WO2025068448A1 - Atp synthase inhibitors for use in the treatment of non-tuberculosis mycobacteria - Google Patents

Abstract

The present invention relates to a new in vivo use in the treatment of non-tuberculosis mycobacteria (especially Mycobacterium avium complex).

Description

METHODS AND USES RELATED TO THE TREATMENT OF NON-TUBERCULOSIS MYCOBACTERIA _________________________________________ The present invention relates to a new use of certain compounds, specifically in non- tuberculosis mycobacteria, including Mycobacterium avium complex (MAC). The invention also relates to such combinations for such use. BACKGROUND OF THE INVENTION Nontuberculous mycobacterial (NTM) lung disease is a significant cause of morbidity and mortality among individuals with preexisting lung conditions such as bronchiectasis and chronic obstructive pulmonary disease (COPD). Mycobacterium avium complex (MAC), Mycobacterium abscessus group (MAB) and Mycobacterium kansasii are the mycobacterium species that result in NTM pulmonary disease (NTM-PD). NTM-PD is distinct from the pulmonary infection caused by Mycobacterium tuberculosis. Mycobacterium avium is one of several individual species within the MAC and it accounts for up to 70% of NTM-positive sputum cultures (although there are regional differences). MAC species are naturally-occurring organisms common in water and soil that often colonize in natural water sources such as indoor water systems, hot tubs and pools. MAC-pulmonary disease (MAC-PD) is most often seen in post-menopausal women and patients with underlying lung disease (such as cystic fibrosis or bronchiectasis) or immune deficiencies. Clinical symptoms vary in scope and intensity but commonly include chronic cough, often with purulent sputum, while hemoptysis may also be present. Systemic symptoms include malaise, fatigue, and weight loss in advanced disease. Current treatment of MAC-PD involves prolonged antibiotic therapy (frequently more than 18 months), with a combination of at least three antibiotics, including a rifamycin (rifampin or rifabutin), a macrolide (azithromycin or clarithromycin), ethambutol and/or aminoglycosides, including injectable or inhalable (amongst others), which are associated with side-effects and a high failure rate. This treatment regimen is currently recommended by the American Thoracic Society (see Griffith et al., Am. J. Respir. Crit. Care Med., 2007, 175, p367) and International Guidelines given the in vitro and clinical activity displayed by the combination against MAC. Recently, amikacin liposome inhalation suspension (ALIS, Arikayce®) was approved by the US FDA for the treatment of MAC-PD in adults but otherwise this disease/condition has limited or no alternative treatment options. There are no other antibiotics approved for the treatment of MAC-PD and recommended use of the above agents is merely empirical. Bedaquiline, or (1R,2S)-1-(6-bromo-2-methoxyquinolin-3-yl)-4-(dimethylamino)-2- naphthalen-1-yl-1-phenylbutan-2-ol, is a mycobacterium adenosine 5’-triphosphate (ATP) synthase inhibitor that has been developed as a part of a combination therapy for the treatment of pulmonary multidrug-resistant tuberculosis (MDR-TB) in adult patients. Bedaquiline has been approved for that indication under certain conditions under the tradename Sirturo® in territories including the US, Japan, China, Russia, the EU, South Africa and the Republic of Korea. Bedaquiline is known to show activity against Mycobacteria including drug resistant strains, in particular M. tuberculosis, M. bovis, M. avium, M. leprae, M. marinum, M. leprae, M. kansasii, and M. abscessus. The active ingredient, including salt thereof, shows activity against active, sensitive, susceptible Mycobacteria strains and latent, dormant, persistent Mycobacteria strains. International Patent Application Publication No. WO 2004/011436 disclosed the activity of the free base of bedaquiline against Mycobacteria. Later documents such as International Patent Application Publication Nos. WO 2005/117875 and WO 2006/067048 disclosed the use of bedaquiline in the treatment of inter alia drug resistant tuberculosis and latent tuberculosis. Bedaquiline is currently being tested in the clinic in a Phase 2/3 trial in Japan to “Evaluate the Efficacy and Safety of Bedaquiline Administered as Part of a Treatment Regimen with Clarithromycin and Ethambutol in Adult Patients With Treatment- refractory Mycobacterium Avium Complex-lung disease (MAC-LD)”. In addition to bedaquiline, there are now other ATP synthase inhibitors that have entered the clinic – including TBAJ-876 and TBAJ-587:

Both these compounds appear to have a different profile than bedaquiline, and both have entered Phase I clinical trials for tuberculosis. Both are also disclosed in international patent application WO 2017/155909, where their activity in tuberculosis is tested (as MIC values using the H₃₇R_v Mycobacterium tuberculosis strain). Journal article by Sarathy et al, American Society for Microbiology, Antimicrobial Agents and Chemotherapy, April 2020, Volume 64 “TBAJ-876, a 3,5-Dialkoxypyridine Analogue of Bedaquiline, Is Active against Mycobacterium abscessus”, displays data in a certain model indicating as one of its conclusions “…we demonstrate that TBAJ-876 shows attractive in vitro and in vivo activities against M. abscessus, similar to its BDQ parent”. Because of the emerging resistance to multiple antibiotics, physicians are confronted with infections for which there is no effective therapy. The morbidity, mortality, and financial costs of such infections impose an increasing burden for health care systems worldwide. Therefore, there is a high need for new therapies to treat bacterial infections, including mycobacterial infections and specific non-tuberculosis mycobacterial infections. SUMMARY OF THE INVENTION The invention relates to the following compounds of formula (I) and (II):

The compounds of formula (I) and (II) are each racemix mixtures or racemates; each of them having four isomers/enantiomers. The separation of these racemates may be performed by using a number of techniques, for instance by chiral chromatography, and their separation has been achieved, for instance as described in the experimental section using supercritical fluid chromatodgraphy (SFC). One of the possible four enantiomers of the compound of formula (I) and one of the four possible enantiomers of the compound of formula (II) show particularly good activity in vitro, for instance as described herein in Test 1 in the pharmacological examples section (also referred to as the NTM Test 1 in M. avium (MAC) or M. abscessus (MAB)). Hence: - the specific enantiomer/isomer of the compound of formula (I) that displays the best potency (e.g. lowest IC90 values, or highest pIC90 values) in the NTM Test 1 (MAC and/or MAB) is referred to herein as Compound XX1. The other less active enantiomers/isomers are arbitrarily referred to as XX2, XX3 and XX4 - the specific enantiomer/isomer of the compound of formula (II) that displays the best potency (e.g. lowest IC90 values, or highest pIC90 values) in the NTM Test 1 (MAC and/or MAB) is referred to herein as Compound YY1. The other less active enantiomers/isomers are arbitrarily referred to as YY2, YY3 and YY4. XX1 is therefore the enantiomer/isomer that exhibits the lowest numerical IC90 value in the NTM Test 1 assay conditions (MAC or MAB), relative to the other enantiomeric/isomeric forms XX2, XX3 and XX4. YY1 is therefore the enantiomer/isomer that exhibits the lowest numerical IC90 value in the NTM Test 1 assay conditions (MAC or MAB), relative to the other enantiomeric/isomeric forms YY2, YY3 and YY4. XX1 and YY1 (and the other enantiomers/isomers) may also be characterised by how they are eluted using chiral chromatography separation tehniques, for instance SFC as described in the experimental hereinafter, Without being bound to any theory, it is understood that XX1 and YY1 respectively correspond to the following two compounds, where assignments are considered:

In an aspect of the invention therefore, there is provided a compound of formula (I) or (II) that is, in each case, one of the four possible isomers/enantiomers (the most active one, as described herein), or a pharmaceutically acceptable salt thereof, for use in the treatment of Mycobacterium avium complex (MAC). In a further embodiment, the treatment of MAC is in vivo treatment. And in a still further embodiment, the compound is YY1, or a pharmaceutically acceptable salt thereof. In an aspect of the invention therefore, there is provided a compound XX1 or YY1, or a pharmaceutically acceptable salt thereof, for use in the treatment of Mycobacterium avium complex (MAC). In a further embodiment, the treatment of MAC is in vivo treatment. And in a still further embodiment, the compound is YY1, or a pharmaceutically acceptable salt thereof. In an embodiment, there is provided a method of treating Mycobacterium avium complex (MAC) (in a patient in need, e.g. diagnosed with MAC) comprising administering to a patient a therapeutically effective amount of a compound of formula (I) or (II) that is, in each case, one of the four possible isomers/enantiomers (the most active one, as described herein), or a pharmaceutically acceptable salt thereof. In a further embodiment, the method of treating MAC is a method of treating in vivo MAC. And in a still further embodiment, the compound being administered to the patient is YY1, or a pharmaceutically acceptable salt thereof. In an embodiment, there is provided a method of treating Mycobacterium avium complex (MAC) (in a patient in need thereof, e.g. diagnosed with MAC) comprising administering to a patient a therapeutically effective amount of a compound of XX1 or YY1, or a pharmaceutically acceptable salt thereof. In a further embodiment, the method of treating MAC is a method of treating in vivo MAC. And in a still further embodiment, the compound being administered to the patient is YY1, or a pharmaceutically acceptable salt thereof. One of the four possible isomers/enantiomers of Compound (I) or (II) as described herein, for instance Compound XX1 and YY1, display improved in vivo efficacy (in a mouse model), for instance when compared to bedaquiline (BDQ) at an equivalent dose (at a dose match) and/or or at an equivalent PK (at a PK match), for instance as described in the experimental/examples. In instances where a corresponding pharmaceutically acceptable salt is used, the dose is measured on the basis of the active ingredient itself (not considering the salt portion). In the comparisons of compounds XX1 or YY1 with bedaquiline (BDQ) in vivo, for the avoidance of doubt, what is meant by “at an equivalent dose” or “at a dose match” is an approximately equal quantity given over approximately equal times (or at an approximately similar frequency) based on the weight of the API portion (and not any salt moiety, in case it is in the form of a salt, such as bedaquiline fumarate). It is understood that the dose will be adjusted to the weight of the mammal to which it is administered. Hence, a daily dose of 25 mg/kg per mammal will be matched for the purpose of the comparison. It is understood that the dose match could be within a range of ±10% (by weight), for instance ±5%, but is preferably equal (within less than ±1%). When indicated “at an equivalent dose” or “at a dose match”, then such administration still has to occur at a particular frequency, for instance daily – in which case the administration frequency should also be approximately equal – and so for the avoidance of doubt in the case when the administration is daily, then the dose is given at approximately the same time, for the purpose of the comparison / comparative test (for instance within one hour of each other, e.g. within 30 mins of each other). In the comparisons of compounds XX1 or YY1 with bedaquiline (BDQ) in vivo, “at an equivalent PK” or “at a PK match” is based on calculation of the exposure of the respective active pharmaceutical ingredient (API, plus associated metabolite). For instance (as specified more explicitly in the results in the experimental), single dose PK data in a mammal may be generated for each of the APIs (and their metabolites), and that data could be simulated for repeated dosing based on that single dose data in the mammal. And hence, for a planned daily dosing schedule, the simulation would be adapted to such repeated dosing. In addition to the API itself, the corresponding N- desmethyl metabolite is also subjected to the same criteria. Once an approximate AUC for BDQ is calculated based on a specific repeated dose regime (e.g. a daily dose regime, such as 25 mg/kg daily for a specific period of time), and the approximate AUC is calculated for the comparators (i.e. XX1 and YY1, and their corresponding metabolites), then “at an equivalent PK” or “at a PK match” can be determined. For instance, for the avoidance of doubt, the equivalent PK or PK match will be approximate (and it is understood that it is calculated based on simulations as explained herein) and once the AUC of the API plus its metabolite is calculated, then corresponding daily doses can be adjusted accordingly by a certain fold. For instance, if the AUC for BDQ (plus its metabolite) is double that of the API to which it is being compared (e.g. XX1 or YY1 plus its corresponding metabolite), then the latter should also be doubled to achieve “an equivalent PK” or “a PK match”. It is understood that this is approximate for a number of reasons, not least due to the comparison being based on a a single PK data point and then simulation of repeated dose, and further due to the relative ratios of the AUCs being approximate. For instance, the ratios of the AUCs when they are extrapolated to relate to the doses considered “an equivalent PK” or “a PK match” may be within a ±25% range in order for it to be considered an equivalent PK or a PK match, for instance within ±10%. Although preferably, to be considered a PK match, the resultant doses should be (roughly) equal to the exact ratio (of respective AUCs). For instance if an AUC for one API is 10000, and the second API is 2500, and the daily dose of the first API is 100 mg/kg, then to be a PK match (or equivalent PK), the daily dose of the second API should be 25 mg/kg (and based on the foregoing approximate range, a PK equivalent dose may be considered to be within 31.25 mg/kg to 18.75 mg/kg daily dose, for instance). As indicated herein, compound XX1 and YY1 display improved in vivo efficacy (as demonstrated for example, in a mouse model), for instance when compared to bedaquiline (BDQ) at an equivalent dose (at a dose match) and/or at an equivalent PK (at a PK match), for instance as described in the experimental/examples. Such improvement may have a number of advantages, for instance, when only a comparatively lower dose (or lower PK equivalent dose) is required to achieve the same efficacy, then there may be advantages linked to fewer side effects (as only a lower relative dose or a lower relative PK matched dose is required), for instance there may be less toxicity / less toxic side effects. Equally, at a dose match (or PK matched dose), compared to BDQ, the compounds XX1 and/or YY1 may display better efficacy. Such compounds (and the one of four possible isomers/enatniomers described herein), including XX1 and/or YY1 may therefore in general have the advantage that they may be more efficacious than, be less toxic than, be longer acting than, be more potent than, produce fewer side effects than, be more easily absorbed than, and/or have a better pharmacokinetic profile (e.g. higher oral bioavailability and/or lower clearance) than, and/or have other useful pharmacological, physical, or chemical properties over, compounds known in the prior art (and specifically over bedaquiline), whether for use in the above-stated indications or otherwise. In an embodiment of the invention, there is also provided a method of increasing potency in vivo relative to bedaquiline in a patient suffering from a Mycobacterial avium complex (MAC) infection, comprising administering to a patient a therapeutically effective amount of a compound of formula (I) or (II):

or a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II) (for instance the most active enantiomer/isomer, e.g. which could be defined as compounds XX1 and YY1). In an embodiment, the compound is enantiomerically and/or isomerically pure. In a further embodiment, the enantiomer/isomer of compound (I) and (II), respectively is:

or a pharmaceutically acceptable salt thereof. In a further embodiment, the higher in vivo potency compared to bedaquiline is measured in accordance with Test 3 (M. avium non-established murine infection infection model to determine) described herein, and for instance may be demonstrated: - via superior response at specific timepoints of lung weight, lung lesion count and/or colony forming units (CFUs) - by measuring at specific timepoints at 28 days and/or 56 days post-infection - by measurement of improvement in colony forming units (CFUs) at 56 days post infection In an embodiment, there is provided a compound of formula (I) or (II) that is, in each case, one of the four possible isomers/enantiomers (the most active one, as described herein, e.g. XX1 or more particularly, YY1), or a pharmaceutically acceptable salt thereof, for use in increasing potency in vivo relative to bedaquiline in the treatment of Mycobacterium avium complex (MAC). In an embodiment of the invention, there is also provided a method of improving patient response relative to bedaquiline in a patient suffering from a Mycobacterial avium complex (MAC) infection, comprising administering to a patient a therapeutically effective amount of a compound of formula (I) or (II):

or a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II) (for instance the most active enantiomer/isomer, e.g. which may be defined as XX1 and YY1). In an embodiment, the compound is enantiomerically and/or isomerically pure. In a further embodiment, the enantiomer/isomer of compound (I) and (II), respectively is:

or a pharmaceutically acceptable salt thereof. In a further embodiment, the improved patient response may be demonstrated: - via superior response at specific timepoints of lung weight, lung lesion count and/or colony forming units (CFUs) - by measuring at specific timepoints at 28 days and/or 56 days post-infection - by measurement of improvement in colony forming units (CFUs) at 56 days post infection In an embodiment, there is provided a compound of formula (I) or (II) that is, in each case, one of the four possible isomers/enantiomers (the most active one, as described herein, e.g. XX1 or, in particular, YY1), or a pharmaceutically acceptable salt thereof, for use in improving patient response relative to bedaquiline in the treatment of Mycobacterial avium complex (MAC) infection. In a further embodiment, there is provided a method of treating Mycobacterium avium complex (MAC) in vivo comprising administering to a patient in need thereof a therapeutically effective amount (for instance, in an embodiment that provides a more potent response in the patient compared to a bedaquiline at an approximate dose match and/or PK match) of a compound of formula (I) or (II):

a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II) (for instance the most active enantiomer/isomer, e.g. which may be defined as XX1 and YY1). In an embodiment, the compound is enantiomerically and/or isomerically pure. In a further embodiment, the enantiomer/isomer of compound (I) and (II), respectively is:

or a pharmaceutically acceptable salt thereof. In an embodiment, there is provided a compound of formula (I) or (II) that is, in each case, one of the four possible isomers/enantiomers (the most active one, as described herein, e.g. XX1 or, in particular, YY1), or a pharmaceutically acceptable salt thereof, for use in the treatment of Mycobacterial avium complex (MAC) infection, wherein the compound provides a more potent response compared to a bedaquiline at an approximate dose match and/or PK match. The pharmaceutically acceptable acid addition salts as mentioned hereinabove are meant to comprise the therapeutically active non-toxic acid addition salt forms that the relevant active ingredient (e.g. TBAJ-587, TBAJ-876) are able to form. These pharmaceutically acceptable acid addition salts can conveniently be obtained by treating the base form with such appropriate acid. Appropriate acids comprise, for example, inorganic acids such as hydrohalic acids, e.g. hydrochloric or hydrobromic acid, sulfuric, nitric, phosphoric and the like acids; or organic acids such as, for example, acetic, propanoic, hydroxyacetic, lactic, pyruvic, oxalic (i.e. ethanedioic), malonic, succinic (i.e. butanedioic acid), maleic, fumaric, malic, tartaric, citric, methanesulfonic, ethanesulfonic, benzenesulfonic, p-toluenesulfonic, cyclamic, salicylic, p-aminosalicyclic, pamoic and the like acids. For the purposes of this invention solvates, prodrugs, N-oxides and stereoisomers of the relevant active ingredient (e.g. TBAJ-587, TBAJ-876) are also included within the scope of compound of formula (I) or (II). The term “prodrug” of a relevant compound of the invention includes any compound that, following oral or parenteral administration, is metabolised in vivo to form that compound in an experimentally-detectable amount, and within a predetermined time (e.g. within a dosing interval of between 6 and 24 hours (i.e. once to four times daily)). For the avoidance of doubt, the term “parenteral” administration includes all forms of administration other than oral administration. Prodrugs of compounds mentioned herein (e.g. of formula (I) or (II), e.g. TBAJ-876) may be prepared by modifying functional groups present on the compound in such a way that the modifications are cleaved, in vivo when such prodrug is administered to a mammalian subject. The modifications typically are achieved by synthesising the parent compound with a prodrug substituent. Prodrugs include compounds mentioned herein (e.g. of formula (I)) wherein a hydroxyl, amino, sulfhydryl, carboxy or carbonyl group in that compound is bonded to any group that may be cleaved in vivo to regenerate the free hydroxyl, amino, sulfhydryl, carboxy or carbonyl group, respectively. Examples of prodrugs include, but are not limited to, esters and carbamates of hydroxy functional groups, esters groups of carboxyl functional groups, N-acyl derivatives and N-Mannich bases. General information on prodrugs may be found e.g. in Bundegaard, H. “Design of Prodrugs” p. l-92, Elesevier, New York-Oxford (1985). The methods of treatment, uses of the invention or compounds of the invention for use (in the treatment of MAC) may also be such that there is combination with other antibacterial drugs that are useful in the treatment of MAC. The combinations of the invention may be useful as they have a bacteriostatic effect, but may also have a bacteriocidal effect against MAC. Other drugs that may be used in combination include a macrolide (clarithromycin, azithromycin), ethambutol and rifampicin. Numerous other drugs may be combined, for instance those outlined in any official guidelines for the treatment of non-tuberculosis mycobacteria (especially MAC) or drug that may have been approved by a regulatory authority (but which is not another ATP synthase inhibitor). The quantity of each drug should be an effective amount to elicit a biological or medicinal response. The daily dose of the drug may of course vary depending on factors such as: - already approved (e.g. by an appropriate regulatory body such as EMA or the US FDA) recommended daily doses; - efficacy of doses lower than those already approved (or being studied in clinical trials); - patient tolerability; - the daily dose of the other drug (or drugs) forming part of the relevant combination; - any synergistic effects between the components of the combination; - the mode of administration. Regarding doses, in general, satisfactory results will be obtained when the relevant compound of the combination of the invention is administered at a daily dosage not exceeding 1 or 2 grams, e.g. in the range from 1 to 50 mg/kg or from 10 to 50 mg/kg body weight. However, doses may be adjusted depending on response rates. Optional further antibacterial drugs that may be included in the combinations of the invention may be administered at daily doses recommended by a regulatory body (when e.g. approved in combination with other antibacterial agents), and are preferably administered at a daily dosage not exceeding 1 or 2 grams, e.g. in the range from 1 to 50 mg/kg body weight (for instance, in the range from 1 to 25 mg/kg, from 1.5 to 25 mg/kg, or from 2 to 15 mg/kg body weight). All amounts mentioned in this disclosure refer to the free form (i.e. non-salt form). The values given below represent free-form equivalents, i.e., quantities as if the free form would be administered. If salts are administered the amounts need to be calculated in function of the molecular weight ratio between the salt and the free form. The doses (e.g. daily doses) described herein are calculated for an average body weight specified, and should be recalculated in case of paediatric applications, or when used with patients with a substantially diverging body weight. The treatment duration for tuberculosis can be more than a year. However, it is envisioned that treatment duration may be reduced using the combinations of the invention. For instance, treatment duration may be 36 weeks or less, for instance 24 weeks or less. In certain embodiments, the treatment duration may be less than 20 weeks, for instance 16 weeks or less, or, 12 weeks or less. In aspects of the invention, there is provided combinations of the invention, as described herein, for use as medicaments or pharmaceuticals. Such combinations may be useful in the treatment of a disease caused by Mycobacterial tuberculosis (e.g. in the treatment of tuberculosis). Hence, there is also provided a pharmaceutical composition (or formulation) comprising a pharmaceutically acceptable carrier and, as active ingredient, a therapeutically effective amount of a combination of the invention. Such combinations may be formulated into pharmaceutical compositions as described hereinafter. Accordingly, in another aspect of the invention, there is provided a method of treating a patient suffering from, or at risk of, a disease caused by Mycobacterial tuberculosis (tuberculosis), which method comprises administering a therapeutically effective amount of a combination of the invention or a pharmaceutical composition of the invention. In an embodiment, the patient is human. In further embodiments, there is provided a method of treatment as defined herein wherein the method further comprises a treatment duration period as defined herein (e.g. a treatment duration of 36 weeks or less, 24 weeks or less or, in a particular embodiment, a treatement period of 16 weeks or less or 12 weeks or less). Alternatively, there is provided a combination for use as described herein, wherein the use is for a certain duration period (e.g. a treatment duration of 36 weeks or less, 24 weeks or less or, in a particular embodiment, a treatement period of 16 weeks or less or 12 weeks or less). The components or antibacterial drugs of the combinations of the invention (including the two essential antibacterial drugs of the combination and the further optional drugs) may be formulated separately (e.g. as defined herein) or may be formulated together so forming for example a fixed dose formulation. The latter may have advantages in terms of compliance. In some embodiments, the two (or optionally more) antibacterial drugs of the combinations of the invention can be co-administered, in other embodiments the antibacterial drugs (of the combinations) may be sequentially administered, while in still other embodiments they can be administered substantially simultaneously. In some of the latter embodiments, administration entails taking such antibacterial drugs within 30 minutes or less of each other, in some embodiments 15 minutes or less of each other. In some embodiments, the antibacterial drugs are administered once per day, at approximately the same time each day. For example, the antibacterial drugs are administered within a time range of 4 hours of the original time of administration on the first day, that is, ± 2 hours, or ± 1 hour, or in still other embodiments ± 30 minutes of the time on the original administration day. In some embodiments, the antibacterial drugs of the invention are administered as separate oral capsules or oral tablets. Other formulations may include solid dispersions. Hence, when a combination is referred to herein, such a combination may be a single formulation comprising all antibacterial drugs of the combinations of the invention (i.e. the two essential ones mentioned herein and, optionally, one or more further antibacterials) or it may be a combination product (such a kit of parts) where each of the antibacterial drugs of the combinations of the invention may be packaged together either as separate forms (each comprising one of the antibacterial drugs) or as two or more forms (depending on the total number of antibacterial drugs in the combination of the invention). In an embodiment, each antibacterial drug of the combination of the invention is formulated separately and/or is also packaged separately but may be labelled for use in combination with one or more of the other antibacterial drugs of the combinations of the invention. The antibacterial drugs of the combination (as described herein) may be co-administered, sequentially administered, or administered substantially simultaneously. Hence the individual dosage forms of each of the antibacterial drugs can be administered as separate forms (e.g., as separate tablets or capsules) as described herein or, in other embodiments, may be administered as a single form containing all three active substances or as two forms (one containing any two of the active substances and the other containing the remaining active substance). The antibacterial drugs of the combinations of the invention may be formulated into various pharmaceutical forms for administration purposes. As mentioned herein, this formulating may be done on an individual antibacterial drug or a combination of antibacterial drugs that form part of the combinations of the invention. As appropriate, compositions may include those usually employed for systemically administering drugs. To prepare the pharmaceutical compositions the relevant antibacterial drug (or combination of relevant antibacterial drugs) is combined in intimate admixture with a pharmaceutically acceptable carrier, which carrier may take a wide variety of forms depending on the form of preparation desired for administration. These pharmaceutical compositions are desirable in unitary dosage form suitable, in particular, for administration orally or by parenteral injection. For example, in preparing the compositions in oral dosage form, any of the usual pharmaceutical media may be employed such as, for example, water, glycols, oils, alcohols and the like in the case of oral liquid preparations such as suspensions, syrups, elixirs, emulsions and solutions; or solid carriers such as starches, sugars, kaolin, diluents, lubricants, binders, disintegrating agents and the like in the case of powders, pills, capsules and tablets. Because of their ease in administration, tablets and capsules represent the most advantageous oral dosage unit forms in which case solid pharmaceutical carriers are obviously employed. For parenteral compositions, the carrier will usually comprise sterile water, at least in large part, though other ingredients, for example, to aid solubility, may be included. Injectable solutions, for example, may be prepared in which the carrier comprises saline solution, glucose solution or a mixture of saline and glucose solution. Injectable suspensions may also be prepared in which case appropriate liquid carriers, suspending agents and the like may be employed. Also included are solid form preparations which are intended to be converted, shortly before use, to liquid form preparations. Depending on the mode of administration, the pharmaceutical composition will preferably comprise from 0.05 to 99 % by weight, more preferably from 0.1 to 70 % by weight, even more preferably from 0.1 to 50 % by weight of the active ingredient(s), and, from 1 to 99.95 % by weight, more preferably from 30 to 99.9 % by weight, even more preferably from 50 to 99.9 % by weight of a pharmaceutically acceptable carrier, all percentages being based on the total weight of the composition. Any pharmaceutical composition mentioned herein (e.g. a pharmaceutical composition comprising one antibacterial drug or a combination of antibacterial drugs of the combination of the invention) may additionally contain various other ingredients known in the art, for example, a lubricant, stabilising agent, buffering agent, emulsifying agent, viscosity-regulating agent, surfactant, preservative, flavouring or colorant. It is especially advantageous to formulate the aforementioned pharmaceutical compositions in unit dosage form for ease of administration and uniformity of dosage. Unit dosage form as used herein refers to physically discrete units suitable as unitary dosages, each unit containing a predetermined quantity of active ingredient calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. Examples of such unit dosage forms are tablets (including scored or coated tablets), capsules, pills, powder packets, wafers, suppositories, injectable solutions or suspensions and the like, and segregated multiples thereof. As mentioned hereion, the combination of antibacterial drugs as described herein may be co-administered, sequentially administered, or administered substantially simultaneously (as described herein). Hence the individual dosage forms of each of the antibacterial drugs can be administered as separate forms (e.g. as separate tablets or capsules) as described herein or, in an alternative embodiment, may be administered as a single form containing all actives or as two or more forms (e.g. where there are three antibacterial drugs, one containing any two and the other containing the remaining one). There is also provided a process for preparing a pharmaceutical formulation as defined herein comprising bringing into association any one (or more, e.g. the two essential active ingredients and, optionally, further antibacterials as defined herein) of the active ingredients of the combination of the invention, with one (or more) pharmaceutically acceptable excipient or carrier. There is also provided a process for preparing a combination product as defined herein comprising: - bringing into association each of the components (e.g. as separate pharmaceutical formulations) of the combination product and co-packaging (e.g. as a kit of parts) or indicated that the intended use is in combination (with the other components); and/or - bringing into association each of the components in the preparation of a pharmaceutical formulation comprising such components. Brief Description of the Figures Figure 1: Represents Lung Weight – following Test 3 described below Figure 2: Represents Macroscopic lung lesions – scoring system – all following Test 3 described below Figure 3: Represents Lung lesions –following Test 3 described below Figure 4: Represents Lung CFUs – Results after 28 days of treatment – all following Test 3 desrcibed below Figure 5: Represents Lung CFUs – Results after 56 days of treatment – all following Test 3 desrcibed below GENERAL PREPARATION The compounds according to the invention can generally be prepared by a succession of steps, each of which may be known to the skilled person or described herein. Analytical Analysis The High Performance Liquid Chromatography (HPLC) measurement was performed using a LC pump, a diode-array (DAD) or a UV detector and a column as specified in the respective methods. If necessary, additional detectors were included (see table of methods below). Flow from the column was brought to the Mass Spectrometer (MS) which was configured with an atmospheric pressure ion source. It is within the knowledge of the skilled person to set the tune parameters (e.g., scanning range, dwell time…) to obtain ions allowing the identification of the compound’s nominal monoisotopic molecular weight (MW). Data acquisition was performed with appropriate software. Compounds are described by their experimental retention times (Rt) and ions. If not specified differently in the table of data, the reported molecular ion corresponds to the [M+H]+ (protonated molecule) and/or [M-H]- (deprotonated molecule). In case the compound was not directly ionizable the type of adduct is specified (i.e. [M+NH + 4] , [M+HCOO]-, etc…). For molecules with multiple isotopic patterns (Br, Cl), the reported value is the one obtained for the lowst isotope mass. All results were obtainedwith experimental uncertainties that are commonly associated with the method used. Hereinafter, “SQD” means Single Quadrupole Detector, “MSD” Mass Selective Detector, “RT” room temperature, “BEH” bridged ethylsiloxane/silica hybrid, “DAD” Diode Array Detector, ”HSS” High Strength silica. LCMS Method Codes (Flow expressed in mL/min, column temperature (T) in °C, Run time in minutes): Table Method Instrument column mobile phase gradient Flow Run ------- time Col T A Waters: Waters BEH® A: CH3COONH4 84.2% A/15.8% B 0.343 6.07 C18 (1.7µm, 7mM 95%/ ------- Acquity® 2.1x100mm) CH3CN 5%, B: for 0.49min, to 40 UPLC - DAD CH3CN 10.5% A in 2.67 and min, held for 1.94 QuattroTM min, back to 84.2% A/15.8% B in 0.73min, held for 0.73min B Waters Xbridge C18 A : 0,2% 80% A / 20% B for 0.8 12 100mm*4,6 Alliance HPLC mm 5µm NH4HCO3 in 0.5 min, to 90% B in mL/mi – DAD & ZQ water (pH = 7,9) 4.5 min, held for 4 n B : CH3CN min, back to 80% A Method Instrument column mobile phase gradient Flow Run ------- time Col T / 20% B in 1.5 min, 30 °C held for 1.5 min SFC-MS methods: The SFC measurement was performed using an Analytical Supercritical fluid chromatography (SFC) system composed by a binary pump for delivering carbon dioxide (CO₂) and modifier, an autosampler, a column oven, a diode array detector equipped with a high-pressure flow cell standing up to 400 bars. If configured with a Mass Spectrometer (MS) the flow from the column was brought to the (MS). It is within the knowledge of the skilled person to set the tune parameters (e.g., scanning range, dwell time…) to obtain ions allowing the identification of the compound’s nominal monoisotopic molecular weight (MW). Data acquisition was performed with appropriate software. Analytical SFC-MS Methods (Flow expressed in mL/min, column temperature (Col T) in °C, Run time in minutes, Backpressure (BPR) in bars unless mentioned otherwise. “iPrNH_2” means isopropylamine, “iPrOH” means 2- propanol, “EtOH” means ethanol, “min” mean minutes, “DEA” means diethylamine, “Hex” means hexanes, “IPA” means isopropylamine. Table: SFC methods Flow Run time SFC Column mobile phase gradient ------- ------- Method Col T BPR 3.5 3 ₁ Chiralpak OD-3 CO285% / (MeOH + isocratic ------- ------- 3µm 0.3 % iPrNH2) 15% 35 103.4 Flow Run time SFC Column mobile phase gradient ------- ------- Method Col T BPR 3.5 3 ₂ Chiralpak OD-3 CO275% / (MeOH + isocratic ------- ------- 3µm 0.3 % iPrNH2) 25% 35 103.4 EXPERIMENTAL PART TBA-587 and TBAJ-876 can each be prepared in accordance with known procedures, for instance those described in international patent application WO 2017/155909. In the first instance, the following racemates of formula (I) and (II) are prepared:

International patent application WO 2017/155909 discloses certain compounds, where their activity in tuberculosis is tested (as MIC values using the H37Rv Mycobacterium tuberculosis strain). Such compounds include Example 13 (Compound 193) and Example 63 (Compound 243), i.e. the compounds of formula (I) and (II) depicted above. Each the individual enantiomers of each racemic compound can be separated, for instance as described herein, to provide specifically TBAJ-587 and TBAJ-876 (obtained from chiral separation of compounds of formula (I) and (II) herein). Compounds of formula (I) and (II) may be prepared by reaction of compounds of formula (IA) and (IIA), respectively,

with a compound of formula (III),

under reaction conditions that couple the respective moieites, for instance using an appropriate base to deprotonate α to the quinolinyl ring (in compound (IA) or (IIA), for instance in the presence of a polar aprotic solvent, followed by a nucleophilic addition reaction with the ketone moiety of the compound of formula (III) and quench with a proton source H+. An Example of a General Coupling Procedure n-BuLi (e.g. approx.1.2 molar equiv.) was added at -30 ^C under dry nitrogen to a solution of dry diisopropylamine (e.g. approx.1.2 molar equiv.) in dry THF (a suitable volume) and the solution was stirred at this temperature for 10 min, then cooled to -78 ^C. A solution of Compound of formula (IA) or (IIA) (approx..1 equiv) in dry THF was added dropwise and the mixture was stirred at -78C for 90 mins, to give a dark wine-red coloured solution. A solution of compound (III) (approx.1.1 equiv.) in dry THF (amount) was added and the reaction mixture was stirred at this temperature for 4 hrs. HOAc (relatively small volume) was added and the reaction mixture was warmed to room temperature. Water (e.g. approx.100 mL, based on approx 5 mmol reaction process) was added and the mixture was extracted with EtOAc (x2). The combined organic extract was washed with sat. aq. NaHCO3 solution, and brine, then dried (Na2SO4) and the solvent removed under reduced pressure. The residue was purified by flash column chromatography. Elution with 0-10% MeOH/DCM may give fractions of starting material (e.g. compound (IA) or (IIA)) and the desired product (i.e. compound of formula (I) or (II); for instance as a mixture of diasteroisomers). A specific process is also described in the Supplementary Material to journal article by Sarathy et al, American Society for Microbiology, Antimicrobial Agents and Chemotherapy, April 2020, Volume 64 “TBAJ-876, a 3,5-Dialkoxypyridine Analogue of Bedaquiline, Is Active against Mycobacterium abscessus”. Thereafter, to obtain the specific enantiomers TBAJ-587 and TBAJ-876, a chiral separation can take place, for instance by chiral column (e.g. OJ-H column, 20 x 250 mm) using a Waters Thar SFC 80 system. Mobile phases are gradients of 30% IPA/70% CO2 at 40 g/min. For instance, depending on which stereoisomer is desired, for TBAJ-876 the (1R)(2S)-stereoisomer is the first eluting P1 in that particular chiral chromatography system. In general, the correct enantiomer / stereoisomer may be isolated using known procedures. Compounds of formula (IA) and (IIA) can be prepared in accordance with the following scheme:

In the scheme above, there is a compound of compound of formula (IV) that is coupled with either a compound of formula (IB) or of formula (IIB), to provide a compound of formula (IA) or (IIA) respectively. Appropriate coupling reaction conditions include reaction in the presence of a suitable catalyst system, e.g. a metal (or a salt or complex thereof) such as Pd, CuI, Pd/C, PdCl₂, Pd(OAc)₂, Pd(Ph₃P)₂Cl₂, Pd(Ph₃P)₄ (i.e. palladium tetrakistriphenylphosphine), Pd₂(dba)₃ and/or NiCl₂ (preferred cataysts include RuPhos Pd G3, XPhos Pd and bis(tri-tert-butylphosphine)palladium(0)) and optionally a ligand such as PdCl₂(dppf).DCM, t-Bu₃P, (C₆H₁₁)₃P, Ph₃P, AsPh₃, P(o- Tol)₃, 1,2-bis(diphenylphosphino)ethane, 2,2'-bis(di-tert-butylphosphino)-1,1'- biphenyl, 2,2'-bis(diphenylphosphino)-1,1'-bi-naphthyl, 1,1’-bis(diphenyl-phosphino- ferrocene), 1,3-bis(diphenylphosphino)propane, xantphos, or a mixture thereof, together with a suitable base, such as Na₂CO₃, K₃PO₄, Cs₂CO₃, NaOH, KOH, K₂CO₃, CsF, Et₃N, (i-Pr)₂NEt, t-BuONa or t-BuOK (or mixtures thereof; preferred bases include Na₂CO₃ and K₂CO₃) in a suitable solvent such as dioxane, toluene, ethanol, dimethylformamide, dimethoxyethane, ethylene glycol dimethyl ether, water, dimethylsulfoxide, acetonitrile, dimethylacetamide, N-methylpyrrolidinone, tetrahydrofuran or mixtures thereof (preferred solvents include dimethylformamide and dimethoxyethane). The compound of formula (III) may be prepared per the reaction scheme below where first oxalyl chloride (e.g.1.2 equiv.) is added to a suspension of 2,6- dimethoxyisonicotinic acid (e.g. I equiv.) in DCM (suitable quantity of solvent) and DMF (e.g.0.2 equiv.) at room temperature. Then, after 1 hour of stirring, the resultant colourless solution was cooled (e.g. to 0 ^C). N,O-dimethylhydroxylamine hydrochloride (e.g.1.1 equiv.) and pyridine (suitable quantity of solvent) were added sequentially and the mixture stirred for 18hr at room temperature, then partitioned, worked up and the intermediate isolated. Vinvylmagnesium bromide (e.g.3 equiv; in a THF solution) was added to a solution of that intermediate (e.g.1 equiv) in solvent (e.g. THF), and stirring, dimethylamine (approx.6 equiv) and water were added. The desired of formula (III) can then be extracted and isolated.

The compound of formula (IV) was prepared by reaction of 6-bromo-2- methoxyquinoline (e.g.1 equiv) and triisopropylborate (e.g. approx.2 equiv), which was added dropwise to a solution of an appropriate lithiated base – thereby forming the compound of formula (IV). The compounds of formulae (IB) and (IIB) may be known or prepared by methods in the literature, for instance compound of formula (IIB) may be prepared in accordance with the following scheme, under reaction conditions for instance those described in WO 2017/155909 or those in a literature article (e.g. mentioned herein).

Hence, the following compounds, that are single enantiomers may be isolated:

Chiral chromatography may be employed. In the example below, supercritical fluid chromatography (SFC) was employed under the conditions mentioned. As can be seen hereinbelow, when the four individual enantiomers/isomers of each of compound of formula (I) and (II) are isolated, one of those enantiomers/isomers is more active in Test 1 (NTM test using MAC/MAB) relative to the others. The most active enantiomer/isomer in each case of compound (I) and (II) respectively is arbitrarily assigned XX1 and YY1. Without being bound by any theory, it is understood that these correspond to TBAJ-587 and TBAJ-876, respectively. Separation of compound of formula (I) to provide XX1 (TBAJ-587), and the other three isomers, may be performed by SFC under the conditions outlined in the table below XX1 RT: 2.01 min, Area %: 100, Method: ChiralPak IG-3 (4.6x100 mm) 15:85 MeOH:CO2 (0.3% v/v iPrNH2) XX4 RT: 2.59, Area %: 100, Method: ChiralPak IG-3 (4.6x100 mm) 15:85 MeOH:CO2 (0.3% v/v iPrNH2) XX3 RT: 1.05, Area %: 100, Method: ChiralPak IG-3 (4.6x100 mm) 20:80 MeOH:CO2 (0.3% v/v iPrNH2) XX2 ee: 97.2 (RT: 1.68, Area %: 98.6, Method: ChiralPak IG-3 (4.6x100 mm) 20:80 MeOH:CO2 (0.3% v/v iPrNH2)) Hence, using SFC ChiralPak IG-3 (4.6x100 mm) 15:85 MeOH:CO2 (0.3% v/v iPrNH2), XX1 (which is understood to be TBAJ-587): - Is observed to elute in a specific order, within the sequence of four eluting enantiomer in the same column/conditions - Has a retention time of about 2 mins (e.g.2.01 min) in these SFC column/conditions Further Analytical information for XX1 (understood to be TBAJ-587) LCMS: RT: 5.12, Area %: 97.6, MH+: 614.2, Method: A (as described above in the analytical methods) OR: -83.104° (589 nm, c 0.22 w/v, DMF, 20 °C) SFC: P6 (RT: 2.01 min, Area %: 100, Method: ChiralPak IG-3 (4.6x100 mm) 15:85 MeOH:CO2 (0.3% v/v iPrNH2)) 1H NMR (400 MHz, DMSO) d 8.53 (s, 1H), 8.18 (d, J = 2.2 Hz, 1H), 7.76 – 7.68 (m, 2H), 7.67 – 7.58 (m, 2H), 6.91 (t, J = 8.2 Hz, 1H), 6.84 – 6.77 (m, 1H), 6.42 (s, 2H), 5.29 (s, 1H), 4.09 (s, 3H), 3.79 (s, 6H), 3.64 (s, 3H), 2.20 – 2.03 (m, 1H), 1.93 (s, 6H), 1.92 – 1.82 (m, 2H), 1.81 – 1.66 (m, 1H). Separation of compound of formula (II) to provide YY1 (TBAJ-876), and the other three isomers, may be performed by SFC under the conditions outlined in the table below YY3 ee 100% (RT: 1.28 min, Area %: 100, Method: IC3 100x4.6mm, iso 25% MeOH+base, 3.5mL/min) (0.3% v/v iPrNH2) YY2 RT: 2.26 min, Area %: 99.25, Method: IC3 100x4.6mm, iso 25% MeOH+base, 3.5mL/min (0.3% v/v iPrNH2) YY1 RT: 2.04 min, Area %: 100, Method: IC3 100x4.6mm, iso 15% MeOH+base, 3.5mL/min (0.3% v/v iPrNH2) YY4 ee 99.16% (RT: 2.55 min, Area %: 99.58, Method: IC3 100x4.6mm, iso 15% MeOH+base, 3.5mL/min) (0.3% v/v iPrNH2) Hence, using SFC ChiralPak IG-3 (100 x 4.6 mm) iso 15% MeOH+base (15:85 MeOH:CO2), 3.5mL/min (0.3% v/v iPrNH2), YY1 (TBAJ-876): - Is observed to elute in a specific order, within the sequence of four eluting enantiomer in the same column/conditions - Has a retention time of about 2 mins (e.g.2.04 min) in these SFC column/conditions If an alternative column chromatography method is employed, for instance as described in the Sarathy journal article mentioned herein, then YY1 (TBAJ-876) may be characterised as follows: using a chiral column (OJ-H column, 20 x 250 mm) using a Waters Thar SFC 80 system, where mobile phases are gradients of 30% IPA/70% CO2 at 40 g/min, then TBAJ-876 the (1R)(2S)-stereoisomer is the first eluting P1 (understood to be YY1). Further Analytical information for YY1 (understood to be TBAJ-876) LCMS: confirm the MW (RT: 12.35, Area %: 100, MH+: 656.9, Method: B (as described above in athe analytical methods) OR: +19.57° (589 nm, c 0.16 w/v, DMF, 20 °C) SFC: ee 100% (RT: 2.04, Area %: 100, Method: IC3100x4.6m, iso 15% MeOH+base, 3.5mL/min) 1H NMR (400 MHz, DMSO) d 8.23 (s, 2H), 7.78 – 7.67 (m, 2H), 7.54 (s, 1H), 7.15 (s, 1H), 6.45 (s, 2H), 5.46 (s, 1H), 4.18 (s, 3H), 3.81 (s, 6H), 3.74 (s, 3H), 3.73 (s, 3H), 3.32 (s, 3H), 2.11 (d, J = 7.8 Hz, 1H), 1.88 (s, 6H), 1.83 (m, 2H), 1.63 – 1.52 (m, 1H). Pharmacological examples Test 1: Determination of the Minimum Inhibitory Concentration (MIC) for testing compounds against Non-tuberculous mycobacteria (NTM) The susceptibility assay to determine the MIC was carried out in vitro by broth microdilution according to the Clinical & Laboratory Standards Institute (CLSI) recommendations and adjusted accordingly. Briefly, MIC of

avium ATCC700898 (MAC101) and M. abscessus ATCC19977 were determined with a start inoculum of 5x105 cells in Middlebrook 7H9 broth supplemented with 10% OADC, 0.5% glycerol, and 0.02% Tween 80. MIC here equals IC90 ( ^g/ml) since values were derived from pIC90 (pIC90= -log10[IC90]). Compounds were prepared in 384 well plates and were serially diluted (3-fold dilutions). Plates with compounds and with either M. avium ATCC700898 or M. abscessus ATCC19977 cells were inoculated with a final volume of 30 µL per well. Plates with M. avium ATCC700898 isolate were incubated at 37°C for 5 days whereas plates with M. abscessus ATCC19977 isolate were incubated at 37°C for 3 days, respectively. Growth inhibition was measured at optical density (OD) of 620 nm and values were used to calculate pIC90/ MIC90. Test 2: Time kill assays Bactericidal or bacteriostatic activity of compounds can be determined in a time kill assay using the broth dilution method. M. avium ATCC700898 or M. abscessus ATCC19977 samples were grown to logarithmic phase (OD₆₂₀=0.5-0.7) in Middlebrook 7H9 broth supplemented with 10% OADC and 0.05% Tween 80. The culture was then adjusted to OD₆₂₀=0.4 and diluted 1:150 in growth media as described above to a starting inoculum of ~5x105 CFU/ml in flasks. Compound were added to a certain concentration, in the range 1-60x MIC. Each condition was tested in triplicate and all conditions contained the same % DMSO (<1%).2 controls were included: a growth control containing no drug, and a killing control containing a drug (amikacin) or a drug combination (amikacin and rifabutin) that kills M. avium ATCC700898. No drug control was used for M. abscessus ATCC19977. Samples were taken from each flask and serial dilutions were plated on 7H10 agar (BD Difco) supplemented with 0.5% (vol/vol) glycerol and 10% (vol/vol) OADC and 0.4% charcoal at several time points during the experimental period. Colony forming units (CFU) on agar plates were counted after an incubation period of 3-5 weeks for M. avium and 5 days for M. abscessus at 37°C. Test 3: M. avium non-established murine infection infection model to determine in vivo efficacy In vivo efficacy experiments were performed with 6-week-old female Balb/cBy mice purchased from Janvier Labs (France). All experiments involving live animals were approved by the Center for Discovery and Innovation Institutional Animal Care and Use Committee. Briefly, mice were anesthetized for 30 sec by 3% isoflurane inhalation and infected intranasally with 50 µL bacteria inoculum corresponding to 5x106 CFU of M. avium ATCC700898. Infection was established within day 1 (D1). Test compounds or vehicle control were orally administrated QD 7 days/ week starting from day 1 post- infection.200 mg/kg Clarithromycin (CLA), 100 mg/kg Ethanbutol (EMD), and 10 mg/kg Rifampin (RIF) were used as standard of care (SOC) reference control. CLA and EMD were co-formulated in 0.5% methocel F4M suspension pH 7.2. Rif was formulated in 20% HPbCD. Investigational compounds bedaquiline (BDQ), TBAJ-876 and TBAJ-578 were solubilized in 20% HPpbCD HC pH2.5. The BDQ dose of 25 mg/kg was used to ensure maximum efficacious exposure based on PK profile. TBAJ- 876 and TABJ-578 were dose matched at 25 mg/kg and PK matched (15 mg/kg for TBAJ-876 and 40 mg/kg for TABJ-578, respectively) with BDQ 25/mg/kg based on pharmacokinetic investigations. Mice were euthanized at different time points (Day 1, Day 28, and Day 56) but 24 h after the last dose. Lungs and spleen samples were aseptically removed prior to homogenization with a gentleMACS™ Dissociator (Miltenyi Biotec). The weights of both organs were determined, and macroscopic lung lesion were scored. The bacterial load in these organs was determined by plating serial dilutions of the organ homogenates onto Middlebrook 7H10 agar (BD Difco) supplemented with 0.5% (vol/vol) glycerol, 10% (vol/vol) OADC, and 0.4% charcoal. Amphotericin B (100 µg/ml), polymycin B (25 µg/ml), carbenicillin (50 µg/ml), and trimethoprim (20 µg/ml) were used in each agar plates to prevent growth by other organism. Of note, the used drug was inactive against M. avium. CFU on agar plates were counted after an incubation period of up to 8 weeks weeks at 37°C.

Design of the study There were 19 study groups and 8 mice per group Study Treatment (compound / dose in Day of euthanasia Formulation Group mg/kg) – given daily for sampling concentration 1 Untreated 1 dpi - 2 Vehicle 20%HPbCD HCl 28 dpi - pH2.5 3 Clarithromycin (200 mg/kg) + 28 dpi 20 mg/ml Ethambutol (100 mg/kg) + 10 mg/ml Rifampicin (10 mg/kg)* 1 mg/ml 4 TBAJ-876 (25 mg/kg) 28 dpi 2.5 mg/ml 5 TBAJ-876 (15 mg/kg) 28 dpi 1.5 mg/ml 6 TBAJ-876 (6 mg/kg) 28 dpi 0.6 mg/ml 7 TBAJ-587 (40 mg/kg) 28 dpi 4 mg/ml 8 TBAJ-587 (25 mg/kg) 28 dpi 2.5 mg/ml 9 TBAJ-587 (15 mg/kg) 28 dpi 1.5 mg/ml 10 BDQ (25 mg/kg) 28 dpi 2.5 mg/ml 11 Vehicle 20% HPbCD HCl 56 dpi - pH2.5 12 Clarithromycin (200 mg/kg) + 56 dpi 20 mg/ml Ethambutol (100 mg/kg) + 10 mg/ml Rifampicin (10 mg/kg)* 1 mg/ml 13 TBAJ-876 (25 mg/kg) 56 dpi 2.5 mg/ml 14 TBAJ-876 (15 mg/kg) 56 dpi 1.5 mg/ml 15 TBAJ-876 (6 mg/kg) 56 dpi 0.6 mg/ml 16 TBAJ-587 (40 mg/kg) 56 dpi 4 mg/ml 17 TBAJ-587 (25 mg/kg) 56 dpi 2.5 mg/ml 18 TBAJ-587 (15 mg/kg) 56 dpi 1.5 mg/ml 19 BDQ (25 mg/kg) 56 dpi 2.5 mg/ml - * Rifampicin should be dosed 1 h before clarithromycin and ethambutol Bedaquiline (BDQ) is employed in these experiments as its corresponding fumarate salt (that is also the form in which it is marketed as Sirturo®), and TBAJ-587 and TBAJ- 876 were all used as their free base (non-salt) forms RESULTS TEST 1: As indicated in the experimental, the following two racemic compounds were prepared: 1-(6-bromo-2-methoxyquinolin-3-yl)-2-(2,6-dimethoxypyridin-4-yl)-4- (dimethylamino)-1-(2-fluoro-3-methoxyphenyl)butan-2-ol (Compoound XX) 1-(6-bromo-2-methoxyquinolin-3-yl)-2-(2,6-dimethoxypyridin-4-yl)-4- (dimethylamino)-1-(2,3,6-trimethoxypyridin-4-yl)butan-2-ol (Compound YY) Each of the above racemates XX and YY, due to their two chiral centres, have four possible stereoisomers, which (as mentioned above) can be separated as described herein by chiral chromatography (e.g. SFC) and characterised. For convenience, the four possible stereoisomers of compound XX are herein assigned XX1 (also referred to as TBAJ-587, which it is understood to correspond to), XX2, XX3 and XX4. The four possible stereoisomers of compound YY are assigned herein as YY1 (also referred to as TBAJ-876, which it is understood to correspond to), YY2, YY3 and YY4. It is understood currently that XX1 (or TBAJ-587) represents (1R,2S)-1-(6-bromo-2- methoxyquinolin-3-yl)-2-(2,6-dimethoxypyridin-4-yl)-4-(dimethylamino)-1-(2-fluoro- 3-methoxyphenyl)butan-2-ol It is currently understood that YY1 (or TBAJ-876) represents (1R,2S)-1-(6-bromo-2- methoxyquinolin-3-yl)-2-(2,6-dimethoxypyridin-4-yl)-4-(dimethylamino)-1-(2,3,6- trimethoxypyridin-4-yl)butan-2-ol As indicated in in vitro test data described herein – see data in the NTM Test 1 below (MAC and MAB), it can be seen that one of the enantiomers/isomers out of the four possible, in each case of the compound of formula (I) and (II), are more active relative to the other three enantiomers/isomers. The most active enatntiomer/isomer of the four in that test is referred to as compound XX1 and YY1 respectively. Without being bound by any theory, it is understood that the following assignments are considered with respect to the most active enantiomer/isomer of compound of formula (I) (also referred to as XX1) and of compound of formula (II) (also referred to as YY1), respectively:

It is known that bedaquiline has an active metabolite (known as M2, or BDQ M2 herein, which is its N-monodesmethyl metabolite). Similary, compounds XX and YY have such a N-monodesmethyl metabolite too, which for XX1 (TBAJ-587) and YY1 (TBAJ-876) is referred to herein as XX1 M2 and YY1 M2, respectively.

The following MIC results were obtained following Test 1, where M. avium (MAC) or M. abscessus (MAB) were used in the test: Compound MAC model – MIC90/ IC90 MAB model – MIC90/ IC90 in 7H9 in 7H9 TBAJ-587 (or XX1) 0.009 µg/ml 0.11 µg/ml TBAJ-876 (or YY1) 0.0043 µg/ml 0.094 µg/ml Bedaquiline (BDQ) 0.038 µg/ml 0.55 µg/ml XXI M2 0.052 µg/ml 0.73 µg/ml YY1 M2 0.59 µg/ml 1.35 µg/ml BDQ M2 0.063 µg/ml 0.93 µg/ml Hence, both TBAJ-587 and TBAJ-876 display potent activity in vitro against the NTMs MAC and MAB, and both, in this setting display improved activity compared with BDQ (in both MAC / MAB), for instance: - TBAJ-876 (YY1) displays about a 9-fold increase in potency in this vitro MAC model compared to BDQ - TBAJ-587 (XX1) displays about a 4-fold increase in potency in this vitro MAC model compared to BDQ - TBAJ-876 (YY1) displays about a 6-fold increase in potency in this vitro MAB model compared to BDQ - TBAJ-587 (XX1) displays about a 5-fold increase in potency in this vitro MAB model compared to BDQ - In the in vitro MAC model, BDQ is about 2-fold more potent than its M2 metabolite, XX1 is about 6 fold more potent than its M2 metabolite, and YY1 is over 100 times more potent than its M2 metabolite Regarding the other stereoisomers, the following in vitro data was obtained using Test 1: Compound MAC model – MIC90/ IC90 MAB model – MIC90/ IC90 in 7H9 in 7H9 YY3 0.41 µg/ml 8.02 µg/ml YY4 0.67 µg/ml 8.37 µg/ml YY2 11.58 µg/ml 27.73 µg/ml XX3 0.72 µg/ml 4.68 µg/ml XX4 0.73 µg/ml 4.61 µg/ml XX2 2.20 µg/ml 16.80 µg/ml Based on the above, it can be seen that in the NTM Test 1 (MAC or MAB), it can be seen that XX1 is the most potent enantiomer/isomer of the compound of formula (I) and YY1 is the most potent enantiomer/isomer of the compound of formula (II). PK STUDIES IN ADVANCE OF TEST 3 Studies / modelling studies were performed in order to assess the PK of various doses of bedaquiline (BDQ), XX1 (TBAJ-587) and YY1 (TBAJ-876), as well as all of their corresponding M2 metabolites in order to make relative comparisons: - Single dose PK data was generated of the parent (XX1/YY1) and the corresponding N-desmethyl metabolite (referred to as the “M2 metabolite) - Exposure data of parent (XX1/YY1) and the M2 metabolite was simulated following repeated dosing starting from single dose data in mouse - Doses of XX1/YY1 (TBAJ-587 and TBAJ-876) were determined that would provide roughly equal exposure to Bedaquiline (BDQ) and its M2 metabolite (BDQ-M2) Bedaquiline (BDQ) - The total exposure of BDQ (+ BDQ-M2) at 25 mg/kg (repeated daily dosing): o AUC BDQ + AUC BDQ-M2 = 10921 + 61468 ^ 72000 XX1 (TBAJ-587) – the following was modelled after generating single dose PK data of parent and its M2 metabolite - Exposure of XX1 (TBAJ-587) and its M2 metabolite at 15 mg/kg o AUC XX1 + AUC XX1-M2 = 20734 + 7035 ^ 27000 o To reach same total exposure as BDQ 25 mg/kg: 72000 / 27000 ^ 2.7 x increase required (linear PK) o Given linear PK, dose multiplies by 2.7 : 15 x 2.7 ^ 40 mg/kg YY1 (TBAJ-876) – the following was modelled after generating single dose PK data of parent and its M2 metabolite - Exposure of YY1 (TBAJ-876) and its M2 metabolite at 15 mg/kg o AUC XX1 + AUC XX1-M2 = 12887 + 58356 ^ 71000 o To reach same total exposure as BDQ 25 mg/kg ^ 15 mg/kg To achieve rough equivalents of a 10 mg/kg BDQ dose, therefore the PK modelling studies predict that this would be approx.15 mg/kg XX1 (TBAJ-587) and approx.6 mg/kg YY1 (TBAJ-876) In the following, plasma and lung exposures are indicated, where the metabolite (also referred to as M2) is the N-desmethyl metabolite: BDQ 25 mg/kg: - Plasma – slight reduction of parent over time, accumulation for M2 (active metabolite) initially, steady state reached afterwards - Lung – only single time point data, but highlight increased exposure in lung on day 56 vs day 28 – about 15-fold increase for BDQ and M2, and about 100-fold higher exposure of M2 vs parent XX1 (TBAJ-587) 15 – 25 – 40 mg/kg - Plasma – 2-fold increase in exposure, while 4-fold increase in exposure of its metabolite in plasma upon repeated dose (RD) (some accumulation); dose proportional increase in exposure for parent, almost for its metabolite - Lung – only single time point data, but highlight increased exposure in lung on day 56 vs day 28 – about 7-fold increase for parent and about 9-fold increase for its metabolite, and about 2-3-fold higher exposure of metabolite vs parent - Stability investigation ongoing as exposure of metabolite higher than in PK study TBAJ-8766 – 15 – 25 mg/kg - Plasma – 2-fold increase in exposure, while 4-fold increase in exposure of its metabolite in plasma upon RD (some accumulation); slightly more than dose proportional increase in exposure for parent and its metabolite - Lung – only single time point data, but highlight increased exposure in lung on day 56 vs day 28 – about 15-fold increase for BDQ and M2, and about 100-fold higher exposure of M2 vs parent - Stability investigation ongoing as comparison The mean terminal elimination half-life of bedaquiline and the N-monodesmethyl metabolite (also known as the M2 metabolite) is approximately 5.5 months. This long terminal elimination phase likely reflects slow release of bedaquiline and M2 from peripheral tissues. In order to make comparisons between bedaquiline (BDQ) and XX1(TBAJ-587) and YY1 (TBAJ-876) can: (i) Have same dose (ii) Have same PK Hence for (ii) above, the modelling studies above were done to come to the the relevant conclusions, i.e.25 mg/kg BDQ daily dose ^ 40 mg/kg XX1 (TBAJ-587) ^ 15 mg/kg YY1 (TBAJ-876) TEST 3: In vivo efficacy results following Test 3, taking into account design of the study Lung Weight As can be seen in Figure 1: - Lung weight is increased >2x due to infection with Mycobacterium Avium Complex (MAC) in vehicle treated mice - Treatment with Standard of Care (SOC), TBAJ-876, TBAJ-587 and bedaquiline (BDQ) all prevent increase in lung weight Lung Lesions The scoring system from 0 to 2 is shown in Figure 2, where a healthy lung (Score 2) and an infected lung (Score 2) is depicted As can be seen from Figure 3: - Lung lesions are observed after 1 month of infection with MAC - Development of lung lesions is prevented (at 28 days and 56 days) with SOC, TBAJ-876, TBAJ-587 and BDQ Lung Colony Forming Units (CFUs) As can be seen from Figure 4 (Lung CFUs after 28 days) and Figure 5 (Lung CFUs after 56 days) – and based on the results of the lung CFU counting after 28 or 56 days: Control/SOC - As can be seen from the control, MAC is significantly replicated after 1 month of infection - Treatment for 56 days wth SOC showed significant killing of MAC compared to start of treatment BDQ dosing - Treatment for 56 days with BDQ at 25 mg/kg dose showed killing of MAC (as seen by the reduced CFUs) TBAJ dosing and comparison with BDQ - Treatment for 56 days with TBAJ-876 at 25 mg/kg (i.e. at at matched dose with BDQ) showed complete killing, i.e. zero CFUs at the detection levels, which complete eradication of the MAC infection was an incredible result – for this time period clearly it showed significantly better killing of MAC than BDQ 25 mg/kg, which did not achieve complete eradication - Treatment for 56 days with other doses of TBAJ-876, namely 15 mg/kg and 6 mg/kg also showed killing of MAC – at 15 mg/kg, there was almost complete eradication of the MAC infection with significantly better results compared to BDQ 25 mg/kg dosing – and at 6 mg/kg, there was killing of the MAC infection seen too, which was also improved compared with BDQ 25 mg/kg - Based on the above therefore, it can be seen that TBAJ-876 in killing CFUs under this in vivo setting is significantly better than BDQ, if the dose is matched (25 mg/kg vs 25 mg/kg), if the PK is matched 25 mg/kg BDQ vs 15 mg/kg of TBAJ-876, and even if the TBAJ-876 dose is even lower) – this was entirely unexpected and a significant result TBAJ-587 dosing and comparison with BDQ - Treatment for 56 days with TBAJ-587 also showed significant killing of MAC infection – at 40 mg/kg dose (which is a PK match), it kills significantly better than BDQ 25 mg/kg – at a dose match 25 mg/kg, TBAJ-587 still kills the MAC infection at a similar or improved rate compared to BDQ – and at a dose of 15 mg/kg, it still kills the MAC infection showing similar results to BDQ 25 mg/kg - Based on the above, TBAJ-587 displays significantly improved MAC killing properties in this in vivo setting and measured by CFUs compared to BDQ at a matched PK dose; at a matched dose TBAJ-587 also displays similar or improved MAC killing properties compared to BDQ Additional Observations - Infection is significantly replicated in vehicle treated mice, with lungs demonstrating clear presence of macroscopic lung lesions after 4 weeks and 8 weeks of infection - No clinical signs were observed after treatment with TBAJ-876 and TBAJ-587 during the in vivo efficacy study, for instance clinical signs such as piloerection, respiration, hunched posture, lethargy, weight / dehydration (and death)

Claims

CLAIMS 1. A compound of formula (I) or (II):

or a pharmaceutically acceptable salt thereof, for the use in the in vivo treatment of Mycobacterial avium complex (MAC), wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II), and wherein such enantiomer/isomer is the more potent relative to the others in the NTM in vitro assay Test 1 (i.e. it is the enantiomer/isomer with the highest pIC90 values).

2. A method of treating Mycobacterium avium complex (MAC) in vivo comprising administering to a patient a therapeutically effective amount of a compound (I) or (II) as defined in Claim 1, or a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II), and wherein such enantiomer/isomer is the more potent relative to the others in the NTM in vitro assay Test 1 (i.e. it is the enantiomer/isomer with the highest pIC90 values).

3. A compound for use as claimed in Claim 1, or a method as claimed in Claim 2, wherein the enantiomer/isomer of compound (I) and (II), respectively is:

4. A compound for use as claimed in Claim 1 or 3, or a method as claimed in Claim 2 or 3, wherein the enantiomer/isomer of compound (I) or (II) respectively displays a higher in vivo potency compared to bedaquiline at an approximate dose match.

5. A compound for use as claimed in Claim 1 or 3, or a method as claimed in Claim 2 or 3, wherein the enantiomer/isomer of compound (I) or (II) respectively displays a higher in vivo potency compared to bedaquiline at an approximate PK match.

6. A compound for use as claimed in Claim 4 or 5, or a method as claimed in Claim 4 or 5, wherein the higher in vivo potency compared to bedaquiline is measured in accordance with Test 3 (M. avium non-established murine infection infection model to determine) described herein.

7. A compound for use or method as claimed in Claim 6 wherein the higher potency is measured at specific timepoints, namely 28 days and 56 days post-infection, by: - lung weight - lung lesion count - colony forming units (CFUs) – especially at 56 days post infection

8. A compound for use or method as claimed in any one of Claims 4 to 7, that is YY1 or TBAJ-876.

9. A method of increasing potency in vivo relative to bedaquiline in a patient suffering from a Mycobacterial avium complex (MAC) infection, comprising administering to a patient a therapeutically effective amount of a compound of formula (I) or (II):

or a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II).

10. The method of claim 9, wherein the enantiomer/isomer of compound (I) and (II), respectively is:

or a pharmaceutically acceptable salt thereof.

11. The method of claim 9, wherein the higher in vivo potency compared to bedaquiline is measured in accordance with Test 3 (M. avium non-established murine infection infection model to determine) described herein.

12. The method of claim 9, wherein the higher potency is demonstrated via superior response at specific timepoints of lung weight, lung lesion count and/or colony forming units (CFUs).

13. The method of claim 12, wherein the specific timepoints are 28 days and/or 56 days post-infection.

14. The method of claim 12, wherein the higher potency is measured as improved colony forming units (CFUs) at 56 days post infection 15. The method of claim 9, wherein the compound is enantiomerically and/or isomerically pure. 16. A method of improving patient response relative to bedaquiline in a patient suffering from a Mycobacterial avium complex (MAC) infection, comprising administering to a patient a therapeutically effective amount of a compound of formula (I) or (II):

or a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II). 17. The method of claim 16, wherein the enantiomer/isomer of compound (I) and (II), respectively is:

or a pharmaceutically acceptable salt thereof. 18. The method of claim 17, wherein the improved patient response is demonstrated via superior response at specific timepoints of lung weight, lung lesion count and/or colony forming units (CFUs). 19. The method of claim 18, wherein the specific timepoints are 28 days and/or 56 days post-infection. 20. The method of claim 18, wherein the improved patient response is measured as improved colony forming units (CFUs) at 56 days post infection 21. The method of claim 16, wherein the compound is enantiomerically and/or isomerically pure. 22. A method of treating Mycobacterium avium complex (MAC) in vivo comprising administering to a patient in need thereof a therapeutically effective amount of a compound of formula (I) or (II):

or a pharmaceutically acceptable salt thereof, wherein the compound is one of four possible enantiomers/isomers of the respective compound (I) or (II). 23. The method of claim 22, wherein the therapeutically effective amount provides a more potent response in the patient compared to a bedaquiline at an approximate dose match. 24. The method of claim 22, wherein the enantiomer/isomer of compound (I) and (II), respectively is:

25. The method of claim 22, wherein the compound is enantiomerically and/or isomerically pure.