be administered directly to a subject to increase red blood count, if desired. Red blood count may also be reflected by a person's hematocrit (i.e., packed cell volume (PCV) or erythrocyte volume fraction (EVF)), which is the proportion or percentage of blood volume that is occupied by red blood cells. A normal hematocrit is normally about 49% for men and about 48% for women. A lower hematocrit value indicates a lower number of red blood cells. In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject increases their red blood cell count or hematocrit. Also included are methods of increasing red blood cells in a subject, and methods of increasing hematocrit in a subject, including a subject that has a lower than normal red blood cell count or hematocrit, or is at risk for developing such a condition, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and thereby increasing red blood cell count or hematocrit in the subject. In some embodiments, the method increases the subject’s red blood cell count. In some embodiments, the method increases the subject’s red blood cell count by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s red blood cell count by at least 15%. In some embodiments, the method increases the subject’s red blood cell count by at least 20%. In some embodiments, the method increases the subject’s red blood cell count by at least 25%. In some embodiments, the method increases the subject’s red blood cell count by at least 30%. In some embodiments, the method increases the subject’s red blood cell count by at least 35%. In some embodiments, the method increases the subject’s red blood cell count by at least 40%. In some embodiments, the method increases the subject’s red blood cell count by at least 45%. In some embodiments, the method increases the subject’s red blood cell count by at least 50%. In some embodiments, the method increases the subject’s red blood cell count by at least 55%. In some embodiments, the method increases the subject’s red blood cell count by at least 60%. In some embodiments, the method increases the subject’s red blood cell count by at least 65%. In some embodiments, the method increases the subject’s red blood cell count by at least 70%. In some embodiments, the method increases the subject’s red blood cell count by at least 75%. In some embodiments, the method increases the subject’s red blood cell count by at least 80%. In some embodiments, the method increases the subject’s red blood cell count by at least 85%. In some embodiments, the method increases the subject’s red blood cell count by at least 90%. In some embodiments, the method increases the subject’s red blood cell count by at least 95%. In some embodiments, the method increases the subject’s red blood cell count by at least 100%. In some embodiments, the method increases the subject’s red blood cell count to normal levels. In some embodiments, the method increases the subject’s red blood cell count to between 4.5-5.9 x1012/L. In some embodiments, the method increases the subject’s red blood cell count to between 4.1-5.1 x1012/L. In some embodiments, the method increases the subject’s hematocrit levels. In some embodiments, the method increases the subject’s hematocrit levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s hematocrit levels by at least 15%. In some embodiments, the method increases the subject’s hematocrit levels by at least 20%. In some embodiments, the method increases the subject’s hematocrit levels by at least 25%. In some embodiments, the method increases the subject’s hematocrit levels by at least 30%. In some embodiments, the method increases the subject’s hematocrit levels by at least 35%. In some embodiments, the method increases the subject’s hematocrit levels by at least 40%. In some embodiments, the method increases the subject’s hematocrit levels by at least 45%. In some embodiments, the method increases the subject’s hematocrit levels by at least 50%. In some embodiments, the method increases the subject’s hematocrit levels by at least 55%. In some embodiments, the method increases the subject’s hematocrit levels by at least 60%. In some embodiments, the method increases the subject’s hematocrit levels by at least 65%. In some embodiments, the method increases the subject’s hematocrit levels by at least 70%. In some embodiments, the method increases the subject’s hematocrit levels by at least 75%. In some embodiments, the method increases the subject’s hematocrit levels by at least 80%. In some embodiments, the method increases the subject’s hematocrit levels by at least 85%. In some embodiments, the method increases the subject’s hematocrit levels by at least 90%. In some embodiments, the method increases the subject’s hematocrit levels by at least 95%. In some embodiments, the method increases the subject’s hematocrit levels by at least 100%. In some embodiments, the method increases the subject’s hematocrit levels to at least 38%. In some embodiments, the method increases the subject’s hematocrit levels to at least 35%. Reticulocyte count and hemoglobin In certain embodiments, the present application relates to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof to a subject in need thereof, wherein the subject has a decreased reticulocyte (e.g., less than 1%, often by a clinically or statistically significant amount), or decreased hemoglobin levels (e.g., less than about 13.2 g/dL for men or about 11.6 g/dL for women, often by a clinically or statistically significant amount). In some embodiments, the subject has hemoglobin levels that are at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 10% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 20% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 30% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 40% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 50% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 60% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 70% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 80% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 90% less than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are less than 13 g/dL. In some embodiments, the subject has hemoglobin levels that are less than 11 g/dL. In some embodiments, the subject has elevated fetal hemoglobin levels. In some embodiments, the subject has a low reticulocyte count, also known as reticulocytopenia. In some embodiments, the subject has a reticulocyte count of less than 1%. In some embodiments, the subject has a reticulocyte count of less than 0.9%. In some embodiments, the subject has a reticulocyte count of less than 0.8%. In some embodiments, the subject has a reticulocyte count of less than 0.7%. In some embodiments, the subject has a reticulocyte count of less than 0.6%. In some embodiments, the subject has a reticulocyte count of less than 0.5%. In some embodiments, the subject has a reticulocyte count of less than 0.4%. In some embodiments, the subject has a reticulocyte count of less than 0.3%. In some embodiments, the subject has a reticulocyte count of less than 0.2%. In some embodiments, the subject has a reticulocyte count of less than 0.1%. In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject increases their reticulocyte or hemoglobin levels. Also included are methods of increasing reticulocytes in a subject, and methods of increasing hemoglobin levels in a subject, including a subject that has a lower than normal reticulocyte or hemoglobin levels, or is at risk for developing such a condition, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and thereby reducing reticulocyte or hemoglobin levels in the subject. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, increase hemoglobin synthesis in a subject with anemia associated with a ribosomal disorder, and may be used to treat a condition associated with decreased red blood cells. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may modulate hemoglobin synthesis by reducing the formation of heme. In some embodiments, the disclosure relates to methods of increasing hemoglobin synthesis in a subject with anemia associated with a ribosomal disorder, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the hemoglobin synthesis is increased in a dose dependent manner. In some embodiments, the method increases the subject’s hemoglobin levels. In some embodiments, the method increases the subject’s hemoglobin levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the subject’s hemoglobin levels by at least 15%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 20%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 25%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 30%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 35%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 40%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 45%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 50%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 55%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 60%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 65%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 70%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 75%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 80%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 85%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 90%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 95%. In some embodiments, the method increases the subject’s hemoglobin levels by at least 100%. In some embodiments, the method increases the subject’s hemoglobin levels to at least 13 g/dL. In some embodiments, the method increases the subject’s hemoglobin levels to at least 11 g/dL. In some embodiments, the method increases the subject’s reticulocyte count. In some embodiments, the method increases the subject’s reticulocyte count to between 1% to 2%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.5%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.6%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.7%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.8%. In some embodiments, the method increases the subject’s reticulocyte count to at least 0.9%. In some embodiments, the method increases the subject’s reticulocyte count to at least 1%. In some embodiments, the method increases the subject’s reticulocyte count to at least 1.5%. In some embodiments, the method increases the subject’s reticulocyte count to at least 2%. In some embodiments, the method increases the subject’s reticulocyte count by 0.5%. In some embodiments, the method increases the subject’s reticulocyte count by 1%. Combination Therapies Certain embodiments may include combination therapies for treating anemia associated with a ribosomal disorder, including the administration of compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in combination with other therapeutic agents or treatment modalities. Examples of combination therapies include, without limitation, any one or more additional active agents and/or supportive therapies selected from the group consisting of: trifluoperazine, HDAC inhibitors, glucocorticoids, sotatercept, luspatercept, iron chelators, blood transfusion, platelet transfusion, allogeneic hematopoietic stem cell transplant, autologous gene therapy, lenalidomide (REVLIMID®), and antibiotics. In some embodiments, the method further comprises administering another therapeutic agent to treat the ribosomal protein defect, selected from the group consisting of: corticosteroids and bone marrow transplants and other treatments known to persons of ordinary skill in the art. For instance, corticosteroids can be used to treat anemia associated with a ribosomal disorder, such as DBA. Blood transfusions can also be used to treat severe anemia associated with a ribosomal disorder, such as DBA. Periods of remission may occur, during which transfusions and steroid treatments are not required. Bone marrow transplantation (BMT) can treat hematological aspects of DBA. However, adverse events in transfusion patients can occur. In some embodiments, the method reduces the need for corticosteroid treatments in the subject. In some embodiments, the method reduces the dose of corticosteroid treatment needed in the subject. In some embodiments, the corticosteroid is a glucocorticoid steroid. As described above, a common therapy for treating anemia associated with a ribosomal disorder includes the use of regularly scheduled blood transfusions. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, is useful in treating a subject who has anemia associated with a ribosomal disorder (e.g., Diamond-Blackfan anemia) requiring blood transfusions. In some embodiments, the method reduces the subject’s need for blood transfusions. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the subject’s need for blood transfusions by at least 15%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 20%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 25%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 30%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 35%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 40%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 45%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 50%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 55%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 60%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 65%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 70%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 75%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 80%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 85%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 90%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 95%. In some embodiments, the method reduces the subject’s need for blood transfusions by at least 100%. In some embodiments, the method eliminates the subject’s need for blood transfusions. Quality of Life and Survival In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder (e.g., treating, preventing, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder) comprising administering to a patient in need thereof an effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases the patient’s quality of life by at least 1% (e.g., 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100%). In some embodiments, the method relates to increasing the patient’s quality of life. In some embodiments, the method relates to increasing the patient’s quality of life by at least 1%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 2%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 3%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 4%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 5%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 10%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 15%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 20%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 25%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 30%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 35%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 40%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 45%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 50%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 55%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 60%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 65%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 70%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 75%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 80%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 85%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 90%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 95%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 100%. In some embodiments, the patients has a low quality of life. In some embodiments, the patient’s quality of life is measured using the Functional Assessment of Cancer Therapy Anemia (FACT-An). In some embodiments, the patient’s quality of life is measured using the Functional Assessment of Cancer Therapy Fatigue (FACT-Fatigue). In some embodiments, the patient’s quality of life is measured using the Functional Assessment of Chronic Illness Therapy (FACIT). In some embodiments, the patient’s quality of life is measured using the Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-Fatigue). In some embodiments, the patient’s quality of life is measured using the Functional Assessment of Chronic Illness Therapy Anemia (FACIT- Anemia). In some embodiments, the patient’s quality of life is measured using the SF-36 generic PRO tool. In some embodiments, the patient’s quality of life is measured using the SF-6D generic PRO tool. In some embodiments, the patient’s quality of life is measured using the linear analog scale assessment (LASA). In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of anemia associated with a ribosomal disorder (e.g., treating, preventing, or reducing the progression rate and/or severity of one or more complications of anemia associated with a ribosomal disorder) comprising administering to a patient in need thereof an effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases the patient’s survival by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method increases the patient’s survival. In some embodiments, the method increases the patient’s survival by at least 15%. In some embodiments, the method increases the patient’s survival by at least 20%. In some embodiments, the method increases the patient’s survival by at least 25%. In some embodiments, the method increases the patient’s survival by at least 30%. In some embodiments, the method increases the patient’s survival by at least 35%. In some embodiments, the method increases the patient’s survival by at least 40%. In some embodiments, the method increases the patient’s survival by at least 45%. In some embodiments, the method increases the patient’s survival by at least 50%. In some embodiments, the method increases the patient’s survival by at least 55%. In some embodiments, the method increases the patient’s survival by at least 60%. In some embodiments, the method increases the patient’s survival by at least 65%. In some embodiments, the method increases the patient’s survival by at least 70%. In some embodiments, the method increases the patient’s survival by at least 75%. In some embodiments, the method increases the patient’s survival by at least 80%. In some embodiments, the method increases the patient’s survival by at least 85%. In some embodiments, the method increases the patient’s survival by at least 90%. In some embodiments, the method increases the patient’s survival by at least 95%. In some embodiments, the method increases the patient’s survival by at least 100%.
In some embodiments, the method increases the patient’s survival by at least 1 month. In some embodiments, the method increases the patient’s survival by at least 2 months. In some embodiments, the method increases the patient's survival by at least 3 months. In some embodiments, the method increases the patient’s survival by at least 4 months. In some embodiments, the method increases the patient’s survival by at least 5 months. In some embodiments, the method increases the patient’s survival by at least 6 months. In some embodiments, the method increases the patient’s survival by at least 7 months. In some embodiments, the method increases the patient’s survival by at least 8 months. In some embodiments, the method increases the patient’s survival by at least 9 months. In some embodiments, the method increases the patient’s survival by at least 10 months. In some embodiments, the method increases the patient’s survival by at least 11 months.
In some embodiments, the method increases the patient’s survival by at least 1 year. In some embodiments, the method increases the patient’s survival by at least 2 years. In some embodiments, the method increases the patient’s survival by at least 3 years. In some embodiments, the method increases the patient’s survival by at least 4 years. In some embodiments, the method increases the patient’s survival by at least 5 years. In some embodiments, the method increases the patient’s survival by at least 6 years. In some embodiments, the method increases the patient’s survival by at least 7 years. In some embodiments, the method increases the patient’s survival by at least 8 years. In some embodiments, the method increases the patient’s survival by at least 9 years. In some embodiments, the method increases the patient’s survival by at least 10 years.
Polycythemia
Polycythemia, or erythrocytosis, is a disease characterized by an abnormally high level of red blood cells, which often leads to hyperviscosity and an increased risk of thrombosis. The increase in red blood cells can be due to an increase in the red blood cell mass ("absolute polycythemia") or to a decrease in the volume of plasma ("relative polycythemia"). Absolute polycythemia can be distinguished from relative polycythemia secondary to fluid loss or decreased intake, because absolute polycythemia results in increased total blood volume, and relative polycythemia does not. Two basic categories of polycythemia are typically recognized: primary polycythemias, due to factors intrinsic to red cell precursors and include the diagnoses of primary familial and congenital polycythemia (PFCP) and polycythemia vera (PV); and secondary polycythemias, which are caused by factors extrinsic to red cell precursors. Primary Polycythemia Primary polycythemia refers to a variety of myeloproliferative syndromes that include, for example, polycythemia vera and pure erythrocytosis. Polycythemia vera has a significant genetic component. For instance, an activating mutation in the tyrosine kinase JAK2 (JAK2V617F) is responsible for most primary cases in adults. Several other mutations in JAK2 have also been described (e.g., exon 12, JAK2H538-K539delinsI). These and possibly other JAK2 mutations are thought to cause hypersensitivity to EPO via the EPO receptor. Familial clustering suggests a genetic predisposition. Also, the clonality of polycythemia vera is well established. Studies also suggest hypersensitivity of the myeloid progenitor cells to growth factors, including EPO, IL-3, SCF, GM-CSF, and insulin-like growth factor (IGF)-1, whereas other studies show defects in programmed cell death. Pure erythrocytosis includes patients who have an isolated elevated RBC mass in the absence of any other precipitating factor. Primary familial polycythemia is caused by a hypersensitivity of erythroid precursors to EPO. Several mutations (approximately 14) have been identified in the EPO receptor gene (EPOR). Most of the identified EPOR mutations cause truncation of the c-terminal cytoplasmic receptor domain of the receptor. These truncated receptors have heightened sensitivity to circulating EPO due to a lack of negative feedback regulation. In certain aspects, the disclosure relates to methods of treating polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the polycythemia is primary polycythemia. In some embodiments, the primary polycythemia is polycythemia vera. In some embodiments, the primary polycythemia is pure erythrocytosis. In some embodiments, the primary polycythemia is primary familial polycythemia. As such, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be used in treating or reducing the risk of primary polycythemia, such as polycythemia vera, pure erythrocytosis, or primary familial polycythemia. In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia. In some embodiments, the myelofibrosis is selected from the group consisting of low-risk myelofibrosis, intermediate-risk myelofibrosis, high-risk myelofibrosis, primary myelofibrosis, post-essential thrombocythemia myelofibrosis, and post-polycythemia vera myelofibrosis. In certain aspects, the disclosure relates to methods of treating splenomegaly associated with polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has an increased spleen size (e.g., splenomegaly). In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce splenomegaly in a subject with polycythemia. In some embodiments, the method reduces the subject’s spleen size. In some embodiments, the method reduces the subject’s spleen size by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the subject’s spleen size by at least 15%. In some embodiments, the method reduces the subject’s spleen size by at least 20%. In some embodiments, the method reduces the subject’s spleen size by at least 25%. In some embodiments, the method reduces the subject’s spleen size by at least 30%. In some embodiments, the method reduces the subject’s spleen size by at least 35%. In some embodiments, the method reduces the subject’s spleen size by at least 40%. In some embodiments, the method reduces the subject’s spleen size by at least 45%. In some embodiments, the method reduces the subject’s spleen size by at least 50%. In some embodiments, the method reduces the subject’s spleen size by at least 55%. In some embodiments, the method reduces the subject’s spleen size by at least 60%. In some embodiments, the method reduces the subject’s spleen size by at least 65%. In some embodiments, the method reduces the subject’s spleen size by at least 70%. In some embodiments, the method reduces the subject’s spleen size by at least 75%. In some embodiments, the method reduces the subject’s spleen size by at least 80%. In some embodiments, the method reduces the subject’s spleen size by at least 85%. In some embodiments, the method reduces the subject’s spleen size by at least 90%. In some embodiments, the method reduces the subject’s spleen size by at least 95%. In some embodiments, the method reduces the subject’s spleen size by at least 100%. In certain aspects, the disclosure relates to methods of treating polycythemia associated with Janus Kinase 2 (JAK2) mutation in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the mutation in JAK2 is a JAK2 V617F exon 14 mutation. In some embodiments, the mutation in JAK2 is a JAK2 exon 12 mutation. In some embodiments, the mutation in JAK2 is a gain-of-function mutation. In some embodiments, the subject’s JAK2 enzyme activity is increased. In certain aspects, the disclosure relates to methods of treating polycythemia associated with a gene mutation in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a mutation in Tet Methylcytosine Dioxygenase 2 (TET2) or Nuclear Factor Erythroid 2 (NFE2). In some embodiments, the subject has a mutation in gene selected from the group consisting of VHL, EPO, EPOR, ELG1, EPAS1, HIF2A, and BPGM. In some embodiments, the subject has a high oxygen affinity variant selected from the group consisting of hemoglobin B (HBB) and hemoglobin A (HBA). Secondary polycythemia Secondary polycythemia may result from functional hypoxia induced by lung disease, heart disease, increased altitude (hemoglobin increase of 4% for each 1000-m increase in altitude), congenital methemoglobinemia, and other high-oxygen affinity hemoglobinopathies stimulating increased EPO production. Secondary polycythemia may also result from increased EPO production secondary to benign and malignant EPO-secreting lesions. Secondary polycythemia may also be a benign familial polycythemia. In some embodiments, secondary polycythemia is due to genetic abnormalities. For instance, Chuvash polycythemia, a congenital polycythemia first recognized in an endemic Russian population, has mutations in the von Hippel-Lindau (VHL) gene, which is associated with a perturbed oxygen dependent regulation of EPO synthesis. Secondary polycythemia of the newborn is fairly common and may result from either chronic or acute fetal hypoxia or delayed cord clamping and stripping of the umbilical cord. Similar to primary polycythemia, secondary polycythemia is associated with many complications, including ischemic events in particular. Accordingly, GlyT1 inhibitors may be used in treating or reducing the risk of primary polycythemia, such as polycythemia vera, or secondary polycythemia. In certain aspects, the disclosure relates to methods of treating secondary polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the secondary polycythemia is associated with a disorder selected from the group consisting of hypoxia, central hypoxic process, lung disease, right-to-left cardiopulmonary vascular shunts (congenital or acquired), heart disease, heart failure, carbon monoxide poisoning, smoker’s erythrocytosis, high-altitude habitat, renal disease, kidney transplant, hemoglobinopathy with high-oxygen-affinity, decreased levels of erythrocyte 2,3,-DPG, bisphosphoglycerate mutase deficiency, methemoglobinemia, hereditary ATP increase, oxygen sensing pathway gene mutations, tumor, drug-induced secondary polycythemia, adrenal cortical hypersecretion, and idiopathic polycythemia. In some embodiments, the patient has an elevated erythropoietin (EPO) level. An elevated EPO level, usually as a secondary response to chronic hypoxemia, often leads to secondary polycythemia. In some embodiments, the elevated EPO level in the patient is in response to chronic hypoxemia. In some embodiments, the secondary polycythemia is associated chronic hypoxemia. In some embodiments, the secondary polycythemia is associated with lung disease. In some embodiments, the lung disease is selected from the group consisting of chronic lung disease, interstitial lung disease, chronic obstructive pulmonary disease (COPD), Pickwickian syndrome, emphysema, pulmonary fibrosis, sleep apnea, hypoventilation syndromes, and obesity hypoventilation syndrome. In some embodiments, the secondary polycythemia associated with lung disease occurs as a result of functional hypoxia. In some embodiments, the secondary polycythemia associated with lung disease occurs as a result of chronic hypoxemia. In some embodiments, the secondary polycythemia is associated with heart disease. In some embodiments, the heart disease is selected from the group consisting of cyanotic heart disease and congenital heart disease. In some embodiments, the secondary polycythemia is associated with renal disease. In some embodiments, the renal disease is selected from the group consisting of local renal hypoxia, renal artery stenosis, cysts, polycystic kidney disease, hydronephrosis, nephrotic syndrome, diffuse parenchymal disease, Bartter’s syndrome, end-stage renal disease, long-term hemodialysis, and post-renal transplant erythrocytosis. In some embodiments, the secondary polycythemia is associated with oxygen sensing pathway gene mutations. In some embodiments, the oxygen sensing pathway gene mutations are selected from the group consisting of EpoR, VHL, HIF2A, and PHD2. In some embodiments, the secondary polycythemia is associated with a tumor. In some embodiments, the tumor is a tumor with an excessive production of erythropoietin or erythropoietin related factors. In some embodiments, the tumor is selected from the group consisting of renal cell carcinoma, renal tumors, hepatocellular carcinoma, pheochromocytoma, cerebellar hemangioblastoma, uterine leiomyoma, ovarian carcinoma, meningioma, parathyroid carcinoma, and parathyroid adenoma. In some embodiments, the secondary polycythemia is drug-associated secondary polycythemia. In some embodiments, the drug-associated secondary polycythemia is selected from the group consisting of erythropoietin administration, androgen administration, anabolic steroid administration, synthetic testosterone administration, protein injections, gentamicin administration, and methyldopa administration. In some embodiments, the polycythemia is relative polycythemia. In some embodiments, the relative polycythemia is selected from the group consisting of Gaisbock’s syndrome, spurious polycythemia, or stress erythrocytosis. In some embodiments, the polycythemia is Chuvash polycythemia. Certain primary treatment regimes may lead to an undesirably increase in red blood cells. For instance, the drugs gentamicin and methyldopa have been associated with increasing the number of red blood cells in a subject. Hence, the a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be used in conjunction or combination with one or more of gentamicin, methyldopa, or other drug that leads to increased production of red blood cells, mainly to off-set the undesired effects of producing too many red blood cells. In certain embodiments, by reducing their undesirable side effects, combination therapy with a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may allow the use of higher concentrations of gentamicin, methyldopa, or related drugs. Accordingly, in certain embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be used to reduce erythropoiesis, and also to reduce the formation of erythroid progenitors, red blood cells, or both. In certain embodiments, methods of reducing erythropoiesis or red blood cell formation may be used to treat a subject that has or is at risk for having increased red blood cell count, increased hemoglobin levels, or increased total red blood cell volume, as described herein. Therapies for polycythemia A well-established hitherto existing method for treating polycythemia includes treatment using regularly scheduled phlebotomies (bloodletting). When first diagnosed, the phlebotomies are usually scheduled fairly frequent, e.g. multiple times per week, until RBC levels are brought to within normal range (e.g., hematocrit less than 45%), followed by phlebotomies which are then scheduled once a month or every other month depending upon the patient's rate of RBC formation. Because phlebotomy does not suppress the production of RBCs in the bone marrow, the effect of each phlebotomy is transient, until patients become iron deficient. Another approach to treating polycythemia attempts to reduce RBC formation by reducing the amount of available iron in the serum by increasing the removal of the iron from the body. Iron is an essential trace element for almost all organisms and is relevant in particular with respect to growth and the formation of blood. The balance of the iron metabolism is in this case primarily regulated on the level of iron recovery from hemoglobin of ageing erythrocytes and the duodenal absorption of dietary iron. The released iron is taken up via the intestine, in particular via specific transport systems (DMT-1, ferroportin), transferred into the blood circulation and thereby conveyed to the appropriate tissues and organs (transferrin, transferrin receptors). In the human body, the element iron is of great importance, inter alia for oxygen transport, oxygen uptake, cell functions such as mitochondrial electron transport, cognitive functions, etc. and ultimately for the entire energy metabolism. Iron uptake and storage is regulated by hepcidin. Hepcidin is produced in the liver and functions as the master iron regulatory hormone controlling intestinal iron uptake, and also regulates iron storage in other organs. Hepcidin limits iron-uptake by binding to the iron transport molecule ferroportin and causing its degradation. Hepcidin deficiency is a frequently found pathogenic feature in patients with iron overload. One method for decreasing iron levels in a patient uses hepcidin agonists, such as hepcidin mimetics. It has been shown in animal models that high doses of hepcidin mimetics can ameliorate certain polycythemias, such as polycythemia vera, by diminishing erythropoiesis. However, over administration of hepcidin agonists can cause suppression of intestinal iron uptake and macrophage iron recycling, with potential exacerbation of suboptimal production of RBCs, as in polycythemia vera. Additionally, hepcidin is limited in its use as a drug because of its complex structure which requires a complicated manufacturing, and also its limited in vivo duration of action. Another method of decreasing iron levels in the patient includes the use of chelating agents. For example, deferoxamine (also known Desferal®), which is a bacterial siderophore, is an established drug used in chelation therapy. Deferoxamine binds iron in the bloodstream as an chelator and enhances its elimination via urine and feces. Two additional drugs, licensed for use in patients receiving regular blood transfusions, resulting in the development of iron overload, are deferasirox and deferiprone. The disadvantage in the treatment of decreasing iron levels using chelation therapy is that iron chelation therapies are known to exhibit a toxic potential. Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the subject has polycythemia. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, treat polycythemia while maintaining the subject’s iron levels. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, treat polycythemia while increasing the subject’s stored iron levels. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, treat polycythemia while decreasing the incidence of iron deficiency. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis while maintaining the subject’s iron levels. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis while increasing the subject’s stored iron levels. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis while decreasing the incidence of iron deficiency. Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an iron deficiency associated with polycythemia. In some embodiments, the method decreases the incidence of iron deficiency by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the incidence of iron deficiency by at least 15%. In some embodiments, the method decreases the incidence of iron deficiency by at least 20%. In some embodiments, the method decreases the incidence of iron deficiency by at least 25%. In some embodiments, the method decreases the incidence of iron deficiency by at least 30%. In some embodiments, the method decreases the incidence of iron deficiency by at least 35%. In some embodiments, the method decreases the incidence of iron deficiency by at least 40%. In some embodiments, the method decreases the incidence of iron deficiency by at least 45%. In some embodiments, the method decreases the incidence of iron deficiency by at least 50%. In some embodiments, the method decreases the incidence of iron deficiency by at least 55%. In some embodiments, the method decreases the incidence of iron deficiency by at least 60%. In some embodiments, the method decreases the incidence of iron deficiency by at least 65%. In some embodiments, the method decreases the incidence of iron deficiency by at least 70%. In some embodiments, the method decreases the incidence of iron deficiency by at least 75%. In some embodiments, the method decreases the incidence of iron deficiency by at least 80%. In some embodiments, the method decreases the incidence of iron deficiency by at least 85%. In some embodiments, the method decreases the incidence of iron deficiency by at least 90%. In some embodiments, the method decreases the incidence of iron deficiency by at least 95%. In some embodiments, the method decreases the incidence of iron deficiency by at least 100%. In some embodiments, the method further improves iron deficiency in the subject. In some embodiments, the method improves iron deficiency in the subject by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method improves iron deficiency in the subject by at least 15%. In some embodiments, the method improves iron deficiency in the subject by at least 20%. In some embodiments, the method improves iron deficiency in the subject by at least 25%. In some embodiments, the method improves iron deficiency in the subject by at least 30%. In some embodiments, the method improves iron deficiency in the subject by at least 35%. In some embodiments, the method improves iron deficiency in the subject by at least 40%. In some embodiments, the method improves iron deficiency in the subject by at least 45%. In some embodiments, the method improves iron deficiency in the subject by at least 50%. In some embodiments, the method improves iron deficiency in the subject by at least 55%. In some embodiments, the method improves iron deficiency in the subject by at least 60%. In some embodiments, the method improves iron deficiency in the subject by at least 65%. In some embodiments, the method improves iron deficiency in the subject by at least 70%. In some embodiments, the method improves iron deficiency in the subject by at least 75%. In some embodiments, the method improves iron deficiency in the subject by at least 80%. In some embodiments, the method improves iron deficiency in the subject by at least 85%. In some embodiments, the method improves iron deficiency in the subject by at least 90%. In some embodiments, the method improves iron deficiency in the subject by at least 95%. In some embodiments, the method improves iron deficiency in the subject by at least 100%. Erythropoiesis Erythropoiesis refers generally to the process by which red blood cells (erythrocytes) are produced from HSCs, and includes the formation of erythroid progenitor cells. Erythropoiesis is a carefully ordered sequence of events. Initially occurring in fetal hepatocytes, the process is taken over by the bone marrow in the child and adult. Although multiple cytokines and growth factors are dedicated to the proliferation of the red blood cell, the primary regulator is erythropoietin (EPO). Red blood cell development is initially regulated by stem cell factor (SCF), which commits hematopoietic stem cells to develop into erythroid progenitors. Subsequently, EPO continues to stimulate the development and terminal differentiation of these progenitors. In the fetus, EPO is produced by monocytes and macrophages found in the liver. After birth, EPO is produced in the kidneys; however, Epo messenger RNA (mRNA) and EPO protein are also found in the brain and in red blood cells (RBCs), suggesting the presence of paracrine and autocrine functions. Erythropoiesis escalates as increased expression of the EPO gene produces higher levels of circulating EPO. EPO gene expression is known to be affected by multiple factors, including hypoxemia, transition metals (Co2+, Ni2+, Mn2+), and iron chelators. However, the major influence is hypoxia, including factors of decreased oxygen tension, red blood cell loss, and increased oxygen affinity of hemoglobin. For instance, EPO production may increase as much as 1000-fold in severe hypoxia. Erythropoiesis requires the proper biosynthesis of heme and as erythroblasts mature, their demand for heme and iron dramatically increase. Erythroid cells synthesize large amounts of heme and hemoglobin while simultaneously absorbing lots of iron into the cell. Glycine is one of the key initial substrates for heme and globin synthesis. As such, decreased levels of glycine due to GlyT1 inhibition could lead to a decrease in heme synthesis. In certain aspects, the disclosure relates to methods of inhibiting heme synthesis in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the heme synthesis is inhibited in a dose dependent manner.
In some embodiments, the compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, reduce red blood cell synthesis (also known as erythropoiesis), and may be used to treat a condition associated with increased red blood cells. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1- 60), or a pharmaceutically acceptable salt thereof, may modulate red blood cell synthesis by reducing the formation of heme. In some embodiments, the disclosure relates to methods of inhibiting red blood cell synthesis in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the red blood cell synthesis is inhibited in a dose dependent manner. In some embodiments, the disclosure relates to methods of decreasing the red blood cell count in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the red blood cell count is decreased in a dose dependent manner. In some embodiments, merely by way of non-limiting example, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be administered directly to a subject to reduce red blood count, if desired. In this regard, a normal red blood cell count typically ranges from about 4.7 to about 6.1 million red blood cells per μl in men, and about 4.2 to about 5.4 million red blood cells per μl in women. A high red blood cell count is generally defined as more than about 5.3 million red blood cells per μl of blood for men and about 5.1 million red blood cells per μl of blood for women. In children, the threshold for high red blood cell count varies with age and sex. Red blood count may also be reflected by a person's hematocrit (i.e., packed cell volume (PCV) or erythrocyte volume fraction (EVE)), which is the proportion or percentage of blood volume that is occupied by red blood cells. A normal hematocrit is normally about 49% for men and about 48% for women. A higher hematocrit value indicates a greater number of red blood cells. In severe cases, a high red blood cell count can impair circulation and lead to abnormal clotting, among other problems.
In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, reduces hemoglobin synthesis in a subject with polycythemia, and may be used to treat a condition associated with increased red blood cells. In some embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may modulate hemoglobin synthesis by reducing the formation of heme. In some embodiments, the disclosure relates to methods of inhibiting hemoglobin synthesis in a subject with polycythemia, comprising administering to a subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the hemoglobin synthesis is inhibited in a dose dependent manner.
Red blood cell count and hematocrit
Certain embodiments of the present application relate to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an increased red blood cell count (e.g, greater than about 5.3 million red blood cells per μl of blood for men and about 5.1 million red blood cells per μl of blood for women, often by a clinically or statistically significant amount), or an increased hematocrit (e.g, greater than about 49% for men or about 48% for women, often by a clinically or statistically significant amount). In some embodiments, the subject has hematocrit levels that are at least 48%. In some embodiments, the subject has hematocrit levels that are at least 49%.
In some embodiments, the subject’s hematocrit levels are at least 10%, 20%, 30%, 40%, or 50% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 10% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 20% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 30% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 40% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject’s hematocrit levels are at least 50% more than hematocrit levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 10%, 20%, 30%, 40%, or 50% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 10% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 20% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 30% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 40% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count that is at least 50% more than a red blood cell count in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has a red blood cell count greater than 5.1 x1012/L. In some embodiments, the subject has a red blood cell count greater than 5.3 x1012/L. In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject reduces their red blood cell count or hematocrit. Also included are methods of reducing red blood cells in a subject, and methods of reducing hematocrit in a subject, including a subject that has a higher than normal red blood cell count or hematocrit, or is at risk for developing such a condition, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and thereby reducing red blood cell count or hematocrit in the subject. In some embodiments, the method decreases the subject’s red blood cell levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the subject’s red blood cell levels by at least 15%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 20%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 25%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 30%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 35%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 40%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 45%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 50%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 55%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 60%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 65%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 70%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 75%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 80%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 85%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 90%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 95%. In some embodiments, the method decreases the subject’s red blood cell levels by at least 100%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the subject’s hematocrit levels by at least 15%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 20%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 25%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 30%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 35%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 40%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 45%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 50%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 55%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 60%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 65%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 70%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 75%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 80%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 85%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 90%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 95%. In some embodiments, the method decreases the subject’s hematocrit levels by at least 100%. In some embodiments, the method decreases the subject’s hematocrit levels to less than 48%. There are many general diseases or conditions that increase the red blood cell count or hematocrit of a subject, and which may be improved or treated by the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. As one general, illustrative example, high red blood cell count may result from increases in red blood cell production, mainly to compensate for low oxygen levels, which may be caused by poor heart or lung function. Also, high red blood cell count may result from increased release of erythropoietin (EPO) from the kidneys (EPO enhances red blood cell production), production of too many red blood cells by the bone marrow, impairment of the oxygen-carrying capacity of red blood cells (leading to over-production), compensation for a limited oxygen supply in higher altitudes, and the loss of blood plasma (i.e., the liquid component of blood), which may create relatively high levels of red blood cells, volume-wise. Further examples of conditions that are associated with high red blood cell count include, without limitation, living at a high altitude, smoking, congenital heart disease, failure of the right side of the heart (i.e., cor pulmonale), scarring and thickening of the lung tissue (i.e., pulmonary fibrosis), bone marrow disorders (e.g., polycythemia vera), dehydration, such as from severe diarrhea or excessive sweating, kidney disease/cancer, exposure to carbon monoxide, anabolic steroid use, COPD or other lung diseases, such as pulmonary fibrosis, and EPO doping, mainly to enhance athletic performance. Hence, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, can be used to treat or reduce the risk of developing high red blood cell count or volume as it is associated with these or any other conditions known in the art. Accordingly, in certain embodiments, a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, may be used to reduce erythropoiesis, and also to reduce the formation of red blood cells. In certain embodiments, methods of reducing erythropoiesis or red blood cell formation may be used to treat a subject that has or is at risk for having increased red blood cell count, increased hemoglobin levels, or increased total red blood cell volume, as described herein and known in the art. Red blood cell mass and hemoglobin In certain embodiments, the present application relates to methods of administering a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to a subject in need thereof, wherein the subject has an increased red blood cell mass (e.g., more than 25% above mean normal predicted value, often by a clinically or statistically significant amount), or increased hemoglobin levels (e.g., greater than about 16.5 g/dL for men or about 16.0 g/dL for women, often by a clinically or statistically significant amount). In some embodiments, the subject has red blood cell mass levels that are at least 10%, 20%, 30%, 40%, or 50% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 10% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 20% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 30% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 40% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 50% more than red blood cell mass levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has red blood cell mass levels that are at least 25% above mean normal predicted value. In some embodiments, the subject has hemoglobin levels that are at least 10%, 20%, 30%, 40%, 50%, or 60% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 10% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 20% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 30% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 40% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 50% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are at least 60% more than hemoglobin levels in a healthy subject prior to administration of the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the subject has hemoglobin levels that are greater than 16.0 g/dL. In some embodiments, the subject has hemoglobin levels that are greater than 16.5 g/dL. In certain embodiments, administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, to such a subject reduces their red blood cell mass or hemoglobin levels. Also included are methods of reducing red blood cells mass in a subject, and methods of reducing hemoglobin levels in a subject, including a subject that has a higher than normal red blood cell mass or hemoglobin levels, or is at risk for developing such a condition, comprising administering to the subject a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, and thereby reducing red blood cell mass or hemoglobin levels in the subject. In some embodiments, the method decreases the subject’s red blood cell mass by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the subject’s red blood cell mass by at least 15%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 20%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 25%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 30%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 35%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 40%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 45%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 50%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 55%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 60%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 65%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 70%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 75%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 80%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 85%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 90%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 95%. In some embodiments, the method decreases the subject’s red blood cell mass by at least 100%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method decreases the subject’s hemoglobin levels by at least 15%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 20%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 25%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 30%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 35%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 40%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 45%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 50%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 55%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 60%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 65%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 70%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 75%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 80%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 85%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 90%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 95%. In some embodiments, the method decreases the subject’s hemoglobin levels by at least 100%. In some embodiments, the method decreases the subject’s hemoglobin levels to less than 16 g/dL. In some embodiments, the method decreases the subject’s hemoglobin levels to less than 16.5 g/dL. Complications of polycythemia In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of one or more complications of polycythemia in a subject, the method comprising administering to the subject a pharmaceutical composition comprising a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In some embodiments, the one or more complications of polycythemia is a thromboembolic event. In some embodiments, the method reduces the risk of thromboembolic events. In some embodiments, the thromboembolic event is arterial thrombosis. In some embodiments, the thromboembolic event is venous thrombosis. In some embodiments, the one or more complications of polycythemia is blurred vision. In some embodiments, the method reduces the risk of blurred vision by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the one or more complications of polycythemia is a headache. In some embodiments, the method reduces the risk of headaches by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia. In some embodiments, the myelofibrosis is selected from the group consisting of low-risk myelofibrosis, intermediate-risk myelofibrosis, high-risk myelofibrosis, primary myelofibrosis, post-essential thrombocythemia myelofibrosis, and post-polycythemia vera myelofibrosis. Combination Therapies Certain embodiments may include combination therapies for treating polycythemias, including the administration of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in combination with other polycythemia-based therapeutic agents or treatment modalities. Examples of combination therapies included, without limitation, any one or more additional active agents and/or supportive therapies selected from the group consisting of: Hydroxyruea (e.g., Droxia®, Hydrea®), Interferon alpha, Interferon alpha-2b (e.g., Intron® A), Ruxolitinib (e.g., Jakafi®), Busulfan (e.g., Busulfex®, Myleran®), radiation treatment, hepcidin mimetics (e.g., PTG-300), matriptase-2 inhibitors, ferroportin inhibitors, JAK inhibitors, BET inhibitors, MDM2 inhibitors, and HDAC inhibitors. Common therapies for high-risk polycythemia vera patients includes hydroxyurea or interferon. Hydroxyurea is a chemotherapeutic agent that can be used for decades, though some studies suggest that it may increase the risk of PV transforming into acute myeloid leukemia. Additionally, many patients do not respond well to or are intolerant of hydroxyurea (mucocutaneous ulcers are the leading toxicity), and require a different therapy. In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, are useful in treating a subject who has an inadequate response or a subject who is intolerant to hydroxyurea. In some embodiments, the subject has an inadequate response to hydroxyurea. In some embodiments, the subject is intolerant to hydroxyurea. Another well-established method for treating polycythemia includes treatment using regularly scheduled phlebotomies (bloodletting). In some embodiments, the compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, are useful in treating a subject who has polycythemia requiring therapeutic phlebotomies. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%). In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 15%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 20%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 25%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 30%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 35%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 40%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 45%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 50%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 55%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 60%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 65%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 70%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 75%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 80%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 85%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 90%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 95%. In some embodiments, the method reduces the patient’s need for therapeutic phlebotomies by at least 100%. In some embodiments, the method eliminates the patient’s need for therapeutic phlebotomies. Quality of Life In certain aspects, the disclosure relates to methods of preventing, treating, or reducing the progression rate and/or severity of polycythemia (e.g., treating, preventing, or reducing the progression rate and/or severity of one or more complications of polycythemia) comprising administering to a patient in need thereof an effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, wherein the method increases the patient’s quality of life by at least 1% (e.g., 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or 100%). In some embodiments, the method relates to increasing the patient’s quality of life by at least 1%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 2%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 3%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 4%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 5%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 10%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 15%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 20%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 25%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 30%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 35%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 40%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 45%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 50%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 55%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 60%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 65%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 70%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 75%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 80%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 85%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 90%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 95%. In some embodiments, the method relates to increasing the patient’s quality of life by at least 100%. In some embodiments, the patient’s quality of life is measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). In some embodiments, the patient’s quality of life is measured using the Myeloproliferative Neoplasm Symptom Assessment Form (MPN-SAF). In some embodiments, the patient’s quality of life is measured using the Pruritus Symptom Impact Scale (PSIS). In some embodiments, the patient’s quality of life is measured using the Patient Global Impression of Change (PGIC). In certain embodiments of the methods as disclosed herein, the compound is a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof. In certain embodiments, the application relates to a pharmaceutical composition comprising as active ingredient a therapeutically effective amount of a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, in association with at least one pharmaceutically acceptable excipient, carrier or diluent. In certain such embodiments, the pharmaceutical composition is for treating a disease or disorder in a patient in need thereof, such as a disease or disorder as disclosed herein. In certain embodiments, the application relates to a pharmaceutical composition comprising (1) a compound of formula (I) (e.g., any one of compounds 1-60), or a pharmaceutically acceptable salt thereof, (2) an additional therapeutic agent, or a pharmaceutically acceptable salt thereof, and (3) pharmaceutically acceptable excipients, carriers or diluents. Definitions The definitions set forth in this application are intended to clarify terms used throughout this application. The term "herein" means the entire application. The term “acyl” is art-recognized and refers to a group represented by the general formula hydrocarbylC(O)-, preferably alkylC(O)-. The term “acylamino” is art-recognized and refers to an amino group substituted with an acyl group and may be represented, for example, by the formula hydrocarbylC(O)NH-. The term “acyloxy” is art-recognized and refers to a group represented by the general formula hydrocarbylC(O)O-, preferably alkylC(O)O-. The term “alkoxy” refers to an alkyl group, preferably a lower alkyl group, having an oxygen attached thereto. Representative alkoxy groups include methoxy, ethoxy, propoxy, tert-butoxy and the like. The term “alkoxyalkyl” refers to an alkyl group substituted with an alkoxy group and may be represented by the general formula alkyl-O-alkyl. The term “alkenyl”, as used herein, refers to an aliphatic group containing at least one double bond and is intended to include both "unsubstituted alkenyls" and "substituted alkenyls", the latter of which refers to alkenyl moieties having substituents replacing a hydrogen on one or more carbons of the alkenyl group. Such substituents may occur on one or more carbons that are included or not included in one or more double bonds. Moreover, such substituents include all those contemplated for alkyl groups, as discussed below, except where stability is prohibitive. For example, substitution of alkenyl groups by one or more alkyl, carbocyclyl, aryl, heterocyclyl, or heteroaryl groups is contemplated. An “alkyl” group or “alkane” is a straight chained or branched non-aromatic hydrocarbon which is completely saturated. Typically, a straight chained or branched alkyl group has from 1 to about 20 carbon atoms, preferably from 1 to about 10 unless otherwise defined. Examples of straight chained and branched alkyl groups include methyl, ethyl, n- propyl, iso-propyl, n-butyl, sec-butyl, tert-butyl, pentyl, hexyl, pentyl and octyl. A C1-C6 straight chained or branched alkyl group is also referred to as a "lower alkyl" group. Moreover, the term "alkyl" (or "lower alkyl") as used throughout the specification, examples, and claims is intended to include both "unsubstituted alkyls" and "substituted alkyls", the latter of which refers to alkyl moieties having substituents replacing a hydrogen on one or more carbons of the hydrocarbon backbone. Such substituents, if not otherwise specified, can include, for example, a halogen, a hydroxyl, a carbonyl (such as a carboxyl, an alkoxycarbonyl, a formyl, or an acyl), a thiocarbonyl (such as a thioester, a thioacetate, or a thioformate), an alkoxyl, a phosphoryl, a phosphate, a phosphonate, a phosphinate, an amino, an amido, an amidine, an imine, a cyano, a nitro, an azido, a sulfhydryl, an alkylthio, a sulfate, a sulfonate, a sulfamoyl, a sulfonamido, a sulfonyl, a heterocyclyl, an aralkyl, or an aromatic or heteroaromatic moiety. It will be understood by those skilled in the art that the moieties substituted on the hydrocarbon chain can themselves be substituted, if appropriate. For instance, the substituents of a substituted alkyl may include substituted and unsubstituted forms of amino, azido, imino, amido, phosphoryl (including phosphonate and phosphinate), sulfonyl (including sulfate, sulfonamido, sulfamoyl and sulfonate), and silyl groups, as well as ethers, alkylthios, carbonyls (including ketones, aldehydes, carboxylates, and esters), -CF3, -CN and the like. Exemplary substituted alkyls are described below. Cycloalkyls can be further substituted with alkyls, alkenyls, alkoxys, alkylthios, aminoalkyls, carbonyl- substituted alkyls, -CF3, -CN, and the like. The term “Cx-y” when used in conjunction with a chemical moiety, such as, acyl, acyloxy, alkyl, alkenyl, alkynyl, or alkoxy is meant to include groups that contain from x to y carbons in the chain. For example, the term “Cx-yalkyl” refers to substituted or unsubstituted saturated hydrocarbon groups, including straight-chain alkyl and branched-chain alkyl groups that contain from x to y carbons in the chain, including haloalkyl groups such as trifluoromethyl and 2,2,2-tirfluoroethyl, etc. C0 alkyl indicates a hydrogen where the group is in a terminal position, a bond if internal. The terms “C2-yalkenyl” and “C2-yalkynyl” refer to substituted or unsubstituted unsaturated aliphatic groups analogous in length and possible substitution to the alkyls described above, but that contain at least one double or triple bond respectively. The term “alkylamino”, as used herein, refers to an amino group substituted with at least one alkyl group. The term “alkylthio”, as used herein, refers to a thiol group substituted with an alkyl group and may be represented by the general formula alkylS-. The term “alkynyl”, as used herein, refers to an aliphatic group containing at least one triple bond and is intended to include both "unsubstituted alkynyls" and "substituted alkynyls", the latter of which refers to alkynyl moieties having substituents replacing a hydrogen on one or more carbons of the alkynyl group. Such substituents may occur on one or more carbons that are included or not included in one or more triple bonds. Moreover, such substituents include all those contemplated for alkyl groups, as discussed above, except where stability is prohibitive. For example, substitution of alkynyl groups by one or more alkyl, carbocyclyl, aryl, heterocyclyl, or heteroaryl groups is contemplated. The term “amide”, as used herein, refers to a group
Figure imgf000151_0001
wherein each R30 independently represent a hydrogen or hydrocarbyl group, or two R30 are taken together with the N atom to which they are attached complete a heterocycle having from 4 to 8 atoms in the ring structure. The terms “amine” and “amino” are art-recognized and refer to both unsubstituted and substituted amines and salts thereof, e.g., a moiety that can be represented by
Figure imgf000152_0001
wherein each R30 independently represents a hydrogen or a hydrocarbyl group, or two R30 are taken together with the N atom to which they are attached complete a heterocycle having from 4 to 8 atoms in the ring structure. The term “aminoalkyl”, as used herein, refers to an alkyl group substituted with an amino group. The term “aralkyl”, as used herein, refers to an alkyl group substituted with an aryl group. The term “aryl” as used herein include substituted or unsubstituted single-ring aromatic groups in which each atom of the ring is carbon. Preferably the ring is a 5- to 7- membered ring, more preferably a 6-membered ring. The term “aryl” also includes polycyclic ring systems having two or more cyclic rings in which two or more carbons are common to two adjoining rings wherein at least one of the rings is aromatic, e.g., the other cyclic rings can be cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls. Aryl groups include benzene, naphthalene, phenanthrene, phenol, aniline, and the like. The term “carbamate” is art-recognized and refers to a group
Figure imgf000152_0002
wherein R29 and R30 independently represent hydrogen or a hydrocarbyl group, such as an alkyl group, or R29 and R30 taken together with the intervening atom(s) complete a heterocycle having from 4 to 8 atoms in the ring structure. The terms “carbocycle”, and “carbocyclic”, as used herein, refers to a saturated or unsaturated ring in which each atom of the ring is carbon. The term carbocycle includes both aromatic carbocycles and non-aromatic carbocycles. Non-aromatic carbocycles include both cycloalkane rings, in which all carbon atoms are saturated, and cycloalkene rings, which contain at least one double bond. “Carbocycle” includes 5-7 membered monocyclic and 8-12 membered bicyclic rings. Each ring of a bicyclic carbocycle may be selected from saturated, unsaturated and aromatic rings. Carbocycle includes bicyclic molecules in which one, two or three or more atoms are shared between the two rings. The term “fused carbocycle” refers to a bicyclic carbocycle in which each of the rings shares two adjacent atoms with the other ring. Each ring of a fused carbocycle may be selected from saturated, unsaturated and aromatic rings. In an exemplary embodiment, an aromatic ring, e.g., phenyl, may be fused to a saturated or unsaturated ring, e.g., cyclohexane, cyclopentane, or cyclohexene. Any combination of saturated, unsaturated and aromatic bicyclic rings, as valence permits, is included in the definition of carbocyclic. Exemplary “carbocycles” include cyclopentane, cyclohexane, bicyclo[2.2.1]heptane, 1,5-cyclooctadiene, 1,2,3,4-tetrahydronaphthalene, bicyclo[4.2.0]oct-3-ene, naphthalene and adamantane. Exemplary fused carbocycles include decalin, naphthalene, 1,2,3,4-tetrahydronaphthalene, bicyclo[4.2.0]octane, 4,5,6,7-tetrahydro- 1H-indene and bicyclo[4.1.0]hept-3-ene. “Carbocycles” may be susbstituted at any one or more positions capable of bearing a hydrogen atom. A “cycloalkyl” group is a cyclic hydrocarbon which is completely saturated. “Cycloalkyl” includes monocyclic and bicyclic rings. Typically, a monocyclic cycloalkyl group has from 3 to about 10 carbon atoms, more typically 3 to 8 carbon atoms unless otherwise defined. The second ring of a bicyclic cycloalkyl may be selected from saturated, unsaturated and aromatic rings. Cycloalkyl includes bicyclic molecules in which one, two or three or more atoms are shared between the two rings. The term “fused cycloalkyl” refers to a bicyclic cycloalkyl in which each of the rings shares two adjacent atoms with the other ring. The second ring of a fused bicyclic cycloalkyl may be selected from saturated, unsaturated and aromatic rings. A “cycloalkenyl” group is a cyclic hydrocarbon containing one or more double bonds. The term “carbocyclylalkyl”, as used herein, refers to an alkyl group substituted with a carbocycle group. The term “carbonate” is art-recognized and refers to a group -OCO2-R30, wherein R30 represents a hydrocarbyl group. The term “carboxy”, as used herein, refers to a group represented by the formula -CO2H. The term “ester”, as used herein, refers to a group -C(O)OR30 wherein R30 represents a hydrocarbyl group. The term “ether”, as used herein, refers to a hydrocarbyl group linked through an oxygen to another hydrocarbyl group. Accordingly, an ether substituent of a hydrocarbyl group may be hydrocarbyl-O-. Ethers may be either symmetrical or unsymmetrical. Examples of ethers include, but are not limited to, heterocycle-O-heterocycle and aryl-O- heterocycle. Ethers include “alkoxyalkyl” groups, which may be represented by the general formula alkyl-O-alkyl. The terms “halo” and “halogen” as used herein means halogen and includes chloro, fluoro, bromo, and iodo. The terms “hetaralkyl” and “heteroaralkyl”, as used herein, refers to an alkyl group substituted with a hetaryl group. The term "heteroalkyl", as used herein, refers to a saturated or unsaturated chain of carbon atoms and at least one heteroatom, wherein no two heteroatoms are adjacent. The terms “heteroaryl” and “hetaryl” include substituted or unsubstituted aromatic single ring structures, preferably 5- to 7-membered rings, more preferably 5- to 6-membered rings, whose ring structures include at least one heteroatom, preferably one to four heteroatoms, more preferably one or two heteroatoms. The terms “heteroaryl” and “hetaryl” also include polycyclic ring systems having two or more cyclic rings in which two or more carbons are common to two adjoining rings wherein at least one of the rings is heteroaromatic, e.g., the other cyclic rings can be cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls. Heteroaryl groups include, for example, pyridyl, 2- oxo-pyridinyl, pyrimidinyl, pyridazinyl, pyrazinyl, triazinyl, furanyl, pyrrolyl, thiophenyl, pyrazolyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, triazolyl, oxadiazolyl, thiadiazolyl, tetrazolyl, indolyl, isoindolyl, benzofuranyl, benzothiophenyl, indolinyl, 2- oxoindolinyl, dihydrobenzofuranyl, dihydrobenzothiophenyl, indazolyl, benzimidazolyl, benzooxazolyl, benzothiazolyl, benzoisoxazolyl, benzoisothiazolyl, benzotriazolyl, benzo[1,3]dioxolyl, quinolinyl, isoquinolinyl, quinazolinyl, cinnolinyl, pthalazinyl, quinoxalinyl, 2,3-dihydro-benzo[1,4]dioxinyl, benzo[1,2,3]triazinyl, benzo[1,2,4]triazinyl, 4H-chromenyl, indolizinyl, quinolizinyl, 6aH-thieno[2,3-d]imidazolyl, 1H-pyrrolo[2,3- b]pyridinyl, imidazo[1,2-a]pyridinyl, pyrazolo[1,5-a]pyridinyl, [1,2,4]triazolo[4,3- a]pyridinyl, [1,2,4]triazolo[1,5-a]pyridinyl, thieno[2,3-b]furanyl, thieno[2,3-b]pyridinyl, thieno[3,2-b]pyridinyl, furo[2,3-b]pyridinyl, furo[3,2-b]pyridinyl, thieno[3,2-d]pyrimidinyl, furo[3,2-d]pyrimidinyl, thieno[2,3-b]pyrazinyl, imidazo[1,2-a]pyrazinyl, 5,6,7,8- tetrahydroimidazo[1,2-a]pyrazinyl, 6,7-dihydro-4H-pyrazolo[5,1-c][1,4]oxazinyl, 2-oxo-2,3- dihydrobenzo[d]oxazolyl, 3,3-dimethyl-2-oxoindolinyl, 2-oxo-2,3-dihydro-1H-pyrrolo[2,3- b]pyridinyl, benzo[c][1,2,5]oxadiazolyl, benzo[c][1,2,5]thiadiazolyl, 3,4-dihydro-2H- benzo[b][1,4]oxazinyl, 5,6,7,8-tetrahydro-[1,2,4]triazolo[4,3-a]pyrazinyl, [1,2,4]triazolo[4,3- a]pyrazinyl, 3-oxo-[1,2,4]triazolo[4,3-a]pyridin-2(3H)-yl, and the like. The term “heteroatom” as used herein means an atom of any element other than carbon or hydrogen. Exemplary heteroatoms are nitrogen, oxygen, and sulfur. The terms “heterocyclyl”, “heterocycloalkyl”, “heterocycle”, and “heterocyclic” refer to substituted or unsubstituted non-aromatic ring structures, preferably 3- to 10-membered rings, more preferably 3- to 7-membered rings, whose ring structures include at least one heteroatom, preferably one to four heteroatoms, more preferably one or two heteroatoms. The terms “heterocyclyl” and “heterocyclic” also include polycyclic ring systems having two or more cyclic rings in which two or more carbons are common to two adjoining rings wherein at least one of the rings is heterocyclic, e.g., the other cyclic rings can be cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls. Heterocyclyl groups include, for example, azepinyl, azocanyl, pyranyl dioxanyl, dithianyl, 1,3-dioxolanyl, tetrahydrofuryl, dihydropyrrolidinyl, decahydroisoquinolyl, imidazolidinyl, isothiazolidinyl, isoxazolidinyl, morpholinyl, octahydroindolyl, octahydroisoindolyl, 2-oxopiperazinyl, 2- oxopiperidinyl, 2-oxopyrrolidinyl, 2-oxoazepinyl, oxazolidinyl, oxiranyl, piperidinyl, piperazinyl, 4-piperidonyl, pyrrolidinyl, pyrazolidinyl, thiazolidinyl, tetrahydropyranyl, thiamorpholinyl, thiamorpholinyl sulfoxide, and thiamorpholinyl sulfone. Further heterocycles and heteroaryls are described in Katritzky et al., eds., Comprehensive Heterocyclic Chemistry: The Structure, Reactions, Synthesis and Use of Heterocyclic Compounds, Vol.1-8, Pergamon Press, N.Y. (1984), which is hereby incorporated by reference in its entirety. The term “heterocyclylalkyl”, as used herein, refers to an alkyl group substituted with a heterocycle group. The term “hydrocarbyl”, as used herein, refers to a group that is bonded through a carbon atom that does not have a =O or =S substituent, and typically has at least one carbon- hydrogen bond and a primarily carbon backbone, but may optionally include heteroatoms. Thus, groups like methyl, ethoxyethyl, 2-pyridyl, and trifluoromethyl are considered to be hydrocarbyl for the purposes of this application, but substituents such as acetyl (which has a =O substituent on the linking carbon) and ethoxy (which is linked through oxygen, not carbon) are not. Hydrocarbyl groups include, but are not limited to aryl, heteroaryl, carbocycle, heterocyclyl, alkyl, alkenyl, alkynyl, and combinations thereof. The term “hydroxyalkyl”, as used herein, refers to an alkyl group substituted with a hydroxy group. The term “lower” when used in conjunction with a chemical moiety, such as, acyl, acyloxy, alkyl, alkenyl, alkynyl, or alkoxy is meant to include groups where there are ten or fewer non-hydrogen atoms in the substituent, preferably six or fewer. A “lower alkyl”, for example, refers to an alkyl group that contains ten or fewer carbon atoms, preferably six or fewer. In certain embodiments, acyl, acyloxy, alkyl, alkenyl, alkynyl, or alkoxy substituents defined herein are respectively lower acyl, lower acyloxy, lower alkyl, lower alkenyl, lower alkynyl, or lower alkoxy, whether they appear alone or in combination with other substituents, such as in the recitations hydroxyalkyl and aralkyl (in which case, for example, the atoms within the aryl group are not counted when counting the carbon atoms in the alkyl substituent). The terms “polycyclyl”, “polycycle”, and “polycyclic” refer to two or more rings (e.g., cycloalkyls, cycloalkenyls, cycloalkynyls, aryls, heteroaryls, and/or heterocyclyls) in which two or more atoms are common to two adjoining rings, e.g., the rings are “fused rings”. Each of the rings of the polycycle can be substituted or unsubstituted. In certain embodiments, each ring of the polycycle contains from 3 to 10 atoms in the ring, preferably from 5 to 7. The term “silyl” refers to a silicon moiety with three hydrocarbyl moieties attached thereto. The term “substituted” refers to moieties having substituents replacing a hydrogen on one or more carbons of the backbone. It will be understood that “substitution” or “substituted with” includes the implicit proviso that such substitution is in accordance with permitted valence of the substituted atom and the substituent, and that the substitution results in a stable compound, e.g., which does not spontaneously undergo transformation such as by rearrangement, cyclization, elimination, etc. As used herein, the term “substituted” is contemplated to include all permissible substituents of organic compounds. In a broad aspect, the permissible substituents include acyclic and cyclic, branched and unbranched, carbocyclic and heterocyclic, aromatic and non-aromatic substituents of organic compounds. The permissible substituents can be one or more and the same or different for appropriate organic compounds. For purposes of this application, the heteroatoms such as nitrogen may have hydrogen substituents and/or any permissible substituents of organic compounds described herein which satisfy the valences of the heteroatoms. Substituents can include any substituents described herein, for example, a halogen, a hydroxyl, a carbonyl (such as a carboxyl, an alkoxycarbonyl, a formyl, or an acyl), a thiocarbonyl (such as a thioester, a thioacetate, or a thioformate), an alkoxyl, a phosphoryl, a phosphate, a phosphonate, a phosphinate, an amino, an amido, an amidine, an imine, a cyano, a nitro, an azido, a sulfhydryl, an alkylthio, a sulfate, a sulfonate, a sulfamoyl, a sulfonamido, a sulfonyl, a heterocyclyl, an aralkyl, or an aromatic or heteroaromatic moiety. It will be understood by those skilled in the art that substituents can themselves be substituted, if appropriate. Unless specifically stated as “unsubstituted,” references to chemical moieties herein are understood to include substituted variants. For example, reference to an “aryl” group or moiety implicitly includes both substituted and unsubstituted variants. The term “sulfate” is art-recognized and refers to the group -OSO3H, or a pharmaceutically acceptable salt thereof. The term “sulfonamide” is art-recognized and refers to the group represented by the general formulae
Figure imgf000157_0001
wherein R29 and R30 independently represents hydrogen or hydrocarbyl, such as alkyl, or R29 and R30 taken together with the intervening atom(s) complete a heterocycle having from 4 to 8 atoms in the ring structure. The term “sulfoxide” is art-recognized and refers to the group -S(O)-R30, wherein R30 represents a hydrocarbyl. The term “sulfonate” is art-recognized and refers to the group SO3H, or a pharmaceutically acceptable salt thereof. The term “sulfone” is art-recognized and refers to the group -S(O)2-R30, wherein R30 represents a hydrocarbyl. The term “thioalkyl”, as used herein, refers to an alkyl group substituted with a thiol group. The term “thioester”, as used herein, refers to a group -C(O)SR30 or -SC(O)R30 wherein R30 represents a hydrocarbyl. The term “thioether”, as used herein, is equivalent to an ether, wherein the oxygen is replaced with asulfur. “Unsubstituted” atoms bear all of the hydrogen atoms dictated by their valency. When a substituent is keto (i.e., =O), then two hydrogens on the atom are replaced. Combinations of substituents and/or variables are permissible only if such combinations result in stable compounds; by “stable compound” or “stable structure” is meant a compound that is sufficiently robust to survive isolation to a useful degree of purity from a reaction mixture, and formulation into an efficacious therapeutic agent. The term “urea” is art-recognized and may be represented by the general formula
Figure imgf000158_0001
wherein R29 and R30 independently represent hydrogen or a hydrocarbyl, such as alkyl, or either occurrence of R29 taken together with R30 and the intervening atom(s) complete a heterocycle having from 4 to 8 atoms in the ring structure. “Protecting group” refers to a group of atoms that, when attached to a reactive functional group in a molecule, mask, reduce or prevent the reactivity of the functional group. Typically, a protecting group may be selectively removed as desired during the course of a synthesis. Examples of protecting groups can be found in Greene and Wuts, Protective Groups in Organic Chemistry, 3rd Ed., 1999, John Wiley & Sons, NY and Harrison et al., Compendium of Synthetic Organic Methods, Vols.1-8, 1971-1996, John Wiley & Sons, NY. Representative nitrogen protecting groups include, but are not limited to, formyl, acetyl, trifluoroacetyl, benzyl, benzyloxycarbonyl (“CBZ”), tert-butoxycarbonyl (“Boc”), trimethylsilyl (“TMS”), 2-trimethylsilyl-ethanesulfonyl (“TES”), trityl and substituted trityl groups, allyloxycarbonyl, 9-fluorenylmethyloxycarbonyl (“FMOC”), nitro- veratryloxycarbonyl (“NVOC”) and the like. Representative hydroxylprotecting groups include, but are not limited to, those where the hydroxyl group is either acylated (esterified) or alkylated such as benzyl and trityl ethers, as well as alkyl ethers, tetrahydropyranyl ethers, trialkylsilyl ethers (e.g., TMS or TIPS groups), glycol ethers, such as ethylene glycol and propylene glycol derivatives and allyl ethers. The term "healthcare providers" refers to individuals or organizations that provide healthcare services to a person, community, etc. Examples of "healthcare providers" include doctors, hospitals, continuing care retirement communities, skilled nursing facilities, subacute care facilities, clinics, multispecialty clinics, freestanding ambulatory centers, home health agencies, and HMO's. The present application includes prodrugs of the compounds formula (I), or pharmaceutically acceptable salts thereof. The term “prodrug” is intended to encompass compounds which, under physiologic conditions, are converted into the therapeutically active agents of the present application (e.g., a compound of formula (I), or pharmaceutically acceptable salts thereof). A common method for making a prodrug is to include one or more selected moieties which are hydrolyzed under physiologic conditions to yield the desired molecule. In certain embodiments, the prodrug is converted by an enzymatic activity of the host animal. For example, a prodrug with a nitro group on an aromatic ring could be reduced by reductase to generate the desired amino group of the corresponding active compound in vivo. In another example, functional groups such as a hydroxyl, carbonate, or carboxylic acid in the parent compound are presented as an ester, which could be cleaved by esterases. Additionally, amine groups in the parent compounds are presented in, but not limited to, carbamate, N-alkylated or N-acylated forms (Simplício et al, “Prodrugs for Amines,” Molecules, (2008), 13:519-547). In certain embodiments, some or all of the compounds of formula (I), or pharmaceutically acceptable salts thereof, in a formulation represented above can be replaced with the corresponding suitable prodrug. The present application includes metabolites of the compounds of formula (I), or pharmaceutically acceptable salts thereof. The term “metabolite” is intended to encompass compounds that are produced by metabolism/biochemical modification of the parent compound under physiological conditions, e.g. through certain enzymatic pathway. For example, an oxidative metabolite is formed by oxidation of the parent compound during metabolism, such as the oxidation of a pyridine ring to pyridine-N-oxide. In another example, an oxidative metabolite is formed by demethylation of a methoxy group to result in a hydroxyl group. Pharmaceutical Compositions The compositions and methods of the present application may be utilized to treat an individual in need thereof. In certain embodiments, the individual is a mammal such as a human, or a non-human mammal. When administered to an animal, such as a human, the composition or the compound is preferably administered as a pharmaceutical composition comprising, for example, a compound of the application and a pharmaceutically acceptable carrier. Pharmaceutically acceptable carriers are well known in the art and include, for example, aqueous solutions such as water or physiologically buffered saline or other solvents or vehicles such as glycols, glycerol, oils such as olive oil, or injectable organic esters. In a preferred embodiment, when such pharmaceutical compositions are for human administration, particularly for invasive routes of administration (i.e., routes, such as injection or implantation, that circumvent transport or diffusion through an epithelial barrier), the aqueous solution is pyrogen-free, or substantially pyrogen-free. The excipients can be chosen, for example, to effect delayed release of an agent or to selectively target one or more cells, tissues or organs. The pharmaceutical composition can be in dosage unit form such as tablet, capsule (including sprinkle capsule and gelatin capsule), granule, lyophile for reconstitution, powder, solution, syrup, suppository, injection or the like. The composition can also be present in a transdermal delivery system, e.g., a skin patch. The composition can also be present in a solution suitable for topical administration, such as an eye drop. A pharmaceutically acceptable carrier can contain physiologically acceptable agents that act, for example, to stabilize, increase solubility or to increase the absorption of a compound such as a compound of the application. Such physiologically acceptable agents include, for example, carbohydrates, such as glucose, sucrose or dextrans, antioxidants, such as ascorbic acid or glutathione, chelating agents, low molecular weight proteins or other stabilizers or excipients. The choice of a pharmaceutically acceptable carrier, including a physiologically acceptable agent, depends, for example, on the route of administration of the composition. The preparation or pharmaceutical composition can be a self-emulsifying drug delivery system or a self-microemulsifying drug delivery system. The pharmaceutical composition (preparation) also can be a liposome or other polymer matrix, which can have incorporated therein, for example, a compound of the application. Liposomes, for example, which comprise phospholipids or other lipids, are nontoxic, physiologically acceptable and metabolizable carriers that are relatively simple to make and administer. The phrase "pharmaceutically acceptable" is employed herein to refer to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio. The phrase "pharmaceutically acceptable carrier" as used herein means a pharmaceutically acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, solvent or encapsulating material. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient. Some examples of materials which can serve as pharmaceutically acceptable carriers include: (1) sugars, such as lactose, glucose and sucrose; (2) starches, such as corn starch and potato starch; (3) cellulose, and its derivatives, such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4) powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients, such as cocoa butter and suppository waxes; (9) oils, such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil; (10) glycols, such as propylene glycol; (11) polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters, such as ethyl oleate and ethyl laurate; (13) agar; (14) buffering agents, such as magnesium hydroxide and aluminum hydroxide; (15) alginic acid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer's solution; (19) ethyl alcohol; (20) phosphate buffer solutions; and (21) other non-toxic compatible substances employed in pharmaceutical formulations. A pharmaceutical composition (preparation) can be administered to a subject by any of a number of routes of administration including, for example, orally (for example, drenches as in aqueous or non-aqueous solutions or suspensions, tablets, capsules (including sprinkle capsules and gelatin capsules), boluses, powders, granules, pastes for application to the tongue); absorption through the oral mucosa (e.g., sublingually); anally, rectally or vaginally (for example, as a pessary, cream or foam); parenterally (including intramuscularly, intravenously, subcutaneously or intrathecally as, for example, a sterile solution or suspension); nasally; intraperitoneally; subcutaneously; transdermally (for example as a patch applied to the skin); and topically (for example, as a cream, ointment or spray applied to the skin, or as an eye drop). The compound may also be formulated for inhalation. In certain embodiments, a compound may be simply dissolved or suspended in sterile water. Details of appropriate routes of administration and compositions suitable for same can be found in, for example, U.S. Pat. Nos.6,110,973, 5,763,493, 5,731,000, 5,541,231, 5,427,798, 5,358,970 and 4,172,896, as well as in patents cited therein. The formulations may conveniently be presented in unit dosage form and may be prepared by any methods well known in the art of pharmacy. The amount of active ingredient which can be combined with a carrier material to produce a single dosage form will vary depending upon the host being treated, the particular mode of administration. The amount of active ingredient that can be combined with a carrier material to produce a single dosage form will generally be that amount of the compound which produces a therapeutic effect. Generally, out of one hundred percent, this amount will range from about 1 percent to about ninety-nine percent of active ingredient, preferably from about 5 percent to about 70 percent, most preferably from about 10 percent to about 30 percent. Methods of preparing these formulations or compositions include the step of bringing into association an active compound, such as a compound of the application, with the carrier and, optionally, one or more accessory ingredients. In general, the formulations are prepared by uniformly and intimately bringing into association a compound of the present application with liquid carriers, or finely divided solid carriers, or both, and then, if necessary, shaping the product. Formulations of the application suitable for oral administration may be in the form of capsules (including sprinkle capsules and gelatin capsules), cachets, pills, tablets, lozenges (using a flavored basis, usually sucrose and acacia or tragacanth), lyophile, powders, granules, or as a solution or a suspension in an aqueous or non-aqueous liquid, or as an oil-in- water or water-in-oil liquid emulsion, or as an elixir or syrup, or as pastilles (using an inert base, such as gelatin and glycerin, or sucrose and acacia) and/or as mouthwashes and the like, each containing a predetermined amount of a compound of the present application as an active ingredient. Compositions or compounds may also be administered as a bolus, electuary or paste. To prepare solid dosage forms for oral administration (capsules (including sprinkle capsules and gelatin capsules), tablets, pills, dragees, powders, granules and the like), the active ingredient is mixed with one or more pharmaceutically acceptable carriers, such as sodium citrate or dicalcium phosphate, and/or any of the following: (1) fillers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; (2) binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; (3) humectants, such as glycerol; (4) disintegrating agents, such as agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; (5) solution retarding agents, such as paraffin; (6) absorption accelerators, such as quaternary ammonium compounds; (7) wetting agents, such as, for example, cetyl alcohol and glycerol monostearate; (8) absorbents, such as kaolin and bentonite clay; (9) lubricants, such a talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, and mixtures thereof; (10) complexing agents, such as, modified and unmodified cyclodextrins; and (11) coloring agents. In the case of capsules (including sprinkle capsules and gelatin capsules), tablets and pills, the pharmaceutical compositions may also comprise buffering agents. Solid compositions of a similar type may also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugars, as well as high molecular weight polyethylene glycols and the like. A tablet may be made by compression or molding, optionally with one or more accessory ingredients. Compressed tablets may be prepared using binder (for example, gelatin or hydroxypropylmethyl cellulose), lubricant, inert diluent, preservative, disintegrant (for example, sodium starch glycolate or cross-linked sodium carboxymethyl cellulose), surface-active or dispersing agent. Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent. The tablets, and other solid dosage forms of the pharmaceutical compositions, such as dragees, capsules (including sprinkle capsules and gelatin capsules), pills and granules, may optionally be scored or prepared with coatings and shells, such as enteric coatings and other coatings well known in the pharmaceutical-formulating art. They may also be formulated so as to provide slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethyl cellulose in varying proportions to provide the desired release profile, other polymer matrices, liposomes and/or microspheres. They may be sterilized by, for example, filtration through a bacteria-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions that can be dissolved in sterile water, or some other sterile injectable medium immediately before use. These compositions may also optionally contain opacifying agents and may be of a composition that releases the active ingredient(s) only, or preferentially, in a certain portion of the gastrointestinal tract, optionally, in a delayed manner. Examples of embedding compositions that can be used include polymeric substances and waxes. The active ingredient can also be in micro- encapsulated form, if appropriate, with one or more of the above-described excipients. Liquid dosage forms useful for oral administration include pharmaceutically acceptable emulsions, lyophiles for reconstitution, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active ingredient, the liquid dosage forms may contain inert diluents commonly used in the art, such as, for example, water or other solvents, cyclodextrins and derivatives thereof, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof. Besides inert diluents, the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, coloring, perfuming and preservative agents. Suspensions, in addition to the active compounds, may contain suspending agents as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof. Formulations of the pharmaceutical compositions for rectal, vaginal, or urethral administration may be presented as a suppository, which may be prepared by mixing one or more active compounds with one or more suitable nonirritating excipients or carriers comprising, for example, cocoa butter, polyethylene glycol, a suppository wax or a salicylate, and which is solid at room temperature, but liquid at body temperature and, therefore, will melt in the rectum or vaginal cavity and release the active compound. Formulations of the pharmaceutical compositions for administration to the mouth may be presented as a mouthwash, or an oral spray, or an oral ointment. Alternatively or additionally, compositions can be formulated for delivery via a catheter, stent, wire, or other intraluminal device. Delivery via such devices may be especially useful for delivery to the bladder, urethra, ureter, rectum, or intestine. Formulations which are suitable for vaginal administration also include pessaries, tampons, creams, gels, pastes, foams or spray formulations containing such carriers as are known in the art to be appropriate. Dosage forms for the topical or transdermal administration include powders, sprays, ointments, pastes, creams, lotions, gels, solutions, patches and inhalants. The active compound may be mixed under sterile conditions with a pharmaceutically acceptable carrier, and with any preservatives, buffers, or propellants that may be required. The ointments, pastes, creams and gels may contain, in addition to an active compound, excipients, such as animal and vegetable fats, oils, waxes, paraffins, starch, tragacanth, cellulose derivatives, polyethylene glycols, silicones, bentonites, silicic acid, talc and zinc oxide, or mixtures thereof. Powders and sprays can contain, in addition to an active compound, excipients such as lactose, talc, silicic acid, aluminum hydroxide, calcium silicates and polyamide powder, or mixtures of these substances. Sprays can additionally contain customary propellants, such as chlorofluorohydrocarbons and volatile unsubstituted hydrocarbons, such as butane and propane. Transdermal patches have the added advantage of providing controlled delivery of a compound of the present application to the body. Such dosage forms can be made by dissolving or dispersing the active compound in the proper medium. Absorption enhancers can also be used to increase the flux of the compound across the skin. The rate of such flux can be controlled by either providing a rate controlling membrane or dispersing the compound in a polymer matrix or gel. Ophthalmic formulations, eye ointments, powders, solutions and the like, are also contemplated as being within the scope of this application. Exemplary ophthalmic formulations are described in U.S. Publication Nos.2005/0080056, 2005/0059744, 2005/0031697 and 2005/004074 and U.S. Patent No.6,583,124, the contents of which are incorporated herein by reference. If desired, liquid ophthalmic formulations have properties similar to that of lacrimal fluids, aqueous humor or vitreous humor or are compatible with such fluids. A preferred route of administration is local administration (e.g., topical administration, such as eye drops, or administration via an implant). The phrases "parenteral administration" and "administered parenterally" as used herein means modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal and intrasternal injection and infusion. Pharmaceutical compositions suitable for parenteral administration comprise one or more active compounds in combination with one or more pharmaceutically acceptable sterile isotonic aqueous or nonaqueous solutions, dispersions, suspensions or emulsions, or sterile powders which may be reconstituted into sterile injectable solutions or dispersions just prior to use, which may contain antioxidants, buffers, bacteriostats, solutes which render the formulation isotonic with the blood of the intended recipient or suspending or thickening agents. Examples of suitable aqueous and nonaqueous carriers that may be employed in the pharmaceutical compositions of the application include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, vegetable oils, such as olive oil, and injectable organic esters, such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials, such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants. These compositions may also contain adjuvants such as preservatives, wetting agents, emulsifying agents and dispersing agents. Prevention of the action of microorganisms may be ensured by the inclusion of various antibacterial and antifungal agents, for example, paraben, chlorobutanol, phenol sorbic acid, and the like. It may also be desirable to include isotonic agents, such as sugars, sodium chloride, and the like into the compositions. In addition, prolonged absorption of the injectable pharmaceutical form may be brought about by the inclusion of agents that delay absorption such as aluminum monostearate and gelatin. In some cases, in order to prolong the effect of a drug, it is desirable to slow the absorption of the drug from subcutaneous or intramuscular injection. This may be accomplished by the use of a liquid suspension of crystalline or amorphous material having poor water solubility. The rate of absorption of the drug then depends upon its rate of dissolution, which, in turn, may depend upon crystal size and crystalline form. Alternatively, delayed absorption of a parenterally administered drug form is accomplished by dissolving or suspending the drug in an oil vehicle. Injectable depot forms are made by forming microencapsulated matrices of the subject compounds in biodegradable polymers such as polylactide-polyglycolide. Depending on the ratio of drug to polymer, and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly(anhydrides). Depot injectable formulations are also prepared by entrapping the drug in liposomes or microemulsions that are compatible with body tissue. For use in the methods of this application, active compounds can be given per se or as a pharmaceutical composition containing, for example, 0.1 to 99.5% (more preferably, 0.5 to 90%) of active ingredient in combination with a pharmaceutically acceptable carrier. Methods of introduction may also be provided by rechargeable or biodegradable devices. Various slow release polymeric devices have been developed and tested in vivo in recent years for the controlled delivery of drugs, including proteinaceous biopharmaceuticals. A variety of biocompatible polymers (including hydrogels), including both biodegradable and non-degradable polymers, can be used to form an implant for the sustained release of a compound at a particular target site. Actual dosage levels of the active ingredients in the pharmaceutical compositions may be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient. The selected dosage level will depend upon a variety of factors including the activity of the particular compound or combination of compounds employed, or the ester, salt or amide thereof, the route of administration, the time of administration, the rate of excretion of the particular compounds) being employed, the duration of the treatment, other drugs, compounds and/or materials used in combination with the particular compound(s) employed, the age, sex, weight, condition, general health and prior medical history of the patient being treated, and like factors well known in the medical arts.
A physician having ordinary skill in the art can readily determine and prescribe the therapeutically effective amount of the pharmaceutical composition required. For example, the physician could start doses of the pharmaceutical composition or compound at levels lower than that required in order to achieve the desired therapeutic effect and gradually increase the dosage until the desired effect is achieved. By “therapeutically effective amount” is meant the concentration of a compound that is sufficient to elicit the desired therapeutic effect. It is generally understood that the effective amount of the compound will vary according to the weight, sex, age, and medical history of the subject. Other factors which influence the effective amount may include, but are not limited to, the severity of the patient's condition, the disorder being treated, the stability of the compound, and, if desired, another type of therapeutic agent being administered with the compound of the application. A larger total dose can be delivered by multiple administrations of the agent. Methods to determine efficacy and dosage are known to those skilled in the art (Isselbacher et al. (1996) Harrison’s Principles of Internal Medicine 13 ed., 1814-1882, herein incorporated by reference).
In general, a suitable daily dose of an active compound used in the compositions and methods of the application will be that amount of the compound that is the lowest dose effective to produce a therapeutic effect. Such an effective dose will generally depend upon the factors described above.
If desired, the effective daily dose of the active compound may be administered as one, two, three, four, five, six or more sub-doses administered separately at appropriate intervals throughout the day, optionally, in unit dosage forms. In certain embodiments of the present application, the active compound may be administered two or three times daily. In preferred embodiments, the active compound will be administered once daily.
The patient receiving this treatment is any animal in need, including primates, in particular humans.
This application includes the use of pharmaceutically acceptable salts of compounds of the application in the compositions and methods of the present application. The term “pharmaceutically acceptable salts” includes salts of the active compounds which are prepared with relatively nontoxic acids or bases, depending on the particular substituents found on the compounds described herein. When compounds of the present application contain relatively acidic functionalities, base addition salts can be obtained by contacting the neutral form of such compounds with a sufficient amount of the desired base, either neat or in a suitable inert solvent. Examples of pharmaceutically acceptable base addition salts include sodium, potassium, calcium, ammonium, organic amino, or magnesium salt, or a similar salt. When compounds of the present application contain relatively basic functionalities, such as an amine, acid addition salts can be obtained by contacting the neutral form of such compounds with a sufficient amount of the desired acid, either neat or in a suitable inert solvent. Examples of pharmaceutically acceptable acid addition salts include those derived from inorganic acids like hydrochloric, hydrobromic, nitric, carbonic, monohydrogencarbonic, phosphoric, monohydrogenphosphoric, dihydrogenphosphoric, sulfuric, monohydrogensulfuric, hydriodic, or phosphorous acids and the like, as well as the salts derived from relatively nontoxic organic acids like acetic, trifluoroacetic, propionic, isobutyric, maleic, malonic, benzoic, succinic, suberic, fumaric, lactic, mandelic, phthalic, benzensulfonic, p-tolylsulfonic, citric, tartaric, methanesulfonic, camphorsulfonic and the like. In certain embodiments, the pharmaceutically acceptable salt is a hydrochloride salt. In certain embodiments, the pharmaceutically acceptable salt is a camsylate salt. In certain embodiments, contemplated salts of the compounds include, but are not limited to, alkyl, dialkyl, trialkyl or tetra-alkyl ammonium salts. In certain embodiments, contemplated salts of compounds include, but are not limited to, L-arginine, benenthamine, benzathine, betaine, calcium hydroxide, choline, deanol, diethanolamine, diethylamine, 2-(diethylamino)ethanol, ethanolamine, ethylenediamine, N-methylglucamine, hydrabamine, 1H-imidazole, lithium, L- lysine, magnesium, 4-(2-hydroxyethyl)morpholine, piperazine, potassium, 1-(2- hydroxyethyl)pyrrolidine, sodium, triethanolamine, tromethamine, and zinc salts. In certain embodiments, contemplated salts of compounds include, but are not limited to, Li, Na, Ca, K, Mg, Zn or other metal salts. Also included are the salts of amino acids such as arginate and the like, and salts of organic acids like glucuronic or galactunoric acids and the like (see, for example, Berge et al., “Pharmaceutical Salts”, Journal of Pharmaceutical Science, 1977, 66, 1-19). Certain specific compounds of the present application may contain both basic and acidic functionalities that allow the compounds to be converted into either base or acid addition salts. The neutral forms of the compounds are preferably regenerated by contacting the salt with a base or acid and isolating the parent compound in the conventional manner. The parent form of the compound differs from the various salt forms in certain physical properties, such as solubility in polar solvents, but otherwise the salts are equivalent to the parent form of the compound for the purposes of the present application. The compounds of the application, including their pharmaceutically acceptable salts, can also exist as various solvates, such as with water (also known as hydrates), methanol, ethanol, dimethylformamide, diethyl ether, acetamide, and the like. Mixtures of such solvates can also be prepared. The source of such solvate can be from the solvent of crystallization, inherent in the solvent of preparation or crystallization, or adventitious to such solvent. The compounds of the application, including their pharmaceutically acceptable salts, can also exist as various polymorphs, pseudo-polymorphs, or in amorphous state. As used herein, the term “polymorph” refers to different crystalline forms of the same compound and other solid state molecular forms including pseudo-polymorphs, such as hydrates, solvates, or salts of the same compound. Different crystalline polymorphs have different crystal structures due to a different packing of molecules in the lattice, as a result of changes in temperature, pressure, or variations in the crystallization process. Polymorphs differ from each other in their physical properties, such as x-ray diffraction characteristics, stability, melting points, solubility, or rates of dissolution in certain solvents. Thus, crystalline polymorphic forms are important aspects in the development of suitable dosage forms in pharmaceutical industry. Wetting agents, emulsifiers and lubricants, such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, release agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the compositions. Examples of pharmaceutically acceptable antioxidants include: (1) water-soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal-chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like. In certain embodiments, the application comprises a method for conducting a pharmaceutical business, by determining an appropriate formulation and dosage of a compound of the application for treating or preventing any of the diseases or conditions as described herein, conducting therapeutic profiling of identified formulations for efficacy and toxicity in animals, and providing a distribution network for selling an identified preparation as having an acceptable therapeutic profile. In certain embodiments, the method further includes providing a sales group for marketing the preparation to healthcare providers. In certain embodiments, the application relates to a method for conducting a pharmaceutical business by determining an appropriate formulation and dosage of a compound of the application for treating or preventing any of the disease or conditions as described herein, and licensing, to a third party, the rights for further development and sale of the formulation. Examples Example 1: Synthetic Protocols As depicted in the Examples below, in certain exemplary embodiments, compounds are prepared according to the following general procedures. It will be appreciated that, although the general methods depict the synthesis of certain compounds of the present application, the following general methods, and other methods known to one of ordinary skill in the art, can be applied to all compounds and subclasses and species of each of these compounds, as described herein. General Modes of Preparation: The general synthetic methods used in each General Procedure follow and include an illustration of a compound that was synthesized using the designated General Procedure. None of the specific conditions and reagents noted herein are to be construed as limiting the scope of the application and are provided for illustrative purposes only. Compounds of this application may be made by synthetic chemical processes, examples of which are shown herein. It is meant to be understood that the order of the steps in the processes may be varied, that reagents, solvents and reaction conditions may be substituted for those specifically mentioned, and that vulnerable moieties may be protected and deprotected, as necessary. Unless otherwise stated, work-up includes distribution of the reaction mixture between the organic and aqueous phase indicated within parentheses, separation of layers and drying the organic layer over anhydrous sodium sulphate or magnesium sulfate, filtration and distillation of the solvent under reduced pressure. Purification, unless otherwise mentioned, includes purification by chromatographic techniques using reverse or normal phase HPLC using acetonitrile water, in case of reverse phase or a mixture of polar and nonpolar organic solvents in the case of normal phase chromatography. The following abbreviations refer respectively to the definitions below: The expressions, “ambient temperature,” “room temperature,” “RT,” and “r.t.” as used herein, are understood in the art, and generally refer to a temperature, e.g., a reaction temperature, that is about the temperature of the room in which the reaction is carried out, for example, a temperature from about 20 ºC to about 30 ºC. ACN – Acetonitrile; br – Broad; ºC - Degree Celsius ; CHCl3 – Chloroform; CD3OD - Deuterated Methanol; DMSO - d6- Deuterated dimethylsulfoxide; DCM – Dichloromethane; DIPEA – Diisopropylethylamine; DMF- N, N- Dimethylformamide; d – Doublet; dd - Doublet of doublet; EDC.HCl- 1-(3-Dimethylaminopropyl)-3-ethylcarbodiimide hydrochloride; mg- Miligram; g – Gram; h – Hours; 1H- Proton; HCl- Hydrochloric acid; HPLC- High- Performance Liquid Chromatography; H2- Hydrogen; HOBt- 1-Hydroxy benzotriazole; K2CO3 – Potassium carbonate; LCMS - Liquid chromatography mass spectroscopy; LiOH.H2O – Lithium hydroxide monohydrate; M – Molar; MHz – Mega hertz (frequency); MeOH – Methanol; mL - MilliLiter; min – Minutes; mol – Moles; M+- Molecular ion; M – Multiplet; N2 – Nitrogen; NH3 – Ammonia; NBS – N-Bromosuccinimide; NCS – N-Chlorosuccinimide; NMR - Nuclear Magnetic Resonance; NaOH - Sodium Hydroxide; RT – Room temperature; s – Singlet; t – Triplet; TLC - Thin Layer Chromatography; TFA - Trifluoroacetic acid; TEA – Triethylamine; THF – Tetrahydrofuran; % - Percentage; µ - Micron; and δ- Delta; Zn – Zinc; mmol - millimoles. Analysis for the compounds of the present application unless mentioned, was conducted in the general methods well known to the person skilled in the art. Having described the application with reference to certain preferred embodiments, other embodiments will become apparent to one skilled in the art from consideration of the specification. The application is further defined by reference to the following examples, describing in detail the analysis of the compounds of the application. It will be apparent to those skilled in the art that many modifications, both to materials and methods, may be practiced without departing from the scope of the application. Materials and Methods Unless otherwise stated, all reagents were obtained from commercial sources and were used as received without further purification. The NMR spectrometers utilized were Bruker or Varian instruments operating at frequencies at 400 MHz or 500 MHz. General Scheme 1: Method A
Figure imgf000172_0001
The compounds as described herein can be prepared as shown in General scheme 1. Step 1:
Figure imgf000172_0002
A solution of compound a (97.8 g, 688 mmol) in THF (1000 mL) was degassed and purged with N2 for three times, then n-BuLi (331 mL, 2.5 M, 828 mmol) was added dropwise at -60 °C. The mixture was stirred at -60 °C for 1 hour. Then CO2 was passed through. The mixture was stirred at 20 °C for 4 hours. TLC (petroleum ether : ethyl acetate = 4 : 1, Rf = 0.8) showed that a little reactant a remained and a new major polar spot was formed. The reaction mixture was quenched with water (1000 mL) and THF was removed under reduced pressure. Then the mixture was washed with DCM (500 mL * 3). The pH of the water phase was adjusted with HCl until pH = 1 ~ 2. The product was extracted with methyl tert-butyl ether (MTBE) (300 mL * 3). The combined organic layer was washed with brine (300 mL), dried over MgSO4, filtered, and concentrated under reduced pressure to give compound b (75.0 g, crude) as a pale yellow solid, which was used in the next step without further purification. 1H NMR: (400 MHz, DMSO-d6) δ 13.17 (br s, 1H), 7.71 - 7.63 (m, 1H), 7.57 - 7.48 (m, 1H), 7.32 - 7.26 (m, 1H), 2.51 (s, 3H). Step 2:
Figure imgf000173_0001
To a solution of compound b (25.7 g, 138 mmol) in THF (300 mL) and H2O (200 mL) Oxone (110 g, 179 mmol) was added at 0 °C. The mixture was stirred at 20 °C for 2 hours. LCMS showed that the reaction was complete. The reaction mixture was diluted with water (100 mL) and concentrated under reduced pressure to remove THF, then extracted with ethyl acetate (200 mL * 3), the organic layers were combined and washed with brine (200 mL), dried over Na2SO4, filtered, and concentrated under reduced pressure to give a residue. The residue was triturated with MTBE (200 mL) for 30 mins to give compound c (17.0 g, 68.4 mmol, 49.6% yield, 87.8% purity) as a pale yellow solid. 1H NMR: (400 MHz, DMSO-d6) δ 15.19 - 12.43 (m, 1H), 8.40 (dd, J = 2.6, 6.8 Hz, 1H), 8.23 (ddd, J = 2.6, 4.3, 8.7 Hz, 1H), 7.66 (dd, J = 8.7, 10.4 Hz, 1H), 3.33 (s, 3H)). Step 3:
Figure imgf000173_0002
To a solution of compound c (41.0 g, 188 mmol) in THF (300 mL) was added compound ca (23.8 g, 209 mmol) and the solution of KOtBu (44.7 g, 398 mmol) in THF (300 mL) then was added dropwise over 0.5 hours. The mixture was heated to 50 °C and stirred for 2 hours. LCMS showed that the reaction was complete. The reaction mixture was quenched with water (600 mL), then concentrated under reduced pressure to remove THF, and washed with ethyl acetate (200 mL * 3). The water phase was treated with 1 M HCl to pH = 1 ~ 2. The precipitate was filtered and dried in vacuum to give compound d (44.5 g, crude) as a pale yellow solid, which was used in the next step without further purification. 1H NMR: (400 MHz, DMSO-d6) δ 13.27 (br s, 1H), 8.16 (d, J = 2.4 Hz, 1H), 8.06 (dd, J = 2.4, 8.8 Hz, 1H), 7.59 (d, J = 8.8 Hz, 1H), 5.51 (m, 1H), 3.24 (s, 3H), 1.47 (d, J = 6.4 Hz, 3H).19F NMR: (377 MHz, DMSO-d6) δ -77.36 (s, 3F). Step 4:
Figure imgf000174_0001
To a solution of compound d (24.0 g, 76.9 mmol) in DMF (240 mL) was added DIEA (24.8 g, 192 mmol, 33.5 mL) and compound A1 (15.8 g, 84.5 mmol), then the reaction was stirred for 10 mins. Then HATU (35.1 g, 92.2 mmol) was added portion-wise to the mixture. The mixture was stirred at 20 °C for 1 hour. LCMS showed that the reaction was complete. The reaction mixture was diluted with water (200 mL) and extracted with MTBE (250 mL *3), the organic layers were combined, washed with brine (250 mL), dried over MgSO4, filtered, and concentrated under reduced pressure to give a residue. The residue was purified by flash silica gel chromatography (ISCO®; 440 g SepaFlash® Silica Flash Column, Eluent of 0~2% MeOH/DCM gradient @ 100 mL/min) to give compound A6 (31.0 g, 61.2 mmol, 79.6% yield, 94.8% purity) as a pale yellow solid. 1H NMR: (400 MHz, CDCl3) δ 7.99 (dd, J = 2.4, 8.8 Hz, 1H), 7.95 - 7.88 (m, 1H), 7.17 - 7.08 (m, 1H), 4.90 - 4.75 (m, 1H), 3.86 - 3.70 (m, 2H), 3.60 - 3.50 (m, 2H), 3.46 - 3.34 (m, 2H), 3.25 - 3.17 (m, 2H), 3.08 (s, 3H), 1.56 - 1.46 (m, 12H). 19F NMR: (376 MHz, CDCl3) δ -77.97 -78.73 (m, 3F). Step 5:
Figure imgf000174_0002
To a solution of compound A6 (16.0 g, 33.3 mmol) in dioxane (60 mL) was added HCl / dioxane (4 M, 100 mL). The mixture was stirred at 20 °C for 2 hours. LCMS showed that the reaction was complete. The reaction mixture was concentrated in vacuum to give compound A7’ (13.8 g, 31.3 mmol, 94.0% yield, 94.5% purity, HCl) as a pale yellow solid, which was used in the next step without further purification. 1H NMR: (400 MHz, DMSO-d6) δ 9.46 (br s, 2H), 8.01 (dd, J = 2.3, 8.8 Hz, 1H), 7.91 (dd, J = 2.0, 13.4 Hz, 1H), 7.59 (t, J = 8.2 Hz, 1H), 5.69 - 5.44 (m, 1H), 4.13 - 3.95 (m, 1H), 3.79 - 3.62 (m, 1H), 3.39 (d, J = 4.9 Hz, 2H), 3.24 (s, 3H), 3.21 - 3.15 (m, 1H), 3.14 - 3.04 (m, 2H), 3.00 - 2.89 (m, 1H), 1.45 (dd, J = 6.4, 36.4 Hz, 3H). 19F NMR: (377 MHz, DMSO-d6) δ -77.48 (d, J = 81.6 Hz, 3F). Step 6:
Figure imgf000175_0002
Examples below describe the synthesis of several compounds having a generic formula (A8). Synthesis of (S)-7-Fluoro-6-(4-(5-(methylsulfonyl)-2-((1,1,1-trifluoropropan-2- yl)oxy)benzoyl)piperazin-1-yl)isobenzofuran-1(3H)-one (compound 4)
Figure imgf000175_0001
To a solution of 6-bromo-7-fluoroisobenzofuran-1(3H)-one (10, 104.0 mg, 0.45 mmol, 1.5 equiv.) and (S)-(5-(methylsulfonyl)-2-((1,1,1-trifluoropropan-2-yl)oxy)phenyl)(piperazin- 1-yl)methanone (6, 114.1 mg, 0.3 mmol, 1.0 equiv.) in Tol (4.0 mL), was added Cs2CO3 (146.6 mg, 0.45 mmol, 3.0 equiv.) and [1,3-bis[2,6-bis(1-propylbutyl)phenyl]-4,5-dichloro-imidazol- 2-ylidene]-dichloro-(3-chloropyridin-1-ium-1-yl)palladium (CAS No. 1814936-54-3) (14.6 mg, 0.015 mmol, 0.05 equiv.) under N2 atmosphere. The mixture was stirred at 100 ºC for 16 hours. Completion of reaction was checked by LC-MS. The mixture was concentrated by speedvac to give a residue. The residue was purified by prep-HPLC to give final compound (S)-7-fluoro-6-(4-(5-(methylsulfonyl)-2-((1,1,1-trifluoropropan-2-yl)oxy)benzoyl)piperazin- 1-yl)isobenzofuran-1(3H)-one. Synthesis of 5-(4-{2-[(S)-2,2,2-trifluoro-1-methylethoxy]-5-mesylbenzoyl}-1- piperazinyl)-6-fluoro-2,3-dihydro-1H-1λ6-benzothiophene-1,1-dione (compound 11)
Figure imgf000176_0001
Step 1
Figure imgf000176_0002
To a solution of 4-bromo-3-fluorobenzenesulfonyl chloride (100 g, 365 mmol, 1.0 equiv) in toluene (1500 mL) was added PPh3 (288 g, 1096 mmol, 3.0 equiv). The reaction mixture was stirred for overnight at room temperature under nitrogen atmosphere. The resulting mixture was filtered, the filter cake was washed with ethyl acetate. The filtrate was concentrated under reduced pressure to provide f, 4-bromo-3-fluorobenzenethiol (70 g crude) as a light yellow oil. GC-MS (ESI, m/z): 206. Step 2
Figure imgf000176_0003
To a solution of 4-bromo-3-fluorobenzenethiol (f, 70 g, 338 mmol, 1.0 equiv) and 2- bromo-1,1-diethoxyethane (86.6 g, 439 mmol, 1.3 equiv) in DMF (150 mL) was added K2CO3 (93.4 g, 676 mmol, 2.0 equiv). The reaction mixture was stirred for overnight at room temperature under nitrogen atmosphere. The reaction was quenched with water (300 mL) and extracted with ethyl acetate (3 x 500 mL). The combined organic layers were washed with brine (3 x 500 mL), dried over anhydrous sodium sulfate, filtered and concentrated under reduced pressure. The residue was chromatographed on a silica gel column with ethyl acetate/petroleum ether (1/99) to provide g, (4-bromo-3-fluorophenyl)(2,2- diethoxyethyl)sulfane (80g crude) as a colorless oil. GC-MS (ESI, m/z): 322 Step 3
Figure imgf000177_0001
To a solution of h (4-bromo-3-fluorophenyl)(2,2-diethoxyethyl)sulfane (80 g, 247mmol, 1.0 equiv) in chlorobenzene (800 mL) was added polyphosphoric acid (200 g, 1737 mmol, 7.0 equiv). The reaction mixture was stirred for overnight at 130 °C under nitrogen atmosphere. The reaction was quenched with water (500 mL) and extracted with ethyl acetate (3 x 1000 mL). The combined organic layers were washed with brine (1000 mL), dried over anhydrous sodium sulfate, filtered and concentrated under reduced pressure. The residue was chromatographed on a silica gel column with ethyl acetate/petroleum ether (1/99) to provide i, 5-bromo-6-fluorobenzo[b]thiophene (25g, 43.71%) as a yellow solid. GC-MS (ESI, m/z): 230 Step 4
Figure imgf000177_0002
To a solution of 5-bromo-6-fluorobenzo[b]thiophene (i, 25 g, 108 mmol, 1.0 equiv) in DCM (250 mL) was added m-CPBA (56 g, 325mmol, 3.0 equiv) at 0 °C. The reaction mixture was stirred for overnight at room temperature. The reaction was quenched with saturated NaHCO3 solution (300 mL) at 0°C and extracted with dichloromethane (3 x 500 mL). The combined organic layers were washed with Na2S2O3 (3 x 500 mL), dried over anhydrous sodium sulfate, filtered and concentrated under reduced pressure. The residue was chromatographed on a silica gel column with ethyl acetate/petroleum ether (15/85) to provide j, 5-bromo-6-fluorobenzo[b]thiophene 1,1-dioxide (16 g, 56.22%) as a white solid. GC-MS (ESI, m/z): 262 Step 5
Figure imgf000178_0002
To a solution of 5-bromo-6-fluorobenzo[b]thiophene 1,1-dioxide (j, 16 g, 60.8mmol, 1.0 equiv) in EtOH (160 mL) was added NaBH4 (4.60 g, 122 mmol, 2.0 equiv) at 0°C. The reaction was stirred for overnight at room temperature under nitrogen atmosphere. The reaction was quenched with a solution of NH4Cl (300 mL) and extracted with ethyl acetate (3 x 500 mL). The combined organic layers were washed with brine (1 x 500 mL), dried over anhydrous sodium sulfate, filtered, and concentrated under reduced pressure. The residue was chromatographed on a silica gel column with ethyl acetate/petroleum ether (19/81) to provide k, 5-bromo-6-fluoro-2,3-dihydrobenzo[b]thiophene 1,1-dioxide (13 g, 80.63%) as a white solid. GC-MS (ESI, m/z): 264 Step 6
Figure imgf000178_0001
A solution of 5-bromo-6-fluoro-2,3-dihydro-1lambda6-benzothiophene-1,1-dione (k, 13 g, 49 mmol, 1.0 equiv), tert-butyl piperazine-1-carboxylate (13.7 g, 73.6 mmol, 1.5 equiv), Cs2CO3 (31.9 g, 98.1 mmol, 2.0 equiv), RuPhos Pd G3 (8.20 g, 9.81 mmol, 0.2 equiv), and RuPhos (4.58 g, 9.81 mmol, 0.2 equiv) in dioxane (130 mL) was stirred for two days at 90 °C under nitrogen atmosphere. The resulting mixture was concentrated under reduced pressure. The residue was chromatographed on a silica gel column with ethyl acetate/petroleum ether (44/56) to provide l, tert-butyl 4-(6-fluoro-1,1-dioxido-2,3-dihydrobenzo[b]thiophen-5- yl)piperazine-1-carboxylate (13 g, 71.56%) as a yellow solid. LC-MS (ESI, m/z): 371 [M+H]+ Step 7
Figure imgf000178_0003
A solution of tert-butyl 4-(6-fluoro-1,1-dioxido-2,3-dihydrobenzo[b]thiophen-5- yl)piperazine-1-carboxylate (l, 13 g, 35.1 mmol, 1.0 equiv) in HCl (130 mL, 4M in 1,4- dioxane) was stirred for 2 h at room temperature. The resulting mixture was concentrated under reduced pressure to provide m, 6-fluoro-5-(piperazin-1-yl)-2,3- dihydrobenzo[b]thiophene 1,1-dioxide (9 g crude) as a brown solid LC-MS (ESI, m/z): 271 [M+H]+ Step 8
Figure imgf000179_0001
To a solution of m, 6-fluoro-5-(piperazin-1-yl)-2,3-dihydrobenzo[b]thiophene 1,1- dioxide (9 g, 33.3 mmol, 1.0 equiv), (S)-5-(methylsulfonyl)-2-((1,1,1-trifluoropropan-2- yl)oxy)benzoic acid (10.4 g, 33.3 mmol, 1.0 equiv), and N-methylimidazole (13.7 g, 166 mmol, 5.0 equiv) in DMF (20 mL) was added TCFH (12.1 g, 43.3 mmol, 1.3 equiv). The reaction mixture was stirred for overnight at room temperature. The resulting solution was purified by a C18 column with ACN/H2O (0.1% NH4HCO3 in water) = 47/53 to provide compound 11, (S)-(4-(6-fluoro-1,1-dioxido-2,3-dihydrobenzo[b]thiophen-5-yl)piperazin-1- yl)(5-(methylsulfonyl)-2-((1,1,1-trifluoropropan-2-yl)oxy)phenyl)methanone (11 g, 58.35%) as a white solid.1H NMR (400 MHz, DMSO-d6) 7.99 - 8.02 (m, 1H), 7.85 - 7.86 (m, 1H), 7.56 - 7.63 (m, 2H), 7.11 - 7.16 (m, 1H), 5.53 - 5.56 (m, 1H), 3.79 - 3.85 (m, 2H), 3.58 (t, J = 6.8 Hz, 2H), 3.33 - 3.40 (m, 2H), 3.29 - 3.33 (m, 4H), 3.26 - 3.28 (m, 2H), 3.03 - 3.16 (m, 3H), 1.41 - 1.60 (m, 3H). LC-MS (ESI, m/z): 565 [M+H]+ MS and HPLC purity values for certain compounds of the present application prepared utilizing procedures similar to those above, e.g., as would be readily understood by one of skill in the art, are provided in Table 2 below. Example 2: Procedure for Assaying Compounds Test compounds were evaluated for their potential to inhibit PPIX accumulation in the K562-clone 10-9 EPP cells using flow cytometry. The K562-EPP-clone 10-9 cells carry one FECH knockout allele in addition to a hypomorphic IVS 3-48C mutation on the FECH gene at both alleles. Briefly, the cells were maintained in culture incubator at 37 ºC with 5% CO2 and were sub-cultured routinely. The cells growing in an exponential growth phase were counted and plated at 10000 cells per well in 96W plates (Costar® 96-wells Clear TC-treated Multiple Well Plates). Compounds were added to the cells in triplicates 1 day after seeding. PPIX levels were measured via flow cytometry before seeding and 4 day after compound treatment using Fortessa flow cytometry machine at wavelength Ex: 405/Em:603nm. Stock solution of compounds were initially prepared in DMSO and appropriate dilutions were made for screening and IC50 determination (final DMSO conc in the assay was 0.1%). The compounds were screened at 0.1µM and 1µM concentration and IC50 was determined for the interested compounds with serial dilution from 3 µM to 0.46 nM. To determine IC50 values, dose response curves were generated by plotting percentage inhibition as a function of inhibitor concentration and the data was fitted to sigmoidal non-linear regression equation (variable slope) using Graph Pad prism software V7. IC50 values for certain compounds of the present application are provided in Table 2 below. Table 2: MS, HPLC Purity, and IC50 Values for Exemplary Compounds
Figure imgf000180_0001
Figure imgf000181_0001
Example 3: A GlyT1 Inhibitor Reduces Phototoxicity in a Mouse Model of EPP The recessive Fechm1Pas allele is an ethylnitrosourea (ENU)-induced missense mutation that retains approximately 5% residual ferrochelatase activity. Fechm1Pas/Fechm1Pas homozygous mice develop protoporphyria characterized by elevated PPIX levels in red blood cells (RBCs) and liver, liver fibrosis, and cutaneous phototoxicity, which manifests as skin lesions when these mice are exposed to light with excitation wavelength of PPIX (395 to 410 nM). To determine if inhibition of Glycine transporter 1 (GlyT1) ameliorates phototoxicity caused by excitation of PPIX, Fechm1Pas/Fechm1Pas homozygous mice were administrated vehicle or compound 11 at 15mg/kg, p.o., twice per day, from day 0 to day 18. After removing the hairs on the back, all mice were exposed to light with wavelength of 395 nM, 588 ±10% lumens (lm)/m2 for 30 minutes on day 14 under anesthesia. Images were taken on day 14 before light exposure and daily on days 15-18. Also, blood samples were collected on day 14 and day 18 to measure the PPIX levels by flow cytometry. Experiment procedures are illustrated in Figure 1. The PPIX levels in RBCs, represented as the mean fluorescence intensity (MFI), reduced by 43% and 37%, on Day 14 and Day 18, respectively, in mice administrated compound 11 (“GlyT1 inhibitor”), compared with mice administrated vehicle (Figure 2). Moreover, mice administered vehicle developed severe skin lesion over time, with the most severe lesions observed at 4 days after light exposure. Administration of compound 11 (“GlyT1 inhibitor”) significantly reduced skin lesion development (Figure 3). To quantify the severity of phototoxicity, the area with skin lesion and the total exposed area were measured using Image J software, and the percentage of area with skin lesion within the total exposed area were calculated. Mice administrated vehicle developed skin lesion in an average of 51.2% of total exposed area (Figure 4). In contrast, mice administrated compound 11 (“GlyT1 inhibitor”) developed skin lesion in only 9.2% of exposed area (Figure 4), which was significantly lower than that in the vehicle administrated mice (p-value < 0.01). In addition, the percentage of area with skin lesion correlates with the PPIX levels in RBCs (Figure 5). In particular, mice with lower PPIX levels in the RBCs were associated with reduction in severity of skin lesion development. In conclusion, these data demonstrate that GlyT1 inhibitor treatment can be used to reduce PPIX levels in RBCs and such treatment can reduce EPP phototoxicity in the Fechm1Pas EPP mouse model. These data support the rationale for treating EPP patients with GlyT1 inhibitors. Example 4. Evaluation of Compounds as Substrates of P-glycoprotein Transporter in Caco-2 Cells GlyT1 inhibitors have been developed for treatment of various disorders and conditions, including neurological disorders such as schizophrenia [see, e.g., Rosenbrock et al. Eur Arch Psychiatry Clin Neurosci.2023 Oct;273(7):1557-1566; Bugarski-Kirola et al. Lancet Psychiatry. 2016 Dec;3(12):1115-1128]. Therefore, some compounds within the GlyT1 inhibitor class have been characterized for their ability to penetrate the blood brain barrier and effects on the central nervous system (CNS). While effective penetration into the CNS, relative prereferral drug exposure, may be desirable profile for certain therapeutic applications (e.g., treatment of neurological disorders such as schizophrenia), one can readily envision that there could be other therapeutic applications for GlyT1 inhibitors wherein CNS penetration is not necessarily required or even undesirable due to possible off-target effects on the nervous system. Therefore, Applicants evaluated the potential of GlyT1 compounds of the disclosure to effectively penetrate the blood brain barrier. The efflux transporter P-glycoprotein (P-gp) is a key element of the molecular machinery that confers special permeability properties to the blood-brain barrier [Demeule et al. Vascular Pharmacology 2002;38(6) 339-348]. P-gp, which was initially recognized for its ability to expel anticancer drugs from multidrug-resistant cancer cells, is strongly expressed in brain capillaries. Its expression in the blood-brain barrier limits the accumulation of many hydrophobic molecules and potentially toxic substances in the brain. As described herein, Applicants evaluated the potential of various compounds to act as a substrate for the human efflux transporter P-glycoprotein (P-gp) in Caco-2 cell monolayers by measuring their apparent permeability (Papp) in the absence or presence of the specific P-gp inhibitor PSC833 or Zosuquidar. Incubations with Caco-2 cell monolayers (14-18 day cultured) were performed in triplicate in 96-well Transwell plates. Transport buffer solution HBSS (10 mM HEPES, pH 7.4) containing the test compound (10 µM), and either the positive control digoxin (5 µM) or the negative control metoprolol (5 µM) with or without the inhibitor (PSC833 at 10 µM) was added to appropriate donor wells of the apical or basolateral plate. The transport buffer with or without inhibitor was also added to appropriate receiver wells. Following incubations at 37 °C for 2 hours, the apical and basolateral sides were extracted with acetonitrile containing internal standards (100 nM alprazolam, 200 nM caffeine, and 100 nM tolbutamide) and analyzed to determine the Papp and efflux ratio of the test compound or controls. Lucifer yellow was used as a marker to confirm the integrity of the cell line after 2 hours incubation. UPLC-MS/MS was used for sample analysis, and peak areas were determined from extracted ion chromatograms. Results are presented in Table 3. The Lucifer Yellow (LY) leakage of Caco-2 monolayers is calculated using the following equation:
Figure imgf000184_0003
Where Iacceptor is the fluorescence intensity in the acceptor well (0.3 mL), and Idonor is the fluorescence intensity in the donor well (0.1 mL) and expressed as % leakage. Any monolayer that produces a Lucifer yellow leakage >1%, indicating poor monolayer formation, was excluded from the evaluation. The apparent permeability (Papp), in units of centimeter per second, was calculated for Caco-2 drug transport assays using the following equation:
Figure imgf000184_0001
Where VA is the volume (in mL) in the acceptor well (0.3 mL for Ap→B1 flux and 0.1 mL for B1→Ap flux), Area is the surface area of the membrane (0.143 cm2 for HTS Transwell- 96 Well Permeable Supports), and time is the total transport time in seconds. The efflux ratio was determined using the following equation:
Figure imgf000184_0004
Where Papp (A-B) indicates the apparent permeability coefficient in basolateral to apical direction, and Papp (A-B) indicates the apparent permeability coefficient in apical to basolateral direction. The recovery rate was determined using the following equation:
Figure imgf000184_0002
Where VA is the volume (in mL) in the acceptor well (0.3 mL for Ap→B1 flux, and 0.1 mL for B1→Ap), VD is the volume (in mL) in the donor well (0.1 mL for Ap→B1 flux, and 0.3 mL for B1→Ap). The Percentage Efflux Reduction was determined using the following equation:
Figure imgf000185_0001
The efflux ratios, percentage recovery, and permeability results (with and without the P-gp inhibitor PSC833 or Zosuquidar) for test compounds and control compounds in Caco-2 cell monolayers are presented in Table3. A compound is considered as a potential substrate of P-gp when the efflux ratio without inhibitor is greater than 2, and more than 50% reduction of the efflux ratio is observed in the presence of the corresponding inhibitor. Functionality of the P-gp mediated efflux transport and permeability in the test system was confirmed using the positive control compound digoxin and negative control compound metoprolol. The efflux ratios for digoxin incubated without and with the P-gp inhibitor PSC833 in Caco-2 monolayers were 64.3 and 0.941, respectively, with corresponding percentage reduction of 98.5%. The efflux ratios for metoprolol incubated without and with the P-gp inhibitor PSC833 in Caco-2 monolayers were 0.954 and 0.926, respectively, with corresponding percentage reduction of 2.94%. The efflux ratios of digoxin and metoprolol were within the historical range. The efflux ratios for Compound 8 at 10 µM incubated without and with the P-gp inhibitor PSC833 in Caco-2 cell line were 0.778 and 0.476, respectively, with corresponding percentage reduction of 38.8%. See Table 3. Under the conditions of this study, Compound 8 had an efflux ratio <2 in the absence of P-gp inhibitor, which was reduced by <50% in the presence of PSC833. Therefore, the results indicate that Compound 8 may not be a substrate of human P-gp transporter. As such, Compound 8 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to have CNS penetration ability and therefore possible CNS pharmacodynamic/pharmacokinetic effects. The efflux ratios for Compound 10 at 10 µM incubated without and with the P-gp inhibitor PSC833 in Caco-2 cell line were 2.95 and 1.18, respectively, with corresponding percentage reduction of 60.0%. See Table 3. Under the conditions of this study, Compound 10 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of PSC833. Therefore, the results indicate that Compound 10 is potentially a substrate of human P-gp transporter. As such, Compound 10 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP. The efflux ratios for Compound 11 at 10 µM incubated without and with the P-gp inhibitor PSC833 in Caco-2 cell line were 20.8 and 0.972, respectively, with corresponding percentage reduction of 95.3%. See Table 3. Under the conditions of this study, Compound 11 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of PSC833. Therefore, the results indicate that Compound 11 is potentially a substrate of human P-gp transporter. As such, Compound 11 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP. The efflux ratios for Compound 49 at 10 µM incubated without and with the P-gp inhibitor Zosuquidar in Caco-2 cell line were 25.6 and 0.969, respectively, with corresponding percentage reduction of 96.2%. See Table 3. Under the conditions of this study, Compound 49 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of Zosuquidar. Therefore, the results indicate that Compound 49 is potentially a substrate of human P-gp transporter. As such, Compound 49 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP. The efflux ratios for Compound 50 at 10 µM incubated without and with the P-gp inhibitor Zosuquidar in Caco-2 cell line were 29.4 and 0.955, respectively, with corresponding percentage reduction of 96.8%. See Table 3. Under the conditions of this study, Compound 50 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of Zosuquidar. Therefore, the results indicate that Compound 50 is potentially a substrate of human P-gp transporter. As such, Compound 50 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP. The efflux ratios for Compound 52 at 10 µM incubated without and with the P-gp inhibitor Zosuquidar in Caco-2 cell line were 38.8 and 1.27, respectively, with corresponding percentage reduction of 96.7%. See Table 3. Under the conditions of this study, Compound 52 had an efflux ratio >2 in the absence of P-gp inhibitor, which was reduced by >50% in the presence of Zosuquidar. Therefore, the results indicate that Compound 52 is potentially a substrate of human P-gp transporter. As such, Compound 52 may be a particularly useful inhibitor of GlyT1 activity in therapeutic applications wherein it is desirable to minimize CNS penetration but otherwise maintain systemic pharmacodynamic/pharmacokinetic effects, e.g., in the treatment of hematological disorders including porphyrias such as EPP, XLP, and/or CEP. Table 3: Permeability results for GlyT1 inhibitors in the absence and presence of specific P-gp inhibitor in Caco-2 cell line
Figure imgf000187_0001
Incorporation by Reference All publications and patents mentioned herein are hereby incorporated by reference in their entirety as if each individual publication or patent was specifically and individually indicated to be incorporated by reference. In case of conflict, the present application, including any definitions herein, will control.
Equivalents
While specific embodiments of the subject application have been discussed, the above specification is illustrative and not restrictive. Many variations of the subject of the application will become apparent to those skilled in the art upon review of this specification and the claims below. The full scope of the application should be determined by reference to the claims, along with their full scope of equivalents, and the specification, along with such variations.

Claims

Claims 1. A compound of formula (I)
Figure imgf000189_0001
or a pharmaceutically acceptable salt thereof, wherein: A is an aryl or heteroaryl ring system wherein the aryl or heteroaryl ring system is optionally substitued one or more times with R1; B is a 4- to 8-membered non-aromatic carbocycle or a 4- to 8-membered non-aromatic heterocyle comprising one or more heteroatoms selected from the group consisting of nitrogen, oxygen, and sulfur, wherein the non-aromatic carbocycle or heterocyle is optionally substituted one or more times with R2; R1 is independently for each occurrence selected from the group consisting of OH, halogen, - CF3, -OCF3, -OCH2F, -OCHF2, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1- 8alkyl, -SC1-8alkyl, -CN, =O, -C(O)H, -(CH2)nNRaRb, -(CH2)nNRaaC(O)Rbb, -C(O)NRaRb, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8alkyl, -NHC(O)OC1-8alkyl, -NRaRb, - (CH2)mC(O)OC1-8alkyl, -S(O)2-NRaRb, -S(O)2-C1-8alkyl, -S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl, wherein -C1-8alkyl, -OC1-8alkyl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CN, -C1-8alkyl, -C1-8alkylheterocyclyl, -C1-8alkylheteroaryl, -OC1-8alkyl, aryl, and monocyclic heteroaryl; R2 is independently for each occurrence selected from the group consisting of OH, halogen, - CF3, -OCF3, -OCH2F, -OCHF2, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, -OC1- 8alkyl, -SC1-8alkyl, -CN, =O, -C(O)H, -(CH2)nNRaRb, -(CH2)nNRaaC(O)Rbb, -C(O)NRaRb, -C(O)OH, -(CH2)kCOC1-8alkyl, -(CH2)nOC1-8alkyl, -NHC(O)OC1-8alkyl, -NRaRb, - (CH2)mC(O)OC1-8alkyl, -S(O)2-NRaRb, -S(O)2-C1-8alkyl, -S(O)2-aryl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl, wherein -C1-8alkyl, -OC1-8alkyl, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CN, -C1-8alkyl, -C1-8alkylheterocyclyl, -C1-8alkylheteroaryl, -OC1-8alkyl, aryl, and monocyclic heteroaryl; R3 is selected from the group consisting of OH, -C1-8alkyl, -OC1-8alkyl, -Oaryl, -Oheteroaryl, and – OC0-8alkylC3-8cycloalkyl, wherein -C1-8alkyl and -OC1-8alkyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, haloalkyl (e.g., CH2F, CHF2, CF3), aryl, heterocyclyl, and –C3-8cycloalkyl; R4 is H; or R3 and R4 together with the carbon atoms to which they are attached form cycloalkyl or heterocyclyl, wherein cycloalkyl and heterocyclyl can be optionally substituted 1 or 2 times with a substituent selected independently at each occurrence from the group consisting of CN, -C1-8alkyl, aryl, and heterocyclyl, wherein -C1-8alkyl, aryl, and heterocyclyl can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen; R5 is selected from the group consisting of H, -OH, -C1-8alkyl, and NH2; R6 is selected from the group consisting of -C1-8alkyl, aryl, and heteroaryl, wherein -C1-8alkyl, aryl, and heteroaryl, can be optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of deuterium, H or - C1-8alkyl, wherein -C1-8alkyl can be optionally substituted with -CONH2, -S(O)2NH2, - S(O)2-C1-8alkyl, aryl, or heterocyclyl; or R5 and R6 together with the atoms to which they are attached form optionally substituted heterocyclyl; R7 is deuterium; Ra is H or -C1-8alkyl; Rb is H or -C1-8alkyl, wherein -C1-8alkyl can be optionally substituted with -CONH2, - S(O)2NH2, -S(O)2-C1-8alkyl, aryl, or heterocyclyl; or Ra and Rb together with the nitrogen atom to which they are attached form non-aromatic heterocyclyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of OH, =O, halogen, CF3, - OCF3, -OCH2F, -OCHF2, -C(O)H, -C1-8alkyl, –C3-8cycloalkyl, –C4-16cycloalkylalkyl, - OC1-8alkyl, -SC1-8alkyl, -NRaRb, -CN, -C(O)OC1-8alkyl, -C(O)OH, -(CH2)kCOC1-8alkyl, - (CH2)nOC1-8 alkyl, -NHC(O)OC1-8alkyl, -(CH2)mC(O)OC1-8alkyl, -S(O)2-C1-8alkyl, - S(O)2-aryl, -S(O)2NRaRb, aryl, monocyclic and bicyclic heteroaryl, monocyclic and bicyclic heterocyclyl, and monocyclic and bicyclic non-aromatic heterocyclyl; Raa is H or -C1-8alkyl; Rbb is -C1-8alkyl, -C4-8 cycloalkylmethyl, or monocyclic non-aromatic heterocyclyl, wherein - C1-8alkyl and -C4-8 cycloalkylmethyl can be optionally substituted with NH2, halogen, or CN; n is 0, 1, 2, 3, 4, 5, or 6; m is 0, 1, 2, 3, 4, 5, or 6; k is 0, 1, 2, 3, 4, 5, or 6; and l is 0, 1, 2, 3, 4, 5, 6, 7, or 8.
2. The compound of claim 1, or a pharmaceutically acceptable salt thereof, wherein A is selected from phenyl, pyrimidine, pyridine, and thiazole, wherein the phenyl, pyrimidine, pyridine, and thiazole, is optionally substituted one or more times with R1.
3. The compound of claim 1 or 2, or a pharmaceutically acceptable salt thereof, wherein R1 is halogen.
4. The compound of any preceding claim, or a pharmaceutically acceptable salt thereof, wherein B is a 5-membered non-aromatic carbocycle optionally substituted one or more times with R2.
5. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 6-membered non-aromatic carbocycle optionally substituted one or more times with R2.
6. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 5-membered non-aromatic heterocyle comprising an oxygen atom wherein the non-aromatic heterocyle is optionally substituted one or more times with R2.
7. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 5-membered non-aromatic heterocyle comprising a sulfur atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2.
8. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 5-membered non-aromatic heterocyle comprising a nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2.
9. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 6-membered non-aromatic heterocyle comprising a nitrogen atom and an oxygen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2.
10. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 6-membered non-aromatic heterocyle comprising one nitrogen atom, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2.
11. The compound of any one of claims 1-3, or a pharmaceutically acceptable salt thereof, wherein B is a 6-membered non-aromatic heterocyle comprising two nitrogen atoms, wherein the non-aromatic heterocyle is optionally substituted one or more times with R2.
12. The compound of any preceding claim, or a pharmaceutically acceptable salt thereof, wherein R2 is independently selected from halogen, =O, -C1-8alkyl, C(O)OC1-8alkyl, and - S(O)2-NRaRb.
13. The compound of any preceding claim, or a pharmaceutically acceptable salt thereof, wherein R3 is -OC1-8alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from the group consisting of halogen, CH2F, CHF2, CF3, aryl, heterocyclyl, and –C3-8cycloalkyl.
14. The compound of any one of claims 1-12, or a pharmaceutically acceptable salt thereof, wherein R3 is -OC1-8alkyl optionally substituted from 1 to 3 times with a substituent selected independently at each occurrence from halogen.
15. The compound of claim 14, or a pharmaceutically acceptable salt thereof, wherein R3 is –OCH(CH3)CF3.
16. The compound of claim 15, wherein R3 has (S) configuration.
17. The compound of claim 15, wherein R3 has (R) configuration.
18. The compound of any preceding claim, or a pharmaceutically acceptable salt thereof, wherein R4 is H.
19. The compound of any preceding claim, or a pharmaceutically acceptable salt thereof, wherein R5 is H.
20. The compound of any preceding claim, or a pharmaceutically acceptable salt thereof, wherein R6 is C1-8alkyl.
21. The compound of claim 20, or a pharmaceutically acceptable salt thereof, wherein R6 is Me
22. A compound selected from any one of compounds 1-60, and pharmaceutically acceptable salts thereof.
23. The compound of claim 22, wherein the compound is compound 1,
Figure imgf000193_0001
or a pharmaceutically acceptable salt thereof.
24. The compound of claim 22, wherein the compound is compound 11,
Figure imgf000193_0002
or a pharmaceutically acceptable salt thereof.
25. The compound of claim 22, wherein the compound is compound 17,
Figure imgf000194_0001
or a pharmaceutically acceptable salt thereof.
26. The compound of claim 22, wherein the compound is compound 52,
Figure imgf000194_0002
or a pharmaceutically acceptable salt thereof.
27. The compound of claim 22, wherein the compound is compound 53,
Figure imgf000194_0004
or a pharmaceutically acceptable salt thereof.
28. The compound of claim 22, wherein the compound is compound 54,
Figure imgf000194_0003
or a pharmaceutically acceptable salt thereof.
29. The compound of claim 22, wherein the compound is compound 55,
Figure imgf000195_0001
or a pharmaceutically acceptable salt thereof.
30. The compound of claim 22, wherein the compound is compound 56,
Figure imgf000195_0002
or a pharmaceutically acceptable salt thereof.
31. The compound of claim 22, wherein the compound is compound 57,
Figure imgf000195_0003
or a pharmaceutically acceptable salt thereof.
32. A pharmaceutical composition comprising (a) a compound of any preceding claim; and (b) a pharmaceutically acceptable excipient.
33. A compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 for use as a medicament.
34. A method of treating a hematological disorder in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
35. A method of treating porphyria in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
36. A method of treating a hepatic porphyria in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
37. A method treating one or more complications of a hepatic porphyria in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
38. The method of claim 37, wherein the one or more complications of hepatic porphyria is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, severe abdominal pain, neuropsychiatric symptoms, autonomic neuropathy, peripheral motor neuropathy, electrolyte disturbances, nausea, vomiting, constipation, diarrhea, difficulty urinating, ileus, paresthesia, insomnia, restlessness, agitation, anxiety, confusion, hallucinations, psychosis, convulsions, pain associated with neuropathy, muscle paralysis, tetraparesis, decreased breathing, respiratory arrest, hyponatremia, tachycardia, hypertension, increased heart rate, increased blood pressure, red urine, dark urine, hepatocellular carcinoma, hypertensive renal damage, chronic kidney disease, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholestasis, cytolysis, gallstones, cholestatic liver failure, cholelithiasis, mild liver disease, deteriorating liver disease, and terminal phase liver disease.
39. The method of any one of claims 36-38, wherein the hepatic porphyria is an acute hepatic porphyria, acute intermittent porphyria (AIP), ALA dehydratase porphyria (ADP), variegate porphyria (VP), hereditary coproporphyria (HCP), or harderoporphyria.
40. The method of any one of claims 36-38, wherein the hepatic porphyria is non-acute hepatic porphyria.
41. The method of claim 40, wherein the non-acute hepatic porphyria is familial or sporadic porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP).
42. A method of treating erythropoietic protoporphyria (EPP), X-linked protoporphyria (XLPP), or congenital erythropoietic porphyria (CEP) in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
43. A method of treating one or more complications of EPP, XLPP, or CEP in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
44. The method of claim 43, wherein the one or more complications of EPP, XLPP, or CEP is selected from the group consisting of: acute photosensitivity, cutaneous photosensitivity, edema, erythema, anemia, hypochromic anemia, hemolytic anemia, hemolysis, mild hemolysis, severe hemolysis, chronic hemolysis, hypersplenism, palmar keratoderma, bullae, lesions, scarring, deformities, loss of fingernails, loss of digits, cholestasis, cytolysis, gallstones, cholestatic liver failure, cholelithiasis, mild liver disease, deteriorating liver disease, terminal phase liver disease, erythrodontia, hypercellular bone marrow, thrombocytopenia, hydrops fetalis and/or death in utero.
45. A method of inhibiting protoporphyrin IX (PPIX) synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
46. A method of inhibiting 5-aminolevulinic acid (5-ALA) synthesis in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject
47. A method of inhibiting coproporphyrin III synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject.
48. A method of inhibiting zinc-protoporphyrin IX (ZPPIX) synthesis in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
49. A method of inhibiting porphobilinogen (PBG) synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
50. A method of inhibiting 5-aminolevulinic acid (5-ALA) and porphobilinogen (PBG) synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject.
51. A method of inhibiting hydroxymethylbilane (HMB) synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject.
52. A method of inhibiting uroporphyrin III synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject.
53. A method of inhibiting heptacarboxyl-porphyrin synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject.
54. A method of inhibiting isocoproporphyrin synthesis in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject.
55. A method of inhibiting synthesis of a porphyrin or porphyrin precursor in vivo, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to a subject, wherein the porphyrin or porphyrin precursor is selected from the group consisting of: s. 5-ALA t. PBG u. Hydroxymethylbilane v. PPIX w. ZPPIX x. Uroporphyrinogen I y. Uroporphyrinogen III z. Heptacarboxyporphyrinogen I aa. Heptacarboxyporphyrinogen III bb. Hexacarboxyporphyrinogen I cc. Hexacarboxyporphyrinogen III dd. Pentacarboxyporphyrinogen I ee. Pentacarboxyporphyrinogen III ff. Coproporphyrinogen I gg. Coproporphyrinogen III hh. Isocoproporphyrin ii. Porphobilinogen; and jj. Protoporphyrinogen IX.
56. The method of any one of claims 34-55, wherein accumulation of one or more heme intermediates is inhibited, and wherein the one or more heme intermediates are selected from the group consisting of 5-ALA, coproporphyrin III, zinc-protoporphyrin IX (ZPPIX), porphobilinogen, uroporphyrin III, heptacarboxyl-porphyrin, and isocoproporphyrin.
57. The method of claim 56, wherein the accumulation of the one or more heme intermediates is inhibited in a dose dependent manner.
58. The method of any one of claims 44-55, wherein the subject has EPP, XLPP, or CEP.
59. The method of any one of claims 44-55, wherein the subject has hepatic porphyria.
60. The method of any one of claims 35-41 and 59, wherein the subject has a mutation in UROS.
61. The method of any one of claims 42-44 and 58, wherein the subject has a gene defect in GATA-1 erythroid-specific transcription factor.
62. The method of any one of claims 42-44, 58, and 61, wherein the subject has liver disease associated with EPP, XLPP, or CEP.
63. The method of any one of claims 35-62, comprising further administering to the subject an additional active agent and/or supportive therapy.
64. The method of claim 63, wherein the additional active agent and/or supportive therapy is selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse ®), bortezomib, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion.
65. The method of claim 63, wherein the additional active agent and/or supportive therapy is selected from the group consisting of: avoiding sunlight, topical sunscreens, skin protection, UVB phototherapy, Afamelanotide (Scenesse®), bortezomib, heme infusions, sufficient caloric support, Givosiran, RNAi mediated silencing of various enzymes (e.g., ALA synthase), avoiding precipitating factors, 4-aminoquinolines, chloroquine, hydroxychloroquine, phlebotomy, intravenous magnesium, LH-RH agonists, enzyme replacement therapy (e.g., recombinant human PBGD), gene therapy (e.g., transfer of PBGD gene in liver cells by viral vectors), hemodialysis, pharmacologic chaperone treatment, proteasome inhibitors, chemical chaperones, cholestyramine, activated charcoal, iron supplementation, liver transplantation, bone marrow transplantation, splenectomy, and blood transfusion.
66. A method of treating anemia associated with a ribosomal disorder in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
67. A method of treating of one or more complications of anemia associated with a ribosomal disorder in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
68. The method of any one of claims 66-67, wherein the anemia associated with a ribosomal disorder is Diamond-Blackfan anemia.
69. The method of claim 68, wherein the subject is haploinsufficient for a ribosomal protein selected from the group consisting of 40S ribosomal protein S14 (RPS14), 40S ribosomal protein S19 (RPS19), 40S ribosomal protein S24 (RPS24), 40S ribosomal protein S17 (RPS17), 60S ribosomal protein L35a (RPL35a), 60S ribosomal protein L5 (RPL5), 60S ribosomal protein L11 (RPL11), and 40S ribosomal protein S7 (RPS7).
70. The method of claim 68, wherein the subject is haploinsufficient for a ribosomal protein selected from the group consisting of 40S ribosomal protein S10 (RPS10), 40S ribosomal protein S26 (RPS26), 60S ribosomal protein L15 (RPL15), 60S ribosomal protein L17 (RPL17), 60S ribosomal protein L19 (RPL19), 60S ribosomal protein L26 (RPL26), 60S ribosomal protein L27 (RPL27), 60S ribosomal protein L31 (RPL31), 40S ribosomal protein S15a (RPS15a), 40S ribosomal protein S20 (RPS20), 40S ribosomal protein S27 (RPS27), 40S ribosomal protein S28 (RPS28), and 40S ribosomal protein S29 (RPS29).
71. The method of claim 68, wherein the subject has one or more mutations in a ribosomal protein gene.
72. The method of claim 68, wherein the subject has one or more mutations in a ribosomal protein gene selected from the group consisting of RPL5, RPL9, RPL11, RPL15, RPL17, RPL18, RPL19, RPL26, RPL27, RPL31, RPL35a, RPS7, RPS10, RPS14, RPS15a, RPS15, RPS17, RPS19, RPS20, RPS24, RPS26, RPS27a, RPS27, RPS28, and RPS29.
73. The method of claim 68, wherein the subject has one or more mutations in a non- ribosomal protein gene selected from the group consisting of TSR2, GATA1, and EPO.
74. The method of claim 66 or claim 67, wherein the anemia associated with a ribosomal disorder is Shwachman-Diamond syndrome.
75. The method of claim 74, wherein the subject has one or more mutations in the SBDS gene.
76. The method of claim 66 or claim 67, wherein the anemia associated with a ribosomal disorder is dyskeratosis congenita.
77. The method of claim 76, wherein the dyskeratosis congenita is x-linked dyskeratosis congenita.
78. The method of claim 76 or 77, wherein the subject has one or more mutations in the DKC1 gene.
79. The method of any one of claims 66-78, wherein the method decreases the risk of bone marrow failure, pulmonary fibrosis, or liver fibrosis in the subject.
80. The method of claim 66 or claim 67, wherein the anemia associated with a ribosomal disorder is cartilage hair hypoplasia.
81. The method of claim 80, wherein the subject has one or more mutations in the RMRP gene.
82. The method of claim 67, wherein the one or more complications of anemia associated with a ribosomal disorder is selected from the group consisting of: thrombocytosis, megakaryotypic hyperplasia, infections, bleeding (e.g., from the nose or gums), bruising, splenomegaly, the need for more frequent blood transfusions, the need for increased glucocorticoid use, the need for allogenic hematopoietic stem cell transplantation, the need for autologous gene therapy, marrow failure, leukemia, and acute myelogenous leukemia.
83. The method of any one of claims 66-82, wherein the method reduces intracellular heme levels.
84. The method of any one of claims 66-82, wherein the method increases the subject’s red blood cell count.
85. The method of any one of claims 66-84, comprising further administering to the subject an additional active agent and/or supportive therapy.
86. The method of claim 85, wherein the additional active agent and/or supportive therapy is selected from the group consisting of: trifluoperazine, lenalidomide, HDAC inhibitors, glucocorticoids, sotatercept, luspatercept, iron chelators, blood transfusion, platelet transfusion,
87. A method of treating polycythemia in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
88. A method of treating one or more complications of polycythemia in a subject in need thereof, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
89. The method of claim 87 or 88, wherein the polycythemia is primary polycythemia.
90. The method of claim 89, wherein the primary polycythemia is polycythemia vera or pure erythrocytosis.
91. The method of claim 89, wherein the primary polycythemia is primary familial polycythemia.
92. The method of claim 87 or 88, wherein the polycythemia is secondary polycythemia.
93. The method of claim 92, wherein the secondary polycythemia is associated with a disorder selected from the group consisting of hypoxia, central hypoxic process, lung disease, right-to-left cardiopulmonary vascular shunts (congenital or acquired), heart disease, heart failure, carbon monoxide poisoning, smoker’s erythrocytosis, high-altitude habitat, renal disease, kidney transplant, hemoglobinopathy with high-oxygen-affinity, decreased levels of erythrocyte 2,3,-DPG, bisphosphoglycerate mutase deficiency, methemoglobinemia, hereditary ATP increase, oxygen sensing pathway gene mutations, tumor, drug-induced secondary polycythemia, adrenal cortical hypersecretion, and idiopathic polycythemia.
94. The method of claim 87 or 88, wherein the polycythemia is relative polycythemia.
95. The method of claim 94, wherein the relative polycythemia is selected from the group consisting of Gaisbock’s syndrome, spurious polycythemia, or stress erythrocytosis.
96. The method of claim 87 or 88, wherein the polycythemia is Chuvash polycythemia.
97. The method of claim 88, wherein the one or more complications of polycythemia is selected from the group consisting of: pulmonary embolisms, transient ischemic attacks, transient visual defects, deep vein thrombosis, splenomegaly, hepatomegaly, myelofibrosis, and acute myeloid leukemia.
98. A method of inhibiting heme synthesis in a subject with polycythemia, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
99. The method of claim 98, wherein the heme synthesis is inhibited in a dose dependent manner.
100. A method of inhibiting hemoglobin synthesis in a subject with polycythemia, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
101. The method of claim 100, wherein the hemoglobin synthesis is inhibited in a dose dependent manner.
102. A method of inhibiting red blood cell synthesis in a subject with polycythemia, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
103. The method of claim 102, wherein the red blood cell synthesis is inhibited in a dose dependent manner.
104. A method of decreasing the red blood cell count in a subject with polycythemia, comprising administering a compound of any one of claims 1-31 or a pharmaceutical composition of claim 32 to the subject.
105. The method of claim 104, wherein the red blood cell count is decreased in a dose dependent manner.
106. The method of any one of claims 87-105, wherein the method decreases the incidence of iron deficiency by at least 10% (e.g., 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%).
107. The method of any one of claims 87-106, comprising further administering to the subject an additional active agent and/or supportive therapy.
108. The method of claim 107, wherein the additional active agent and/or supportive therapy is selected from the group consisting of: Hydroxyruea (e.g., Droxia®, Hydrea®), Interferon alpha, Interferon alpha-2b (e.g., Intron® A), Ruxolitinib (e.g., Jakafi®), Busulfan (e.g., Busulfex®, Myleran®), radiation treatment, hepcidin mimetics (e.g., PTG-300), matriptase-2 inhibitors, ferroportin inhibitors, JAK inhibitors, BET inhibitors, MDM2 inhibitors, and HDAC inhibitors.
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