Patent Description:
Cystic Fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene which encodes a multi-membrane spanning epithelial chloride channel (<NPL>)). Approximately ninety percent of patients have a deletion of phenylalanine (Phe) <NUM> (ΔF508) on at least one allele. This mutation results in disruption of the energetics of the protein fold leading to degradation of CFTR in the endoplasmic reticulum (ER). The ΔF508 mutation is thus associated with defective folding and trafficking, as well as enhanced degradation of the mutant CFTR protein (<NPL>)). The loss of a functional CFTR channel at the plasma membrane disrupts ionic homeostasis (Cl-, Na+, HCO<NUM>-) and airway surface hydration leading to reduced lung function (Riordan et al. Reduced periciliary liquid volume and increased mucus viscosity impede mucociliary clearance resulting in chronic infection and inflammation, phenotypic hallmarks of CF disease (<NPL>)). In addition to respiratory dysfunction, ΔF508 CFTR also impacts the normal function of additional organs (pancreas, intestine, gall bladder), suggesting that the loss-of-function impacts multiple downstream pathways that will require correction.

In addition to cystic fibrosis, mutations in the CFTR gene and/or the activity of the CFTR channel has also been implicated in other conditions, including for example, congenital bilateral absence of vas deferens (CBAVD), acute, recurrent, or chronic pancreatitis, disseminated bronchiectasis, asthma, allergic pulmonary aspergillosis, smoking-related lung diseases, such as chronic obstructive pulmonary disease (COPD), dry eye disease, Sjogren's syndrome and chronic sinusitis, cholestatic liver disease (e.g. Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC)) (<NPL>; <NPL>; (<NPL>;<NPL>; <NPL>), <NPL>.

There remains a need in the art for compounds, compositions and methods of increasing CFTR activity as well as for methods of treating CF, other CFTR-related diseases, and other maladies of protein misfolding.

<CIT> relates to compounds which can increase cystic fibrosis transmembrane conductance regulator (CFTR) activity as measured in human bronchial epithelial (hBE) cells.

<CIT> relates to compounds that modulate, e.g., address underlying defects in cellular processing of CFTR activity.

<CIT> relates to modulators of ATP-Binding Cassette ("ABC") transporters or fragments thereof, including Cystic Fibrosis Transmembrane Conductance Regulator, compositions thereof, and methods therewith.

<CIT> relates to direct blend formulations comprising <NUM>-chloro-<NUM>-(<NUM>- hydroxyquinolin-<NUM>-yl)benzoic acid and a method of treating or lessening the severity of cystic fibrosis in a patient, comprising the step of stabilizing the CFTR protein both in the cell and at the cell membrane by administering to said patient an effective amount of an inhibitor of S-nitrosoglutathione reductase (GSNOR).

<NPL> relates generally to the introduction of biosteres, such as by sila-substitution, into lead molecules to improve their properties in the drug design process.

<CIT> relates to compounds that modulate e.g., address underlying defects in cellular processing of CFTR activity.

The present disclosure is based, in part, on the discovery that disclosed compounds such as those having the Formulae Ia, Ib, Ic, Id, II, and III increase cystic fibrosis transmembrane conductance regulator (CFTR) activity as measured in human bronchial epithelial (hBE) cells.

The present invention, which is defined by the appended claims, relates to aspects and embodiments as described herein wherein a compound of formula Ia, Ib, Ic or Id is:
<CHM>.

In one aspect, the invention provides a compound represented by
<CHM>
or a pharmaceutically acceptable salt thereof, for use in a method of treating a disease associated with decreased cystic fibrosis transmembrane conductance regulator (CFTR) activity in a subject in need thereof, the method comprising administering said compound in combination with compounds:
<CHM>
or a pharmaceutically acceptable salt thereof, and
<CHM>
wherein the disease is selected from the group consisting of cystic fibrosis, congenital bilateral absence of vas deferens (CBAVD), acute, recurrent, or chronic pancreatitis, disseminated bronchiectasis, asthma, allergic pulmonary aspergillosis, chronic obstructive pulmonary disease (COPD), chronic sinusitis, dry eye disease, protein C deficiency, A-β-lipoproteinemia, lysosomal storage disease, type <NUM> chylomicronemia, mild pulmonary disease, lipid processing deficiencies, type <NUM> hereditary angioedema, coagulation-fibrinolyis, hereditary hemochromatosis, CFTR-related metabolic syndrome, chronic bronchitis, constipation, pancreatic insufficiency, hereditary emphysema, Sjogren's syndrome, familial hypercholesterolemia, I-cell disease/pseudo-Hurler, mucopolysaccharidoses, Sandhof/Tay-Sachs, Crigler-Najjar type II, polyendocrinopathy/hyperinsulemia, Diabetes mellitus, Laron dwarfism, myleoperoxidase deficiency, primary hypoparathyroidism, melanoma, glycanosis CDG type <NUM>, congenital hyperthyroidism, osteogenesis imperfecta, hereditary hypofibrinogenemia, ACT deficiency, Diabetes insipidus (DI), neurophyseal DI, nephrogenic DI, Charcot-Marie Tooth syndrome, Perlizaeus-Merzbacher disease, Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, progressive supranuclear palsy, Pick's disease, Huntington's disease, spinocerebellar ataxia type I, spinal and bulbar muscular atrophy, dentatorubral pallidoluysian, myotonic dystrophy, hereditary Creutzfeldt-Jakob disease (due to prion protein processing defect), Fabry disease, cholestatic liver disease (primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC)), and Straussler-Scheinker syndrome.

In another aspect, the invention provides a CFTR amplifier compound for use in a method of treating cystic fibrosis in a patient homozygous for the ΔF508 mutation or having a ΔF508/G542X mutation, the method comprising administering to the patient an effective combination, sequentially or substantially simultaneously, of the CFTR amplifier compound, a CFTR corrector compound, and a CFTR potentiator compound, wherein:.

The references to the methods of treatment by therapy or surgery or in vivo diagnostic methods herein are to be interpreted as references to compounds, pharmaceutical compositions, combinations and/or medicaments for use in those methods.

In an embodiment, this disclosure is at least partially directed to a method of enhancing cystic fibrosis transmembrane conductance regulator (CFTR) activity in a subject in need thereof, which includes administering to said subject a therapeutically effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein.

In additional embodiments, a method of enhancing (e.g., increasing) cystic fibrosis transmembrane conductance regulator (CFTR) activity in a subject in need thereof is provided, comprising administering to said subject a therapeutically effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein.

In certain of these embodiments, the activity of one or more (e.g., one or two) mutant CFTRs (e.g., ΔF508, S549N, G542X, G551D, R117H, N1303K, W1282X, R553X, <NUM>+<NUM>>T, <NUM>-<NUM>>A, <NUM>+10kbC>T, <NUM>+<NUM>>A, <NUM>+<NUM>>A, I507del, R1162X, <NUM>+<NUM>>A, 3659delC, G85E, D1152H, R560T, R347P, 2184insA, A455E, R334W, Q493X, E56K, P67L, R74W, D110E, D110H, R117C, G178R, E193K, L206W, R347H, R352Q, A455E, S549R, G551S, D579G, S945L, S997F, F1052V, K1060T, A1067T, G1069R, R1070Q, R1070W, F1074L, G1244E, S1251N, S1255P, D1270N, G1349D, and 2184delA CFTR) is enhanced (e.g., increased). In certain embodiments, ΔF508 CFTR activity is enhanced (e.g., increased). In other embodiments, the activities of two mutant CFTRs (e.g., ΔF508 and G551D; ΔF508 and A455E; or G542X; Δ508F) are enhanced (e.g., increased).

In certain embodiments, a method is provided comprising administering a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein, to a subject (e.g., a human patient) suffering from a disease associated with decreased CFTR activity (e.g., cystic fibrosis, congenital bilateral absence of vas deferens (CBAVD), acute, recurrent, or chronic pancreatitis, disseminated bronchiectasis, asthma, allergic pulmonary aspergillosis, chronic obstructive pulmonary disease (COPD), chronic sinusitis, dry eye disease, protein C deficiency, A-β-lipoproteinemia, lysosomal storage disease, type <NUM> chylomicronemia, mild pulmonary disease, lipid processing deficiencies, type <NUM> hereditary angioedema, coagulation-fibrinolyis, hereditary hemochromatosis, CFTR-related metabolic syndrome, chronic bronchitis, constipation, pancreatic insufficiency, hereditary emphysema, Sjogren's syndrome, familial hypercholesterolemia, I-cell disease/pseudo-Hurler, mucopolysaccharidoses, Sandhof/Tay-Sachs, Crigler-Najjar type II, polyendocrinopathy/ hyperinsulemia, Diabetes mellitus, Laron dwarfism, myleoperoxidase deficiency, primary hypoparathyroidism, melanoma, glycanosis CDG type <NUM>, congenital hyperthyroidism, osteogenesis imperfecta, hereditary hypofibrinogenemia, ACT deficiency, Diabetes insipidus (DI), neurophyseal DI, nephrogenic DI, Charcot-Marie Tooth syndrome, Perlizaeus-Merzbacher disease, Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, progressive supranuclear palsy, Pick's disease, Huntington's disease, spinocerebellar ataxia type I, spinal and bulbar muscular atrophy, dentatorubral pallidoluysian, myotonic dystrophy, hereditary Creutzfeldt-Jakob disease (due to prion protein processing defect), Fabry disease, cholestatic liver disease (e.g. Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC)), and Straussler-Scheinker syndrome). In certain embodiments, the disease is cystic fibrosis.

In yet additional embodiments, this disclosure is directed to treating a patient suffering from cystic fibrosis comprising administering to said patient an effective amount of a first compound of Formula Ia, Ib, Ic or Id,, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein.

In another embodiment, this disclosure provides methods of treating cystic fibrosis in a patient homozygous for the ΔF508 mutation or having a ΔF508/G542X mutation, comprising administering to the patient an effective combination, sequentially or substantially simultaneously, of a CFTR amplifier compound, a CFTR corrector compound, and a CFTR potentiator compound, as disclosed herein.

In some embodiments, the methods described herein can further include administering an additional CFTR modulator. In certain embodiments, the additional CFTR modulator is a CFTR corrector (e.g., VX-<NUM> (lumacaftor), deuterated lumacaftor, VX-<NUM> (tezacaftor), deuterated tezacaftor, VX-<NUM>, VX-<NUM>, VX-<NUM>, VX-<NUM>, VX-<NUM>, GLPG2851, GLPG2665, GLPG2737, GLPG3221, or GLPG2222).

As used herein, the words "a" and "an" are meant to include one or more unless otherwise specified. For example, the term "an agent" encompasses both a single agent and a combination of two or more agents.

As discussed above, the present disclosure is directed in part to methods of treating CFTR that include administering a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein, or a pharmaceutically acceptable salt, prodrug or solvate thereof.

Disclosed herein are methods of enhancing cystic fibrosis transmembrane conductance regulator (CFTR) activity in a subject in need thereof, comprising administering to said subject a therapeutically effective amount of:.

In certain embodiments, the patient has one or more CFTR mutations selected from the group consisting of ΔF508, S549N, G542X, G551D, R117H, N1303K, W1282X, R553X, <NUM>+<NUM>>T, <NUM>-<NUM>>A, <NUM>+10kbC>T, <NUM>+<NUM>>A, <NUM>+<NUM>>A, I507del, R1162X, <NUM>+<NUM>>A, 3659delC, G85E, D1152H, R560T, R347P, 2184insA, A455E, R334W, Q493X, E56K, P67L, R74W, D110E, D110H, R117C, G178R, E193K, L206W, R347H, R352Q, A455E, S549R, G551S, D579G, S945L, S997F, F1052V, K1060T, A1067T, G1069R, R1070Q, R1070W, F1074L, G1244E, S1251N, S1255P, D1270N, G1349D, and 2184delA CFTR.

In certain embodiments, the patient has a ΔF508 and a G542X mutation. In other embodiments, the patient has a homozygous ΔF508 mutation.

In some embodiments, the subject is suffering from a disease associated with decreased CFTR activity. For example, the disease is selected from the group consisting of, e.g., cystic fibrosis, congenital bilateral absence of vas deferens (CBAVD), acute, recurrent, or chronic pancreatitis, disseminated bronchiectasis, asthma, allergic pulmonary aspergillosis, chronic obstructive pulmonary disease (COPD), chronic sinusitis, dry eye disease, protein C deficiency, A-β-lipoproteinemia, lysosomal storage disease, type <NUM> chylomicronemia, mild pulmonary disease, lipid processing deficiencies, type <NUM> hereditary angioedema, coagulation-fibrinolyis, hereditary hemochromatosis, CFTR-related metabolic syndrome, chronic bronchitis, constipation, pancreatic insufficiency, hereditary emphysema, Sjogren's syndrome, familial hypercholesterolemia, I-cell disease/pseudo-Hurler, mucopolysaccharidoses, Sandhof/Tay-Sachs, Crigler-Najjar type II, polyendocrinopathy/hyperinsulemia, Diabetes mellitus, Laron dwarfism, myleoperoxidase deficiency, primary hypoparathyroidism, melanoma, glycanosis CDG type <NUM>, congenital hyperthyroidism, osteogenesis imperfecta, hereditary hypofibrinogenemia, ACT deficiency, Diabetes insipidus (DI), neurophyseal DI, nephrogenic DI, Charcot-Marie Tooth syndrome, Perlizaeus-Merzbacher disease, Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, progressive supranuclear palsy, Pick's disease, Huntington's disease, spinocerebellar ataxia type I, spinal and bulbar muscular atrophy, dentatorubral pallidoluysian, myotonic dystrophy, hereditary Creutzfeldt-Jakob disease (due to prion protein processing defect), Fabry disease, cholestatic liver disease, and Straussler-Scheinker syndrome. For example, the disease is cystic fibrosis.

In certain embodiments, the subject is a human patient.

In certain embodiments, a method disclosed herein comprises administering an effective amount of the following compounds to the patient:
<CHM>
and
<CHM>.

For example, disclosed herein is a method of enhancing cystic fibrosis transmembrane conductance regulator (CFTR) activity in a subject in need thereof, comprising administering to said subject a therapeutically effective amount of the following compounds to the patient:
<CHM>
and a compound selected from the group consisting of:
<CHM>.

Also provided herein are methods of treating cystic fibrosis in a patient homozygous for the ΔF508 mutation or having a ΔF508/G542X mutation, comprising administering to the patient an effective combination, sequentially or substantially simultaneously, of a CFTR amplifier compound, a CFTR corrector compound and CFTR potentiator compound, wherein:.

Further disclosed herein are methods of treating cystic fibrosis in a patient homozygous for the ΔF508 mutation or having a ΔF508/G542X mutation, comprising administering to the patient an effective combination, sequentially or substantially simultaneously, of a CFTR corrector compound and a CFTR potentiator compound, wherein:.

Further disclosed herein are methods of treating cystic fibrosis in a patient homozygous for the ΔF508 mutation or having a ΔF508/G542X mutation, comprising administering to the patient an effective combination, sequentially or substantially simultaneously, of a CFTR amplifer compound and a CFTR potentiator compound, wherein:.

In certain embodiments, a method disclosed herein further comprises administering an additional CFTR modulator, as described anywhere herein. In some embodiments, the CFTR modulator is a CFTR corrector. For example, the CFTR corrector may be selected from the group consisting of (<NUM>-(<NUM>-(<NUM>-(<NUM>,<NUM>-difluorobenzo[d][<NUM>,<NUM>]dioxol-S-yl)cyclopropanecarboxamido)-<NUM>-methylpyridin-<NUM>-yl)benzoic acid (lumacaftor), deuterated lumacaftor, ((R)-<NUM>-(<NUM>,<NUM>-difluorobenzo[d][<NUM>,<NUM>]dioxol-<NUM>-yl)-N-(<NUM>-(<NUM>,<NUM> -dihydroxypropyl)-<NUM>-fluoro-<NUM>-(<NUM>-hydroxy-<NUM>-methylpropan-<NUM>-yl)-<NUM>-indol-<NUM>-yl)cyclopropane-<NUM>-carboxamide (tezacaftor), deuterated tezacaftor, VX-<NUM>, VX-<NUM>, VX-<NUM>, VX-<NUM>, GLPG2222, GLPG2851, GLPG2737, GLPG3221 and VX-<NUM>.

It is to be understood that the specific embodiments described herein can be taken in combination with other specific embodiments delineated herein.

The features and other details of the disclosure will now be more particularly described. Before further description of the present disclosure, certain terms employed in the specification, examples and appended claims are collected here. These definitions should be read in light of the remainder of the disclosure and as understood by a person of skill in the art. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by a person of ordinary skill in the art.

It will be appreciated that the description of the present disclosure herein should be construed in congruity with the laws and principals of chemical bonding.

The term "alkyl", as used herein, unless otherwise indicated, refers to both branched and straight-chain saturated aliphatic hydrocarbon groups having the specified number of carbon atoms; for example, "C<NUM>-C<NUM> alkyl" denotes alkyl having <NUM> to <NUM> carbon atoms, and straight or branched hydrocarbons of <NUM>-<NUM>, <NUM>-<NUM>, or <NUM>-<NUM> carbon atoms, referred to herein as C<NUM>-<NUM> alkyl, C<NUM>-<NUM> alkyl, and C<NUM>-<NUM> alkyl, respectively. Examples of alkyl include, but are not limited to, methyl, ethyl, n-propyl, i-propyl, n-butyl, i-butyl, sec-butyl, t-butyl, n-pentyl, n-hexyl, <NUM>-methylbutyl, <NUM>-methylpentyl, <NUM>-ethylbutyl, <NUM>-methylpentyl, and <NUM>-methylpentyl.

The term, "alkenyl", as used herein, refers to both straight and branched-chain moieties having the specified number of carbon atoms and having at least one carbon-carbon double bond. Exemplary alkenyl groups include, but are not limited to, a straight or branched group of <NUM>-<NUM> or <NUM>-<NUM> carbon atoms, referred to herein as C<NUM>-<NUM> alkenyl, and C<NUM>-<NUM> alkenyl, respectively. Exemplary alkenyl groups include, but are not limited to, vinyl, allyl, butenyl, pentenyl, etc..

The term, "alkynyl", as used herein, refers to both straight and branched-chain moieties having the specified number or carbon atoms and having at least one carbon-carbon triple bond.

The term "cycloalkyl," as used herein, refers to saturated alkyl cyclic structures, including monocyclic, bridged bicyclic, fused bicyclic, or spirocyclic structures having <NUM> or more carbon atoms, for example, <NUM>-<NUM>, <NUM>-<NUM>, or <NUM>-<NUM> carbons, referred to herein as C<NUM>-<NUM> cycloalkyl, C<NUM>-<NUM> cycloalkyl or C<NUM>-<NUM> cycloalkyl, whose rings mayrespectively for example, examples of cycloalkyl include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl and adamantyl.

The term "cycloalkenyl," as used herein, refers to cyclic alkenyl moieties having <NUM> or more carbon atoms.

The term "cycloalkynyl," as used herein, refers to cyclic alkynyl moieties having <NUM> or more carbon atoms.

"Alkylene" means a straight or branched, saturated aliphatic divalent radical having the number of carbons indicated. "Cycloalkylene" refers to a divalent radical of carbocyclic saturated hydrocarbon group having the number of carbons indicated.

The term "alkoxy" as used herein refers to a straight or branched alkyl group attached to oxygen (alkyl-O-). Exemplary alkoxy groups include, but are not limited to, alkoxy groups of <NUM>-<NUM> or <NUM>-<NUM> carbon atoms, referred to herein as C<NUM>-<NUM> alkoxy, and C<NUM>-<NUM> alkoxy, respectively. Exemplary alkoxy groups include, but are not limited to methoxy, ethoxy, isopropoxy, etc..

The term "heterocyclic" or "heterocycle" encompasses heterocycloalkyl, heterocycloalkenyl, heterobicycloalkyl, heterobicycloalkenyl, heteropolycycloalkyl, heteropolycycloalkenyl, and the like unless indicated otherwise. Heterocycloalkyl refers to cycloalkyl groups containing one or more heteroatoms (O, S, or N) within the ring. Heterocycloalkenyl as used herein refers to cycloalkenyl groups containing one or more heteroatoms (O, S or N) within the ring. Heterobicycloalkyl refers to bicycloalkyl groups containing one or more heteroatoms (O, S or N) within a ring. Heterobicycloalkenyl as used herein refers to bicycloalkenyl groups containing one or more heteroatoms (O, S or N) within a ring. A heterocycle can refer to, for example, a saturated or partially unsaturated <NUM>- to <NUM> or <NUM>-<NUM>-membered ring structure, including bridged or fused rings, and whose ring structures include one to three heteroatoms, such as nitrogen, oxygen, and sulfur. Where possible, heterocyclic rings may be linked to the adjacent radical through carbon or nitrogen. Examples of heterocyclic groups include, but are not limited to, pyrrolidine, piperidine, morpholine, thiomorpholine, piperazine, oxetane, azetidine, tetrahydrofuran or dihydrofuran etc..

Cycloalkyl, cycloalkenyl, heterocyclic, groups also include groups similar to those described above for each of these respective categories, but which are substituted with one or more oxo moieties.

The term "aryl", as used herein, refers to mono- or polycyclic aromatic carbocyclic ring systems. A polycyclic aryl is a polycyclic ring system that comprises at least one aromatic ring. Polycyclic aryls can comprise fused rings, covalently attached rings or a combination thereof. The term "aryl" embraces aromatic radicals, such as, phenyl, naphthyl, indenyl, tetrahydronaphthyl, and indanyl. An aryl group may be substituted or unsubstituted. In some embodiments, the aryl is a C<NUM>-C<NUM> aryl. Examples of optionally substituted aryl are phenyl, substituted phenyl, napthyl and substituted naphthyl.

The term "heteroaryl", as used herein, refers to aromatic carbocyclic groups containing one or more heteroatoms (O, S, or N) within a ring. A heteroaryl group, unless indicated otherwise, can be monocyclic or polycyclic. A heteroaryl group may additionally be substituted or unsubstituted. The heteroaryl groups of this disclosure can also include ring systems substituted with one or more oxo moieties. A polycyclic heteroaryl can comprise fused rings, covalently attached rings or a combination thereof. A polycyclic heteroaryl is a polycyclic ring system that comprises at least one aromatic ring containing one or more heteroatoms within a ring. Examples of heteroaryl groups include, but are not limited to, pyridinyl, pyridazinyl, imidazolyl, pyrimidinyl, pyrazolyl, triazolyl, pyrazinyl, quinolyl, isoquinolyl, tetrazolyl, furyl, thienyl, isoxazolyl, thiazolyl, oxazolyl, isothiazolyl, pyrrolyl, quinolinyl, isoquinolinyl, indolyl, benzimidazolyl, benzofuranyl, cinnolinyl, indazolyl, indolizinyl, phthalazinyl, triazinyl, isoindolyl, purinyl, oxadiazolyl, thiadiazolyl, furazanyl, benzofurazanyl, benzothiophenyl, benzotriazolyl, benzothiazolyl, benzoxazolyl, quinazolinyl, quinoxalinyl, naphthyridinyl, dihydroquinolyl, tetrahydroquinolyl, dihydroisoquinolyl, tetrahydroisoquinolyl, benzofuryl, furopyridinyl, pyrolopyrimidinyl, thiazolopyridinyl, oxazolopyridinyl and azaindolyl. The foregoing heteroaryl groups may be C-attached or heteroatom-attached (where such is possible). For instance, a group derived from pyrrole may be pyrrol-<NUM>-yl (N-attached), pyrrol-<NUM>-yl (C-attached), or pyrrol-<NUM>-yl (C-attached). In some embodiments, the heteroaryl is <NUM>- to <NUM>-membered heteroaryl. In yet other embodiments, the heteroaryl is a mono or bicyclic <NUM>- to <NUM>-membered heteroaryl.

The term "substituted" refers to substitution by independent replacement of one, two, or three or more of the hydrogen atoms with substituents including, but not limited to, and unless indicated otherwise, -C<NUM>-C<NUM> alkyl, -C<NUM>-C<NUM> alkenyl, -C<NUM>-C<NUM> alkynyl, -C<NUM>-C<NUM> cycloalkyl, -C<NUM>-C<NUM> cycloalkenyl, C<NUM>-C<NUM> cycloalkynyl, -heterocyclic, -F, -Cl, -Br, -I, -OH, - NO<NUM>, -N<NUM>, -CN, -NH<NUM>, oxo, thioxo, -NHRx, -NRxRx, dialkylamino, -diarylamino, - diheteroarylamino, -ORx, -C(O)Ry, -C(O)C(O)Ry, -OCO<NUM>Ry, -OC(O)Ry, OC(O)C(O)Ry, - NHC(O)Ry, -NHCO<NUM>Ry, -NHC(O)C(O)Ry, NHC(S)NH<NUM>, -NHC(S)NHRx, -NHC(NH)NH<NUM>, - NHC(NH)NHRx, -NHC(NH)Rx, -C(NH)NHRx, and (C=NRx)Rx; -NRxC(O)Rx, - NRxC(O)N(Rx)<NUM>, -NRxCO<NUM>Ry, -NRxC(O)C(O)Ry, -NRxC(S)NH<NUM>, -NRxC(S)NHRx, - NRxC(NH)NH<NUM>, -NRxC(NH)NHRx, -NRxC(NH)Rx, -C(NRx)NHRx -S(O)Ry, -NHSO<NUM>Rx, - CH<NUM>NH<NUM>, -CH<NUM>SO<NUM>CH<NUM>, -aryl, -arylalkyl, -heteroaryl, -heteroarylalkyl, -heterocycloalkyl, -C<NUM>-C<NUM> cycloalkyl, -polyalkoxyalkyl, -polyalkoxy, -methoxymethoxy, -methoxyethoxy, -SH, -S-Rx, or -methylthiomethyl, wherein Rx is selected from the group consisting of hydrogen, -C<NUM>-C<NUM> alkyl, -C<NUM>-C<NUM> alkenyl, -C<NUM>-C<NUM> alkynyl, -C<NUM>-C<NUM> cycloalkyl, -aryl, -heteroaryl and - heterocyclic and -Ry is selected from the group consisting of hydrogen, -C<NUM>-C<NUM> alkyl, -C<NUM>-C<NUM> alkenyl, -C<NUM>-C<NUM> alkynyl, -C<NUM>-C<NUM> cycloalkyl, -aryl, -heteroaryl, -heterocyclic, -NH<NUM>, -NH-C<NUM>-C<NUM> alkyl, -NH-C<NUM>-C<NUM> alkenyl, -NH-C<NUM>-C<NUM>-alkynyl, -NH-C<NUM>-C<NUM> cycloalkyl, -NH-aryl, -NH-heteroaryl and -NH-heterocyclic. It is understood that the aryls, heteroaryls, alkyls, and the like can be further substituted.

The terms "halo" or "halogen" as used herein refer to F, Cl, Br, or I.

The term "haloalkyl" as used herein refers to an alkyl group having <NUM> to (2n+<NUM>) substituent(s) independently selected from F, Cl, Br or I, where n is the maximum number of carbon atoms in the alkyl group. It will be understood that haloalkyl is a specific example of an optionally substituted alkyl.

The terms "hydroxy" and "hydroxyl" as used herein refers to the radical -OH.

As will be understood by the skilled artisan, "H" is the symbol for hydrogen, "N" is the symbol for nitrogen, "S" is the symbol for sulfur, "O" is the symbol for oxygen. "Me" is an abbreviation for methyl.

The compounds of the disclosure may contain one or more chiral centers and, therefore, exist as stereoisomers. The term "stereoisomers" when used herein consist of all enantiomers or diastereomers. These compounds may be designated by the symbols "(+)," "(-)," "R" or "S," depending on the configuration of substituents around the stereogenic carbon atom, but the skilled artisan will recognize that a structure may denote a chiral center implicitly. The present disclosure encompasses various stereoisomers of these compounds and mixtures thereof. Mixtures of enantiomers or diastereomers may be designated "(±)" in nomenclature, but the skilled artisan will recognize that a structure may denote a chiral center implicitly.

The compounds of the disclosure may contain one or more double bonds and, therefore, exist as geometric isomers resulting from the arrangement of substituents around a carbon-carbon double bond. The symbol <IMG> denotes a bond that may be a single, double or triple bond as described herein. Substituents around a carbon-carbon double bond are designated as being in the "Z" or "E" configuration wherein the terms "Z" and "E" are used in accordance with IUPAC standards. Unless otherwise specified, structures depicting double bonds encompass both the "E" and "Z" isomers. Substituents around a carbon-carbon double bond alternatively can be referred to as "cis" or "trans," where "cis" represents substituents on the same side of the double bond and "trans" represents substituents on opposite sides of the double bond.

Compounds of the disclosure may contain a carbocyclic or heterocyclic ring and therefore, exist as geometric isomers resulting from the arrangement of substituents around the ring. The arrangement of substituents around a carbocyclic or heterocyclic ring are designated as being in the "Z" or "E" configuration wherein the terms "Z" and "E" are used in accordance with IUPAC standards. Unless otherwise specified, structures depicting carbocyclic or heterocyclic rings encompass both "Z" and "E" isomers. Substituents around a carbocyclic or heterocyclic ring may also be referred to as "cis" or "trans", where the term "cis" represents substituents on the same side of the plane of the ring and the term "trans" represents substituents on opposite sides of the plane of the ring. Mixtures of compounds wherein the substituents are disposed on both the same and opposite sides of plane of the ring are designated "cis/trans.

Individual enantiomers and diasterisomers of compounds of the present disclosure can be prepared synthetically from commercially available starting materials that contain asymmetric or stereogenic centers, or by preparation of racemic mixtures followed by resolution methods well known to those of ordinary skill in the art. These methods of resolution are exemplified by (<NUM>) attachment of a mixture of enantiomers to a chiral auxiliary, separation of the resulting mixture of diastereomers by recrystallization or chromatography and liberation of the optically pure product from the auxiliary, (<NUM>) salt formation employing an optically active resolving agent, (<NUM>) direct separation of the mixture of optical enantiomers on chiral liquid chromatographic columns or (<NUM>) kinetic resolution using stereoselective chemical or enzymatic reagents. Racemic mixtures can also be resolved into their component enantiomers by well known methods, such as chiral-phase liquid chromatography or crystallizing the compound in a chiral solvent. Stereoselective syntheses, a chemical or enzymatic reaction in which a single reactant forms an unequal mixture of stereoisomers during the creation of a new stereocenter or during the transformation of a pre-existing one, are well known in the art. Stereoselective syntheses encompass both enantio- and diastereoselective transformations, and may involve the use of chiral auxiliaries. For examples, see <NPL>. Where a particular compound is described or depicted, it is intended to encompass that chemical structure as well as tautomers of that structure.

The term "enantiomerically pure" means a stereomerically pure composition of a compound. For example, a stereochemically pure composition is a composition that is free or substantially free of other stereoisomers of that compound. In another example, for a compound having one chiral center, an enantiomerically pure composition of the compound is free or substantially free of the other enantiomer. In yet another example, for a compound having two chiral centers, an enantiomerically pure composition is free or substantially free of the other diastereomers.

Where a particular stereochemistry is described or depicted it is intended to mean that a particular enantiomer is present in excess relative to the other enantiomer. A compound has an R-configuration at a specific position when it is present in excess compared to the compound having an S-configuration at that position. A compound has an S-configuration at a specific position when it is present in excess compared to the compound having an R-configuration at that position.

The compounds disclosed herein can exist in solvated as well as unsolvated forms with pharmaceutically acceptable solvents such as water, ethanol, and the like, and it is intended that the disclosure embrace both solvated and unsolvated forms. In one embodiment, the compound is amorphous. In one embodiment, the compound is a single polymorph. In another embodiment, the compound is a mixture of polymorphs. In another embodiment, the compound is in a crystalline form.

The disclosure also embraces isotopically labeled compounds of the disclosure which are identical to those recited herein, except that one or more atoms are replaced by an atom having an atomic mass or mass number different from the atomic mass or mass number usually found in nature. Examples of isotopes that can be incorporated into compounds of the disclosure include isotopes of hydrogen, carbon, nitrogen, oxygen, phosphorus, sulfur, fluorine and chlorine, such as <NUM>H, <NUM>H, <NUM>C, <NUM>C, <NUM>N, <NUM>O, <NUM>O, <NUM>P, <NUM>P, <NUM>S, <NUM>F, and <NUM>Cl, respectively. For example, a compound of the disclosure may have one or more H atom replaced with deuterium.

For example, a disclosed compound may have one or more H atoms replaced with deuterium. It will be recognized that some variation of natural isotopic abundance occurs in a synthesized compound depending upon the origin of chemical materials used in the synthesis. Thus, a preparation of a disclosed compound will inherently contain small amounts of deuterated isotopologues. The concentration of naturally abundant stable hydrogen and carbon isotopes, notwithstanding this variation, is small and immaterial as compared to the degree of stable isotopic substitution of compounds of this disclosure.

In the compounds of this disclosure any atom not specifically designated as a particular isotope is meant to represent any stable isotope of that atom. Unless otherwise stated, when a position is designated specifically as "H" or "hydrogen", the position is understood to have hydrogen at its natural abundance isotopic composition. Also unless otherwise stated, when a position is designated specifically as "D" or "deuterium", the position is understood to have deuterium at an abundance that is at least <NUM> times greater than the natural abundance of deuterium, which is <NUM>% (i.e., at least <NUM>% incorporation of deuterium).

The term "isotopic enrichment factor" as used herein means the ratio between the isotopic abundance and the natural abundance of a specified isotope.

In other embodiments, a disclosed compound has an isotopic enrichment factor for each designated deuterium atom of at least <NUM> (<NUM>% deuterium incorporation at each designated deuterium atom), at least <NUM> (<NUM>% deuterium incorporation), at least <NUM> (<NUM>% deuterium incorporation), at least <NUM> (<NUM>% deuterium), at least <NUM> (<NUM>% deuterium incorporation), at least <NUM> (<NUM>% deuterium incorporation), at least <NUM> (<NUM>% deuterium incorporation), at least <NUM> (<NUM>% deuterium incorporation), at least <NUM> (<NUM>% deuterium incorporation), or at least <NUM> (<NUM>% deuterium incorporation).

The term "isotopologue" refers to a species in which the chemical structure differs from a specific compound of this disclosure only in the isotopic composition thereof.

The term "compound," when referring to a compound of this disclosure, refers to a collection of molecules having an identical chemical structure, except that there may be isotopic variation among the constituent atoms of the molecules. Thus, it will be clear to those of skill in the art that a compound represented by a particular chemical structure containing indicated deuterium atoms, will also contain lesser amounts of isotopologues having hydrogen atoms at one or more of the designated deuterium positions in that structure. The relative amount of such isotopologues in a compound of this disclosure will depend upon a number of factors including the isotopic purity of deuterated reagents used to make the compound and the efficiency of incorporation of deuterium in the various synthesis steps used to prepare the compound. However, as set forth above the relative amount of such isotopologues in total will be less than <NUM>% of the compound. In other embodiments, the relative amount of such isotopologues in total will be less than <NUM>%, less than <NUM>%, less than <NUM>%, less than <NUM>%, less than <NUM>%, less than <NUM>%, less than <NUM>%, less than <NUM>%, less than <NUM>%, or less than <NUM>% of the compound.

Certain isotopically-labeled disclosed compounds (e.g., those labeled with <NUM>H and <NUM>C) are useful in compound and/or substrate tissue distribution assays. Tritiated (i.e., <NUM>H) and carbon-<NUM> (i.e., <NUM>C) isotopes are particularly suitable for their ease of preparation and detectability. Further, substitution with heavier isotopes such as deuterium (i.e., <NUM>H) may afford certain therapeutic advantages resulting from greater metabolic stability (e.g., increased in vivo half-life or reduced dosage requirements) and hence may be suitable in some circumstances. Isotopically labeled compounds of the disclosure can generally be prepared by following procedures analogous to those disclosed in the examples herein by substituting an isotopically labeled reagent for a non-isotopically labeled reagent.

The disclosure additionally encompasses embodiments wherein one or more of the nitrogen atoms in a disclosed compound are oxidized to N-oxide.

Representative and exemplary synthetic routes for the preparation of compounds described herein are shown in the schemes below and throughout the Examples section. As will be understood by the skilled artisan, diastereomers can be separated from the reaction mixture using column chromatography.

Compounds of the disclosure can also be prepared using methods described in the literature, including, but not limited to, <NPL>; <NPL>; <CIT>; <CIT>, and <CIT>.

As discussed above, the disclosure encompasses to a method of enhancing (e.g., increasing) CFTR activity in a subject (e.g., a subject suffering from any one or more of the conditions described herein) comprising administering a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein, in an effective amount. The disclosure also encompasses a method of treating a patient suffering from a condition associated with CFTR activity comprising administering to said patient an effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein. In certain embodiments, the disease is cystic fibrosis.

"Treating" or "treatment" includes preventing or delaying the onset of the symptoms, complications, or biochemical indicia of a disease, alleviating or ameliorating the symptoms or arresting or inhibiting further development of the disease, condition, or disorder. A "subject" is an animal to be treated or in need of treatment. A "patient" is a human subject in need of treatment.

An "effective amount" or "therapeutically effective amount" refers to that amount of an agent that is sufficient to achieve a desired and/or recited effect. In the context of a method of treatment, an "effective amount" or "therapeutically effective amount" of the therapeutic agent that is sufficient to ameliorate of one or more symptoms of a disorder and/or prevent advancement of a disorder, cause regression of the disorder and/or to achieve a desired effect.

The term "modulating" encompasses increasing, enhancing, inhibiting, decreasing, suppressing, and the like. The terms "increasing" and "enhancing" mean to cause a net gain by either direct or indirect means. As used herein, the terms "inhibiting" and "decreasing" encompass causing a net decrease by either direct or indirect means.

In some examples, CFTR activity is enhanced after administration of first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein, when there is an increase in the CFTR activity as compared to that in the absence of the administration of disclosed compounds. CFTR activity encompasses, for example, chloride channel activity of the CFTR, and/or other ion transport activity for example, HCO<NUM>- transport). In certain of these embodiments, the activity of one or more (e.g., one or two) mutant CFTRs (e.g., ΔF508, S549N, G542X, G551D, R117H, N1303K, W1282X, R553X, <NUM>+<NUM>>T, <NUM>-<NUM>>A, <NUM>+10kbC>T, <NUM>+<NUM>>A, <NUM>+<NUM>>A, I507del, R1162X, <NUM>+<NUM>>A, 3659delC, G85E, D1152H, R560T, R347P, 2184insA, A455E, R334W, Q493X, and 2184delA CFTR) is enhanced (e.g., increased). Contemplated patients may have a CFTR mutation(s) from one or more classes, such as without limitation, Class I CFTR mutations, Class II CFTR mutations, Class III CFTR mutations, Class IV CFTR mutations, Class V CFTR mutations, and Class VI mutations. Contemplated subject (e.g., human subject) CFTR genotypes include, without limitation, homozygote mutations (e.g., ΔF508 / ΔF508 and R117H / R117H) and compound heterozygote mutations (e.g., ΔF508 / G551D; ΔF508 / A455E; ΔF508 / G542X; Δ508F / W1204X; Δ508F / S549N; R553X / W1316X; W1282X/N1303K, 591Δ18 / E831X; F508del/R117H/ N1303K/ <NUM>+10kbC>T; Δ <NUM>/ <NUM> and DF508/G178R).

In certain embodiments, the mutation is a Class I mutation, e.g., a G542X; a Class III I mutation, e.g., a ΔF508 / G542X compound heterozygous mutation. In other embodiments, the mutation is a Class III mutation, e.g., a G551D; a Class III Class III mutation, e.g., a ΔF508 / G551D compound heterozygous mutation. In still other embodiments, the mutation is a Class V mutation, e.g., a A455E; Class III Class V mutation, e.g., a ΔF508 / A455E compound heterozygous mutation. Of the more than <NUM> known mutations of the CFTR gene, ΔF508 is the most prevalent mutation of CFTR which results in misfolding of the protein and impaired trafficking from the endoplasmic reticulum to the apical membrane (<NPL>). In certain embodiments, ΔF508 CFTR activity is enhanced (e.g., increased). In certain embodiments, ΔF508 CFTR activity and/or G542X CFTR activity and/or G551D CFTR activity and/or A455E CFTR activity is enhanced (e.g., increased). An enhancement of CFTR activity can be measured, for example, using literature described methods, including for example, Ussing chamber assays, patch clamp assays, and hBE Ieq assay (<NPL>; <NPL>; <NPL>).

As discussed above, the disclosure also encompasses a method of treating cystic fibrosis. The present disclosure can also be used to treat other conditions associated with CFTR activity, including conditions associated with deficient CFTR activity.

In some embodiments, the disclosure is directed to a method of treating a condition associated with deficient or decreased CFTR activity comprising administering an effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as disclosed herein. Non-limiting examples of conditions associated with deficient CFTR activity are cystic fibrosis, congenital bilateral absence of vas deferens (CBAVD), acute, recurrent, or chronic pancreatitis, disseminated bronchiectasis, asthma, allergic pulmonary aspergillosis, smoking-related lung diseases, such as chronic obstructive pulmonary disease (COPD), chronic sinusitis, dry eye disease, protein C deficiency, Aβ-lipoproteinemia, lysosomal storage disease, type <NUM> chylomicronemia, mild pulmonary disease, lipid processing deficiencies, type <NUM> hereditary angioedema, coagulation-fibrinolyis, hereditary hemochromatosis, CFTR-related metabolic syndrome, chronic bronchitis, constipation, pancreatic insufficiency, hereditary emphysema, and Sjogren's syndrome.

In some embodiments, disclosed methods of treatment further comprise administering an additional therapeutic agent. For example, in an embodiment, provided herein is a method of administering an effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, and an additional therapeutic agent. Additional therapeutic agents include, for example, mucolytic agents, bronchodilators, antibiotics, anti-infective agents, anti-inflammatory agents, ion channel modulating agents, therapeutic agents used in gene therapy, CFTR amplifiers, CFTR correctors, or other agents that modulates CFTR activity. In some embodiments, the additional therapeutic agent is a CFTR amplifier or a CFTR corrector. Non-limiting examples of CFTR correctors include (<NUM>-(<NUM>-(<NUM>-(<NUM>,<NUM>-difluorobenzo[d][<NUM>,<NUM>]dioxol-<NUM>-yl)cyclopropanecarboxamido)-<NUM>-methylpyridin-<NUM>-yl)benzoic acid (lumacaftor), deuterated lumacaftor, ((R)-<NUM>-(<NUM>,<NUM>-difluorobenzo[d][<NUM>,<NUM>]dioxol-<NUM>-yl)-N-(<NUM>-(<NUM>,<NUM>-dihydroxypropyl)-<NUM>-fluoro-<NUM>-(<NUM>-hydroxy-<NUM>-methylpropan-<NUM>-yl)-<NUM>-indol-<NUM>-yl)cyclopropane-<NUM>-carboxamide (tezacaftor), deuterated tezacaftor, VX-<NUM>, VX-<NUM>, VX-<NUM>, VX-<NUM>, GLPG2222, GLPG2851, GLPG2737, GLPG3221 and VX-<NUM>, and compounds described in, e.g., <CIT>. Non-limiting examples of modulators include QBW-<NUM>, QR-<NUM>, NB-<NUM>, riociquat, SPX-<NUM>, and compounds described in, e.g., <CIT>, <CIT>, <CIT>; <CIT>, <CIT>, <CIT>; <CIT>, <CIT>, <CIT>; <CIT>, <CIT>, <CIT>, <CIT>; and <CIT>, of which the disclosed modulators in those publications are contemplated as an additional therapeutic agent.

Non-limiting examples of anti-inflammatory agents include N6022 (<NUM>-(<NUM>-(<NUM>-(<NUM>-imidazol-<NUM>-yl) phenyl)-<NUM>-(<NUM>-carbamoyl-<NUM>-methylphenyl)-<NUM>H-pyrrol-<NUM>-yl) propanoic acid), CTX-<NUM>, N1861, N1785, and N91115. In certain of these embodiments, the CFTR modulator is an agent that enhances read-through of stop codons (e.g., NB124 or ataluren).

In certain embodiments, the subject's CFTR genotype includes, without limitation, one or more Class I CFTR mutations, one or more Class II CFTR mutations, one or more Class III CFTR mutations, one or more Class IV CFTR mutations, or one or more Class V CFTR mutations, or one or more Class VI CFTR mutations. In certain embodiments, the subject's CFTR genotype includes, without limitation, one or more homozygote mutations (e.g., ΔF508 / ΔF508 or R117H / R117H) and/or one or more compound heterozygote mutations (e.g., ΔF508 / G551D; ΔF508 / A455E; ΔF508 / G542X; Δ508F / W1204X; Δ508F / S549N; R553X / W1316X; W1282X/N1303K; F508del/R17H; N1303K/ <NUM>+10kbC>T; ΔF508/R334W; DF508/G178R; and 591Δ18 / E831X). In certain embodiments, the subject's CFTR genotype includes a Class I mutation, e.g., a G542X Class I mutation, e.g., a ΔF508 / G542X compound heterozygous mutation. In other embodiments, the subject's CFTR genotype includes a Class III mutation, e.g., a G551D Class III mutation, e.g., a ΔF508 / G551D compound heterozygous mutation. In still other embodiments, the subject's CFTR genotype includes a Class V mutation, e.g., a A455E Class V mutation, e.g., a ΔF508 / A455E compound heterozygous mutation. In certain embodiments, ΔF508 CFTR activity and/or G542X CFTR activity and/or GSS 1D CFTR activity and/or A455E activity is enhanced (e.g., increased). In certain embodiments, the enhancement in activity (e.g., increase in activity) provided by the combination of disclosed compounds is greater than additive when compared to the enhancement in activity provided by each therapeutic component individually.

For example, provided herein is a method of treating a patient having one or more of the following mutations in the CFTR gene: ΔF508, G542X, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, S549R, G970R, orR117H, and/or e.g., a patient with one or two copies of the F508del mutation, or one copy of the ΔF508 mutation and a second mutation that results in a gating effect in the CFTR protein (e.g., a patient that is heterozygous for ΔF508 and G542X or G551D mutation), a patient with one copy of the ΔF508 mutation and a second mutation that results in residual CFTR activity , or a patient with one copy of the ΔF508 mutation and a second mutation that results in residual CFTR activity, comprising administering an effective amount of a disclosed compound. As described herein, such exemplary methods (e.g., of a patient having one or mutations such as those described above) may include, for example, administering to such patient a combination therapy, e.g., administering (simultaneously or sequentially) an effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, to said patient. Such administration may result, for example, in increased chloride transport in human bronchial epithelial cells with e.g., one or two copies of mutations, e. g, ΔF508 mutation, as compared to administration of a disclosed compound alone.

The phrase "combination therapy," as used herein, refers to an embodiment where a patient is co-administered an effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, as described herein, an optionally one or more additional CFTR modulators as described anywhere herein, as part of a specific treatment regimen intended to provide the beneficial effect from the co-action of these therapeutic agents. For example, a beneficial effect of a combination may include, but is not limited to, pharmacokinetic or pharmacodynamic co-action resulting from the combination of therapeutic agents. For example, administration of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, may result in a level of function, e.g., as measured by chloride activity in HBE cells or patients that have a ΔF508 mutation, that achieves clinical improvement (or better) as compared to the chloride activity level in cells or patients with a ΔF508 mutation receiving a disclosed compound alone; or for example, administration of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, may result in a level of function (e.g., as measured by chloride activity in HBE cells or patients that have a G542X mutation, that achieves clinical improvement (or better) as compared to the chloride activity level at e.g., <NUM>% or more of wild type cells. Administration of disclosed therapeutic agents in combination typically is carried out over a defined time period (usually a day, days, weeks, months or years depending upon the combination selected). Combination therapy is intended to embrace administration of multiple therapeutic agents in a sequential manner, that is, wherein each therapeutic agent is administered at a different time, as well as administration of these therapeutic agents, or at least two of the therapeutic agents, in a substantially simultaneous manner. Substantially simultaneous administration can be accomplished, for example, by administering to the subject a single tablet or capsule having a fixed ratio of each therapeutic agent or in multiple, single capsules for each of the therapeutic agents. Sequential or substantially simultaneous administration of each therapeutic agent can be effected by any appropriate route including, but not limited to, oral routes, inhalational routes, intravenous routes, intramuscular routes, and direct absorption through mucous membrane tissues. The therapeutic agents can be administered by the same route or by different routes. For example, a first therapeutic agent of the combination selected may be administered by intravenous injection or inhalation or nebulizer while the other therapeutic agents of the combination may be administered orally. Alternatively, for example, all therapeutic agents may be administered orally or all therapeutic agents may be administered by intravenous injection, inhalation or nebulization.

Combination therapy also can embrace the administration of the therapeutic agents as described herein in further combination with other biologically active ingredients and non-drug therapies. Where the combination therapy further comprises a non-drug treatment, the non-drug treatment may be conducted at any suitable time so long as a beneficial effect from the co-action of the combination of the therapeutic agents and non-drug treatment is achieved. For example, in appropriate cases, the beneficial effect is still achieved when the non-drug treatment is temporally removed from the administration of the therapeutic agents, perhaps by a day, days or even weeks.

The components of a disclosed combination may be administered to a patient simultaneously or sequentially. It will be appreciated that the components may be present in the same pharmaceutically acceptable carrier and, therefore, are administered simultaneously. Alternatively, the active ingredients may be present in separate pharmaceutical carriers, such as, conventional oral dosage forms, that can be administered either simultaneously or sequentially.

The term "pharmaceutically acceptable salt(s)" as used herein refers to salts of acidic or basic groups that may be present in a disclosed compound used in disclosed compositions. Compounds included in the present compositions that are basic in nature are capable of forming a wide variety of salts with various inorganic and organic acids. The acids that may be used to prepare pharmaceutically acceptable acid addition salts of such basic compounds are those that form non-toxic acid addition salts, i.e., salts containing pharmacologically acceptable anions, including, but not limited to, malate, oxalate, chloride, bromide, iodide, nitrate, sulfate, bisulfate, phosphate, acid phosphate, isonicotinate, acetate, lactate, salicylate, citrate, tartrate, oleate, tannate, pantothenate, bitartrate, ascorbate, succinate, maleate, gentisinate, fumarate, gluconate, glucaronate, saccharate, formate, benzoate, glutamate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate and pamoate (i.e., <NUM>,<NUM>'-methylene-bis-(<NUM>-hydroxy-<NUM>-naphthoate)) salts. Compounds included in the present compositions that are acidic in nature are capable of forming base salts with various pharmacologically acceptable cations. Examples of such salts include alkali metal or alkaline earth metal salts, particularly calcium, magnesium, sodium, lithium, zinc, potassium, and iron salts. Compounds included in the present compositions that include a basic or acidic moiety may also form pharmaceutically acceptable salts with various amino acids. The compounds of the disclosure may contain both acidic and basic groups; for example, one amino and one carboxylic acid group. In such a case, the compound can exist as an acid addition salt, a zwitterion, or a base salt.

Also included in the present disclosure are methods that include administering prodrugs of the compounds described herein, for example, prodrugs of a compound of Formula Ia, Ib, Ic or Id, II, or III, or a pharmaceutical composition thereof or method of use of the prodrug.

The term "prodrug" refers to compounds that are transformed in vivo to yield a disclosed compound or a pharmaceutically acceptable salt, hydrate or solvate of the compound. The transformation may occur by various mechanisms (such as by esterase, amidase, phosphatase, oxidative and or reductive metabolism) in various locations (such as in the intestinal lumen or upon transit of the intestine, blood or liver). Prodrugs are well known in the art (for example, see<NPL>). For example, if a compound of the disclosure or a pharmaceutically acceptable salt, hydrate or solvate of the compound contains a carboxylic acid functional group, a prodrug can comprise an ester formed by the replacement of the hydrogen atom of the acid group with a group such as (C<NUM>-<NUM>) alkyl, (C<NUM>-<NUM>) alkylcarbonyloxymethyl, <NUM>-(alkylcarbonyloxy)ethyl having from <NUM> to <NUM> carbon atoms, <NUM>-methyl-<NUM>-(alkylcarbonyloxy)-ethyl having from <NUM> to <NUM> carbon atoms, alkoxycarbonyloxymethyl having from <NUM> to <NUM> carbon atoms, <NUM>-(alkoxycarbonyloxy)ethyl having from <NUM> to <NUM> carbon atoms, <NUM>-methyl-<NUM>-(alkoxycarbonyloxy)ethyl having from <NUM> to <NUM> carbon atoms, N-(alkoxycarbonyl)aminomethyl having from <NUM> to <NUM> carbon atoms, <NUM>-(N-(alkoxycarbonyl)amino)ethyl having from <NUM> to <NUM> carbon atoms, <NUM>-phthalidyl, <NUM>-crotonolactonyl, gamma-butyrolacton-<NUM>-yl, di-N,N-(C<NUM>-<NUM>)alkylamino(C<NUM>-<NUM>)alkyl (such as β-dimethylaminoethyl), carbamoyl-(C<NUM>-<NUM>)alkyl, N,N-di(C<NUM>-<NUM>)alkylcarbamoyl-(C<NUM>-<NUM>)alkyl and piperidino-, pyrrolidino- or morpholino(C<NUM>-<NUM>)alkyl.

Similarly, if a compound of the disclosure contains an alcohol functional group, a prodrug can be formed by the replacement of the hydrogen atom of the alcohol group with a group such as (C<NUM>-<NUM>)alkylcarbonyloxymethyl, <NUM>-((C<NUM>-<NUM>)alkylcarbonyloxy)ethyl, <NUM>-methyl-<NUM>-((C<NUM>-<NUM>)alkylcarbonyloxy)ethyl (C<NUM>-<NUM>)alkoxycarbonyloxymethyl, N-(C<NUM>-<NUM>)alkoxycarbonylaminomethyl, succinoyl, (C<NUM>-<NUM>)alkylcarbonyl, α-amino(C<NUM>-<NUM>)alkylcarbonyl, arylalkylcarbonyl and α-aminoalkylcarbonyl, or α-aminoalkylcarbonyl-α-aminoalkylcarbonyl, where each α-aminoalkylcarbonyl group is independently selected from the naturally occurring L-amino acids, P(O)(OH)<NUM>, -P(O)(O(C<NUM>-<NUM>)alkyl)<NUM> or glycosyl (the radical resulting from the removal of a hydroxyl group of the hemiacetal form of a carbohydrate).

If a compound of the disclosure incorporates an amine functional group, a prodrug can be formed, for example, by creation of an amide or carbamate, an N-alkylcarbonyloxyalkyl derivative, an (oxodioxolenyl)methyl derivative, an N-Mannich base, imine or enamine. In addition, a secondary amine can be metabolically cleaved to generate a bioactive primary amine, or a tertiary amine can metabolically cleaved to generate a bioactive primary or secondary amine. For examples, see <NPL> and references therein.

The disclosure additionally includes use of clathrates of the compounds described herein, pharmaceutical compositions comprising the clathrates, and methods of use of the clathrates. In some embodiments, the disclosure is directed to clathrates of a disclosed compound of e.g., Formula Ia, Ib, Ic or Id, II, or III, or a pharmaceutical composition thereof.

As discussed above, the disclosure includes administration of pharmaceutical compositions comprising a pharmaceutically acceptable carrier or excipient and a compound described herein. A disclosed compound, or a pharmaceutically acceptable salt, solvate, clathrate or prodrug thereof, can be administered in pharmaceutical compositions comprising a pharmaceutically acceptable carrier or excipient. The excipient can be chosen based on the expected route of administration of the composition in therapeutic applications. The route of administration of the composition depends on the condition to be treated. For example, intravenous injection may be suitable for treatment of a systemic disorder and oral administration may be suitable to treat a gastrointestinal disorder. The route of administration and the dosage of the composition to be administered can be determined by the skilled artisan without undue experimentation in conjunction with standard dose-response studies. Relevant circumstances to be considered in making those determinations include the condition or conditions to be treated, the choice of composition to be administered, the age, weight, and response of the individual patient, and the severity of the patient's symptoms. A pharmaceutical composition comprising a disclosed compound or a pharmaceutically acceptable salt, solvate, clathrate or prodrug, can be administered by a variety of routes including, but not limited to, parenteral, oral, pulmonary, ophthalmic, nasal, rectal, vaginal, aural, topical, buccal, transdermal, intravenous, intramuscular, subcutaneous, intradermal, intraocular, intracerebral, intralymphatic, intraarticular, intrathecal and intraperitoneal. The compositions can also include, depending on the formulation desired, pharmaceutically-acceptable, non-toxic carriers or diluents, which are defined as vehicles commonly used to formulate pharmaceutical compositions for animal or human administration. The diluent is selected so as not to affect the biological activity of the pharmacologic agent or composition. Examples of such diluents are distilled water, physiological phosphate-buffered saline, Ringer's solutions, dextrose solution, and Hank's solution. In addition, the pharmaceutical composition or formulation may also include other carriers, adjuvants, or nontoxic, nontherapeutic, nonimmunogenic stabilizers and the like. Pharmaceutical compositions can also include large, slowly metabolized macromolecules such as proteins, polysaccharides such as chitosan, polylactic acids, polyglycolic acids and copolymers (such as latex functionalized SEPHAROSE™, agarose, cellulose, and the like), polymeric amino acids, amino acid copolymers, and lipid aggregates (such as oil droplets or liposomes).

The compositions can be administered parenterally such as, for example, by intravenous, intramuscular, intrathecal or subcutaneous injection. Parenteral administration can be accomplished by incorporating a composition into a solution or suspension. Such solutions or suspensions may also include sterile diluents such as water for injection, saline solution, fixed oils, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents. Parenteral formulations may also include antibacterial agents such as, for example, benzyl alcohol or methyl parabens, antioxidants such as, for example, ascorbic acid or sodium bisulfite and chelating agents such as EDTA. Buffers such as acetates, citrates or phosphates and agents for the adjustment of tonicity such as sodium chloride or dextrose may also be added. The parenteral preparation can be enclosed in ampules, disposable syringes or multiple dose vials made of glass or plastic.

Additionally, auxiliary substances, such as wetting or emulsifying agents, surfactants, pH buffering substances and the like can be present in compositions. Other components of pharmaceutical compositions are those of petroleum, animal, vegetable, or synthetic origin, for example, peanut oil, soybean oil, and mineral oil. In general, glycols such as propylene glycol or polyethylene glycol are suitable liquid carriers, particularly for injectable solutions.

Injectable formulations can be prepared either as liquid solutions or suspensions; solid forms suitable for solution in, or suspension in, liquid vehicles prior to injection can also be prepared. The preparation also can also be emulsified or encapsulated in liposomes or micro particles such as polylactide, polyglycolide, or copolymer for enhanced adjuvant effect, as discussed above [<NPL> and <NPL>]. The compositions and pharmacologic agents described herein can be administered in the form of a depot injection or implant preparation which can be formulated in such a manner as to permit a sustained or pulsatile release of the active ingredient.

Additional formulations suitable for other modes of administration include oral, intranasal, and pulmonary formulations, suppositories, transdermal applications and ocular delivery. For suppositories, binders and carriers include, for example, polyalkylene glycols or triglycerides; such suppositories can be formed from mixtures containing the active ingredient in the range of about <NUM>% to about <NUM>%, or about <NUM>% to about <NUM>%. Oral formulations include excipients, such as pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharine, cellulose, and magnesium carbonate. Topical application can result in transdermal or intradermal delivery. Transdermal delivery can be achieved using a skin patch or using transferosomes. [<NPL>; <NPL>].

For the purpose of oral therapeutic administration, the pharmaceutical compositions can be incorporated with excipients and used in the form of tablets, troches, capsules, elixirs, suspensions, syrups, wafers, chewing gums and the like. Tablets, pills, capsules, troches and the like may also contain binders, excipients, disintegrating agent, lubricants, glidants, sweetening agents, and flavoring agents. Some examples of binders include microcrystalline cellulose, gum tragacanth or gelatin. Examples of excipients include starch or lactose. Some examples of disintegrating agents include alginic acid, corn starch and the like. Examples of lubricants include magnesium stearate or potassium stearate. An example of a glidant is colloidal silicon dioxide. Some examples of sweetening agents include sucrose, saccharin and the like. Examples of flavoring agents include peppermint, methyl salicylate, orange flavoring and the like. Materials used in preparing these various compositions should be pharmaceutically pure and non-toxic in the amounts used. In another embodiment, the composition is administered as a tablet or a capsule.

Various other materials may be present as coatings or to modify the physical form of the dosage unit. For instance, tablets may be coated with shellac, sugar or both. A syrup or elixir may contain, in addition to the active ingredient, sucrose as a sweetening agent, methyl and propylparabens as preservatives, a dye and a flavoring such as cherry or orange flavor, and the like. For vaginal administration, a pharmaceutical composition may be presented as pessaries, tampons, creams, gels, pastes, foams or spray.

The pharmaceutical composition can also be administered by nasal administration. As used herein, nasally administering or nasal administration includes administering the composition to the mucus membranes of the nasal passage or nasal cavity of the patient. As used herein, pharmaceutical compositions for nasal administration of a composition include therapeutically effective amounts of the compounds prepared by well-known methods to be administered, for example, as a nasal spray, nasal drop, suspension, gel, ointment, cream or powder. Administration of the composition may also take place using a nasal tampon or nasal sponge.

For topical administration, suitable formulations may include biocompatible oil, wax, gel, powder, polymer, or other liquid or solid carriers. Such formulations may be administered by applying directly to affected tissues, for example, a liquid formulation to treat infection of conjunctival tissue can be administered dropwise to the subject's eye, or a cream formulation can be administered to the skin.

Rectal administration includes administering the pharmaceutical compositions into the rectum or large intestine. This can be accomplished using suppositories or enemas. Suppository formulations can easily be made by methods known in the art. For example, suppository formulations can be prepared by heating glycerin to about <NUM>, dissolving the pharmaceutical composition in the glycerin, mixing the heated glycerin after which purified water may be added, and pouring the hot mixture into a suppository mold.

Transdermal administration includes percutaneous absorption of the composition through the skin. Transdermal formulations include patches, ointments, creams, gels, salves and the like.

In addition to the usual meaning of administering the formulations described herein to any part, tissue or organ whose primary function is gas exchange with the external environment, for purposes of the present disclosure, "pulmonary" will also mean to include a tissue or cavity that is contingent to the respiratory tract, in particular, the sinuses. For pulmonary administration, an aerosol formulation containing the active agent, a manual pump spray, nebulizer or pressurized metered-dose inhaler as well as dry powder formulations are contemplated. Suitable formulations of this type can also include other agents, such as antistatic agents, to maintain the disclosed compounds as effective aerosols.

A drug delivery device for delivering aerosols comprises a suitable aerosol canister with a metering valve containing a pharmaceutical aerosol formulation as described and an actuator housing adapted to hold the canister and allow for drug delivery. The canister in the drug delivery device has a head space representing greater than about <NUM>% of the total volume of the canister. Often, the compound intended for pulmonary administration is dissolved, suspended or emulsified in a mixture of a solvent, surfactant and propellant. The mixture is maintained under pressure in a canister that has been sealed with a metering valve.

The disclosure also encompasses the treatment of a condition associated with a dysfunction in proteostasis in a subject comprising administering to said subject an effective amount of a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, that enhances, improves or restores proteostasis of a protein. Proteostasis refers to protein homeostasis. Dysfunction in protein homeostasis is a result of protein misfolding, protein aggregation, defective protein trafficking or protein degradation. For example, the disclosure encompasses administering a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, that corrects protein misfolding, reduces protein aggregation, corrects or restores protein trafficking and/or affects protein degradation for the treatment of a condition associated with a dysfunction in proteostasis. In some aspects of the disclosure, a first compound of Formula Ia, Ib, Ic or Id, a second compound of Formula II, and a third compound of Formula III or IV, that corrects protein misfolding and/or corrects or restores protein trafficking is administered. In cystic fibrosis, the mutated or defective enzyme is the cystic fibrosis transmembrane conductance regulator (CFTR). One of the most common mutations of this protein is ΔF508 which is a deletion (Δ) of three nucleotides resulting in a loss of the amino acid phenylalanine (F) at the 508th (<NUM>) position on the protein. As described above, mutated cystic fibrosis transmembrane conductance regulator exists in a misfolded state and is characterized by altered trafficking as compared to the wild type CFTR. Additional exemplary proteins of which there can be a dysfunction in proteostasis, for example that can exist in a misfolded state, include, but are not limited to, glucocerebrosidase, hexosamine A, aspartylglucosaminidase, α-galactosidase A, cysteine transporter, acid ceramidase, acid α-L-fucosidase, protective protein, cathepsin A, acid β-glucosidase, acid β-galactosidase, iduronate <NUM>-sulfatase, α-L-iduronidase, galactocerebrosidase, acid α -mannosidase, acid β -mannosidase, arylsulfatase B, arylsulfatase A, N-acetylgalactosamine-<NUM>-sulfate sulfatase, acid β -galactosidase, N-acetylglucosamine-<NUM>-phosphotransferase, acid sphingmyelinase, NPC-<NUM>, acid α-glucosidase, β-hexosamine B, heparin N-sulfatase, α -N-acetylglucosaminidase, α -glucosaminide N-acetyltransferase, N-acetylglucosamine-<NUM>-sulfate sulfatase, α -N-acetylgalactosaminidase, α - neuramidase, β -glucuronidase, β-hexosamine A and acid lipase, polyglutamine, α - synuclein, TDP-<NUM>, superoxide dismutase (SOD), Aβ peptide, tau protein transthyretin and insulin. The disclosed compounds may be used to restore proteostasis (e.g., correct folding and/or alter trafficking) of the proteins described above.

Protein conformational diseases encompass gain of function disorders and loss of function disorders. In one embodiment, the protein conformational disease is a gain of function disorder. The terms "gain of function disorder," "gain of function disease," "gain of toxic function disorder" and "gain of toxic function disease" are used interchangeably herein. A gain of function disorder is a disease characterized by increased aggregation-associated proteotoxicity. In these diseases, aggregation exceeds clearance inside and/or outside of the cell. Gain of function diseases include, but are not limited to, neurodegenerative diseases associated with aggregation of polyglutamine, Lewy body diseases, amyotrophic lateral sclerosis, transthyretin-associated aggregation diseases, Alzheimer's disease, Machado-Joseph disease, cerebral B-amyloid angiopathy, retinal ganglion cell degeneration, tautopathies (progressive supranuclear palsy, corticobasal degeneration, frontotemporal lobar degeneration), cerebral hemorrhage with amyloidosis, Alexander disease, Serpinopathies, familial amyloidotic neuropathy, senile systemic amyloidosis, ApoAI amyloidosis, ApoAII amyloidosis, ApoAIV amyloidosis, familial amyloidosis of the Finnish type, lysozyme amyloidosis, fibrinogen amyloidosis, dialysis amyloidosis, inclusion body myositis/myopathy, cataracts, medullary thyroid carcinoma, cardiac atrial amyloidosis, pituitary prolactinoma, hereditary lattice corneal dystrophy, cutaneous lichen amyloidosis, corneal lactoferrin amyloidosis, corneal lactoferrin amyloidosis, pulmonary alveolar proteinosis, odontogenic tumor amyloid, seminal vesical amyloid, sickle cell disease, critical illness myopathy, von Hippel-Lindau disease, spinocerebellar ataxia <NUM>, Angelman syndrome, giant axon neuropathy, inclusion body myopathy with Paget disease of bone, frontotemporal dementia (IBMPFD) and prion diseases. Neurodegenerative diseases associated with aggregation of polyglutamine include, but are not limited to, Huntington's disease, dentatorubral and pallidoluysian atrophy, several forms of spino-cerebellar ataxia, and spinal and bulbar muscular atrophy. Alzheimer's disease is characterized by the formation of two types of aggregates: extracellular aggregates of Aβ peptide and intracellular aggregates of the microtubule associated protein tau. Transthyretin-associated aggregation diseases include, for example, senile systemic amyloidoses and familial amyloidotic neuropathy. Lewy body diseases are characterized by an aggregation of α-synuclein protein and include, for example, Parkinson's disease, Lewy body dementia (LBD) and multiple system atrophy (SMA). Prion diseases (also known as transmissible spongiform encephalopathies or TSEs) are characterized by aggregation of prion proteins. Exemplary human prion diseases are Creutzfeldt-Jakob Disease (CJD), Variant Creutzfeldt-Jakob Disease, Gerstmann-Straussler-Scheinker Syndrome, Fatal Familial Insomnia and Kuru. In another embodiment, the misfolded protein is alpha-<NUM> anti-trypsin.

In a further embodiment, the protein conformation disease is a loss of function disorder. The terms "loss of function disease" and "loss of function disorder" are used interchangeably herein. Loss of function diseases are a group of diseases characterized by inefficient folding of a protein resulting in excessive degradation of the protein. Loss of function diseases include, for example, lysosomal storage diseases. Lysosomal storage diseases are a group of diseases characterized by a specific lysosomal enzyme deficiency which may occur in a variety of tissues, resulting in the build-up of molecules normally degraded by the deficient enzyme. The lysosomal enzyme deficiency can be in a lysosomal hydrolase or a protein involved in the lysosomal trafficking. Lysosomal storage diseases include, but are not limited to, aspartylglucosaminuria, Fabry's disease, Batten disease, Cystinosis, Farber, Fucosidosis, Galactasidosialidosis, Gaucher's disease (including Types <NUM>, <NUM> and <NUM>), Gm1 gangliosidosis, Hunter's disease, Hurler-Scheie's disease, Krabbe's disease, α-Mannosidosis, β-Mannosidosis, Maroteaux-Lamy's disease, Metachromatic Leukodystrophy, Morquio A syndrome, Morquio B syndrome, Mucolipidosis II, Mucolipidosis III, Neimann-Pick Disease (including Types A, B and C), Pompe's disease, Sandhoff disease, Sanfilippo syndrome (including Types A, B, C and D), Schindler disease, Schindler-Kanzaki disease, Sialidosis, Sly syndrome, Tay-Sach's disease and Wolman disease.

In another embodiment, the disease associated with a dysfunction in proteostasis is a cardiovascular disease. Cardiovascular diseases include, but are not limited to, coronary artery disease, myocardial infarction, stroke, restenosis and arteriosclerosis. Conditions associated with a dysfunction of proteostasis also include ischemic conditions, such as, ischemia/reperfusion injury, myocardial ischemia, stable angina, unstable angina, stroke, ischemic heart disease and cerebral ischemia.

In yet another embodiment, the disease associated with a dysfunction in proteostasis is diabetes and/or complications of diabetes, including, but not limited to, diabetic retinopathy, cardiomyopathy, neuropathy, nephropathy, and impaired wound healing.

In a further embodiment, the disease associated with a dysfunction in proteostasis is an ocular disease including, but not limited to, age-related macular degeneration (AMD), diabetic macular edema (DME), diabetic retinopathy, glaucoma, cataracts, retinitis pigmentosa (RP) and dry macular degeneration.

In yet additional embodiments, the method of the disclosure is directed to treating a disease associated with a dysfunction in proteostasis, wherein the disease affects the respiratory system or the pancreas. In certain additional embodiments, the methods of the disclosure encompass treating a condition selected from the group consisting of polyendocrinopathy/hyperinsulinemia, diabetes mellitus, Charcot-Marie Tooth syndrome, Pelizaeus-Merzbacher disease, and Gorham's Syndrome.

Additional conditions associated with a dysfunction of proteostasis include hemoglobinopathies, inflammatory diseases, intermediate filament diseases, drug-induced lung damage and hearing loss. The disclosure also encompasses methods for the treatment of hemoglobinopathies (such as sickle cell anemia), an inflammatory disease (such as inflammatory bowel disease, colitis, ankylosing spondylitis), intermediate filament diseases (such as non-alcoholic and alcoholic fatty liver disease) and drug induced lung damage (such as methotrexate-induced lung damage). The disclosure additionally encompasses methods for treating hearing loss, such as noise-induced hearing loss, aminoglycoside-induced hearing loss, and cisplatin-induced hearing loss.

Additional conditions include those associated with a defect in protein trafficking and that can be treated according to methods of the disclosure include: PGP mutations, hERG trafficking mutations, nephrongenic diabetes insipidus mutations in the arginine-vasopressin receptor <NUM>, persistent hyperinsulinemic hypoglycemia of infancy (PHH1) mutations in the sulfonylurea receptor <NUM>, and α1AT.

The disclosure is illustrated by the following examples which are not meant to be limiting in any way.

The compounds described herein can be prepared in a number of ways based on the teachings contained herein and synthetic procedures known in the art. In the description of the synthetic methods described below, it is to be understood that all proposed reaction conditions, including choice of solvent, reaction atmosphere, reaction temperature, duration of the experiment and workup procedures, can be chosen to be the conditions standard for that reaction, unless otherwise indicated. It is understood by one skilled in the art of organic synthesis that the functionality present on various portions of the molecule should be compatible with the reagents and reactions proposed. Substituents not compatible with the reaction conditions will be apparent to one skilled in the art, and alternate methods are therefore indicated. The starting materials for the examples are either commercially available or are readily prepared by standard methods from known materials. At least some of the compounds identified as "intermediates" herein are contemplated as compounds of the disclosure.

Step 1a: methyl (<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]propanoate: into a <NUM>-mL round-bottom flask was placed a solution of methyl (<NUM>R)-<NUM>-hydroxypropanoate (<NUM>, <NUM> mmol, <NUM> eq. ) and imidazole (<NUM>, <NUM> mmol, <NUM> eq. ) in dichloromethane (<NUM>), followed by the dropwise addition of a solution of tert-butyl(chloro)dimethylsilane (<NUM>, <NUM> mmol, <NUM> eq. ) in dichloromethane (<NUM>) at <NUM>. The resulting solution was stirred for <NUM> at room temperature. The reaction was quenched by the addition of <NUM> of water/ice. The resulting solution was extracted with dichloromethane (<NUM> x <NUM>) and the organic layers combined. The resulting mixture was washed with brine (<NUM> x <NUM>), dried over anhydrous sodium sulfate and concentrated under vacuum to afford <NUM> (<NUM>%) of methyl (<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]propanoate as a colorless oil.

Step 1b: (<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]propanehydrazide: into a <NUM>-mL round-bottom flask was placed a solution of methyl (<NUM>R)-<NUM>-[(tertbutyldimethylsilyl)oxy]propanoate (<NUM>, <NUM> mmol, <NUM> eq. ) in ethanol (<NUM>). To the solution was added hydrazine (<NUM>, <NUM> mmol, <NUM> eq. The resulting solution was stirred for <NUM> at <NUM> in an oil bath. The resulting solution was quenched by the addition of water/ice. The resulting solution was extracted with ethyl acetate (<NUM> x <NUM>) and the organic layers combined. The resulting mixture was washed with brine (<NUM> x <NUM>), dried over anhydrous sodium sulfate and concentrated under vacuum to afford <NUM> (<NUM>%) of (<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]propanehydrazide as a colorless oil. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>.

Step <NUM>: methyl (trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutane-<NUM>-carboxylate: into a <NUM>-mL round-bottom flask, under nitrogen was placed a solution of methyl <NUM>-cis-hydroxycyclobutane-<NUM>-carboxylate (<NUM>, <NUM> mmol, <NUM> eq. ), <NUM>,<NUM>-dihydro-<NUM>-isoindole-<NUM>,<NUM>-dione (<NUM>, <NUM> mmol, <NUM> eq. ) and triphenylphosphine (<NUM>, <NUM> mmol, <NUM> eq. ) in THF (<NUM>), followed by addition of DIAL) (<NUM>, <NUM> mmol, <NUM> eq. ) dropwise with stirring at <NUM>. The resulting solution was stirred for <NUM> hours at room temperature. The resulting mixture was concentrated under vacuum. The residue was applied onto a silica gel column with ethyl acetate/petroleum ether (<NUM>:<NUM>). The crude product was re-crystallized from petroleum ether/ethyl acetate in the ratio of <NUM>:<NUM> to afford <NUM> (<NUM>%) of methyl trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutane-<NUM>-carboxylate as a white solid. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>. <NUM>H-NMR (<NUM>, CDCl<NUM>): δ <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM> (s, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>).

Step <NUM>: trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutane-<NUM>-carboxylic acid: into a <NUM>-mL round-bottom flask, was placed a solution of methyl trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutane-<NUM>-carboxylate (<NUM>, <NUM> mmol, <NUM> eq. ) in <NUM>,<NUM>-dioxane (<NUM>). To the solution was added <NUM> hydrogen chloride aqueous (<NUM>). The resulting solution was stirred for <NUM> hours at <NUM> in an oil bath. The resulting mixture was concentrated under vacuum to afford <NUM> (<NUM>%) of trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutane-<NUM>-carboxylic acid as a white solid. LC-MS (ES, m/z): [M-<NUM>]- = <NUM>.

Step <NUM>: (<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]-N-[trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutyl]carbonyl]propanehydrazide: into a <NUM>-mL round-bottom flask, was placed a solution of trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutane-<NUM>-carboxylic acid (<NUM>, <NUM> mmol, <NUM> eq. ), (<NUM>R)-<NUM>-[(tertbutyldimethylsilyl)oxy]propanehydrazide (<NUM>, <NUM> mmol, <NUM> eq. ) and HATU (<NUM>, <NUM> mmol, <NUM> eq. ) in THF (<NUM>), followed by the addition of DIEA (<NUM>, <NUM> mmol, <NUM> eq. ) dropwise with stirring at <NUM>. The resulting solution was stirred for <NUM> hour at room temperature. The reaction was then quenched by the addition of <NUM> of water/ice. The resulting solution was extracted with ethyl acetate (<NUM> x <NUM>) and the organic layers combined. The resulting mixture was washed with brine (<NUM> x <NUM>), dried over anhydrous sodium sulfate and concentrated under vacuum. The residue was applied onto a silica gel column with ethyl acetate/petroleum ether (<NUM>:<NUM>) to afford <NUM> (<NUM>%) of (2R)-<NUM>-[(tert-butyldimethylsilyl)oxy]-N-[ trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutyl]carbonyl]propanehydrazide as colorless oil. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>.

Step <NUM>: <NUM>-[trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl]-<NUM>,<NUM>-dihydro-<NUM>-isoindole-<NUM>,<NUM>-dione: into a <NUM>-mL round-bottom flask was placed a solution of (2R)-<NUM>-[(tert-butyldimethylsilyl)oxy]-N-[[ trans-<NUM>-(<NUM>,<NUM>-dioxo-<NUM>,<NUM>-dihydro-<NUM>-isoindol-<NUM>-yl)cyclobutyl]carbonyl]propanehydrazide (<NUM>, <NUM> mmol, <NUM> eq. ) and TEA (<NUM>, <NUM> mmol, <NUM> eq. ) in dichloromethane (<NUM>), followed by addition of a solution of <NUM>-methylbenzene-<NUM>-sulfonyl chloride (<NUM>, <NUM> mmol, <NUM> eq. ) in dichloromethane (<NUM>) dropwise with stirring at <NUM>. The resulting solution was stirred for <NUM> hours at room temperature. The reaction was then quenched by the addition of <NUM> of water/ice. The resulting solution was extracted with dichloromethane (<NUM> x <NUM>) and the organic layers combined. The resulting mixture was washed with brine (<NUM> x <NUM>), dried over anhydrous sodium sulfate and concentrated under vacuum. The crude product was purified by Flash-Prep-HPLC with the following conditions (IntelFlash-<NUM>): Column, C18; mobile phase, H<NUM>O/CH<NUM>CN = <NUM>: <NUM> increasing to H<NUM>O/CH<NUM>CN = <NUM>:<NUM> within <NUM>; Detector, UV <NUM> to afford <NUM> (<NUM>%) of <NUM>-[ trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl]-<NUM>,<NUM>-dihydro-<NUM>H-isoindole-<NUM>,<NUM>-dione as colorless oil. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>. <NUM>H-NMR (<NUM>, CDCl<NUM>): δ <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (d, J = <NUM>, <NUM>), <NUM> (s, <NUM>), <NUM> (s, <NUM>), <NUM> (s, <NUM>).

Step <NUM>: trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutan-<NUM>-amine: into a <NUM>-mL round-bottom flask, was placed a solution of <NUM>-[ trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl]-<NUM>,<NUM>-dihydro-<NUM>-isoindole-<NUM>,<NUM>-dione (<NUM>, <NUM> mmol, <NUM> eq. ) in ethanol (<NUM>). To the solution was added hydrazine hydrate (<NUM>, <NUM> mmol, <NUM> eq. The resulting solution was stirred for <NUM> hours at room temperature. The solids were filtered. The resulting mixture was concentrated under vacuum to afford <NUM> (crude) of trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutan-<NUM>-amine as colorless oil. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>.

Step <NUM>: N-(trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl)-<NUM>-phenylisoxazole-<NUM>-carboxamide: into a <NUM>-mL round-bottom flask, was placed a solution of lithio <NUM>-phenylisoxazole-<NUM>-carboxylate (<NUM>, <NUM> mmol, <NUM> eq. ), <NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutan-<NUM>-amine (<NUM>, <NUM> mmol, <NUM> eq. ) and HATU (<NUM>, <NUM> mmol, <NUM> eq. ) in THF (<NUM>). This was followed by the addition of DIEA (<NUM>, <NUM> mmol, <NUM> eq. ) dropwise with stirring at <NUM>. The resulting solution was stirred for <NUM> hour at room temperature. The resulting solution was diluted with <NUM> of water/ice. The resulting solution was extracted with ethyl acetate (<NUM> x <NUM>) and the organic layers combined. The resulting mixture was washed with brine (<NUM> x <NUM>), dried over anhydrous sodium sulfate and concentrated under vacuum to afford <NUM> (<NUM>%) of N-(trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-[(tertbutyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl)-<NUM>-phenylisoxazole-<NUM>-carboxamide as an off-white crude solid. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>.

Step <NUM>: N-(trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-hydroxyethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl)-<NUM>-phenylisoxazole-<NUM>-carboxamide: into a <NUM>-mL round-bottom flask, was placed a solution of N-(<NUM>-[trans-S-[(<NUM>R)-<NUM>-[(tert-butyldimethylsilyl)oxy]ethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl)-<NUM>-phenylisoxazole-<NUM>-carboxamide (<NUM>, <NUM> mmol, <NUM> eq. ) and TBAF (1mol/L in tetrahydrofuran, <NUM>) in THF (<NUM>). The resulting solution was stirred for <NUM> hours at room temperature and diluted with <NUM> of water. The resulting solution was extracted with ethyl acetate (<NUM> x <NUM>) and the organic layers combined. The resulting mixture was washed with brine (<NUM> x <NUM>), dried over anhydrous sodium sulfate and concentrated under vacuum. The residue was applied onto a silica gel column with dichloromethane/methanol (<NUM>:<NUM>). The crude product was purified by Flash-Prep-HPLC with the following conditions (IntelFlash-<NUM>): Column, C18; mobile phase, H<NUM>O/CH<NUM>CN = <NUM>:<NUM> increasing to H<NUM>O/CH<NUM>CN = <NUM>:<NUM> within <NUM>; Detector, UV <NUM> to afford <NUM> (<NUM>%) of N-(trans-<NUM>-[<NUM>-[(<NUM>R)-<NUM>-hydroxyethyl]-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl]cyclobutyl)-<NUM>-phenylisoxazole-<NUM>-carboxamide (Compound A) as a white solid. LC-MS (ES, m/z): [M+<NUM>]+ = <NUM>; <NUM>H NMR (<NUM>, DMSO-d<NUM>): δ <NUM>-<NUM> (d, J = <NUM>, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM> (s, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (d, J = <NUM>, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (m, <NUM>), <NUM>-<NUM> (d, J = <NUM>, <NUM>).

General procedures for the preparation of diclosed compounds are outlined in Scheme I and Scheme II. The disclosed compounds may be prepared, for example, either by base-mediated condensation of an aromatic aldehyde with a suitably functionalized isatin derivative (Scheme I), or three-component coupling between an aromatic aldehyde, a functionalized aniline, and an alpha-keto acid as shown in Scheme II. Further functional group conversion provides a sulfonamide. <CHM>
<CHM>.

For example, R<NUM>, R<NUM>, R<NUM>, R<NUM>, R<NUM>, R<NUM>, R<NUM>, and Het may be groups readily contemplated by a person of skill in the art. For example, R<NUM> may be, e. g, C<NUM>-<NUM>alkyl, C<NUM>-<NUM>cycloalkyl, phenyl, heteroaryl (e.g., pyridinyl, pyrrazolyl or thiazolyl) or heterocyclyl (e.g., morpholinyl or thiazolyl). For example, R<NUM> may be, e. g, hydrogen or C<NUM>-<NUM>alkyl. For example, R<NUM> may be C<NUM>-<NUM>alkoxy, wherein C<NUM>-<NUM>alkoxy may optionally be substituted by phenyl or a <NUM>-<NUM> membered monocyclic heteroaryl (e.g., tetrahydropyranyl, optionally substituted by one, two, three, or four substituents each independently selected from hydroxyl, C<NUM>-<NUM>alkyl, C<NUM>-<NUM>alkoxy, and oxo). For example, R<NUM>, R<NUM>, R<NUM>, and R<NUM> may be independently selected from hydrogen or C<NUM>-<NUM>alkyl. For example, Het may be, e.g., benzofuranyl or benothiofuranyl.

Ussing measurements were used to measure CFTR activity. In this method, primary lung epithelial cells (hBEs) with a cystic fibrosis causing mutation were differentiated for a minimum of <NUM> weeks in an air-liquid interface on SnapWell™ filter plates prior to the Ussing measurements. Cells were apically mucus-washed for <NUM> minutes prior to treatment with compounds. The basolateral media was removed and replaced with media containing the compounds of interest diluted to its final concentration from DMSO or aqueous stocks. The cells were treated with the potentiator, continuously with the corrector and the amplifier, for <NUM> hours prior to assessment of CFTR activity in the Ussing chamber assay. The treated cells were incubated at <NUM> and <NUM>% CO<NUM> for <NUM> hours. At the end of the treatment period, the cells on filters were transferred to the Ussing chamber and equilibrated for <NUM> minutes. The short-circuit current was measured in voltage clamp-mode (Vhold = <NUM> mV), and the entire assay was conducted at a temperature of <NUM> -<NUM>. Once the voltages stabilized, the chambers were clamped, and data were recorded by pulse readings every <NUM> seconds. Following baseline current stabilization, the following additions were applied and the changes in current and resistance of the cells were monitored:.

The forskolin-sensitive current and inhibitable current (that potentiated current that was blocked by CFTRinh-<NUM>) were measured as the specific activity of the ΔF508-CFTR channel, and increase in response to compounds in this activity over that observed in vehicle-treated samples were identified as the correction of ΔF508-CFTR function imparted by the compounds tested. The results are shown below in Table <NUM>.

In a separate study, chronic double combination treatment of CFTR homozygous F508del HBE cells with Compound <NUM> and Compound <NUM> gave an average maximum measured effect ("MME") of <NUM>µA/cm<NUM> (CFTRinh172-inhibitable current). These results corresponded to an average of <NUM>% of non-CF HBE activity (designated as <NUM>µA/cm<NUM>). The results of three experiments and their combined average is shown below in Table <NUM>.

A study was conducted to determine the in vitro CFTR modulating effects of doublet and triplet combinations of disclosed CFTR modulators in CFTR homozygous F508del patient cells. The results are shown in <FIG>. TEZA = tezacaftor (((R)-<NUM>-(<NUM>,<NUM>-difluorobenzo[d][<NUM>,<NUM>]dioxol-<NUM>-yl)-N (<NUM>-(<NUM>,<NUM>-dihydroxypropyl)-<NUM>-fluoro-<NUM>-(<NUM>-hydroxy-<NUM>-methylpropan-<NUM>-yl)-<NUM>-indol-<NUM>-yl)cyclopropane-<NUM>-carboxamide), <NUM>); IVA = ivacaftor (N-(<NUM>,<NUM>-Di-tert-butyl-<NUM>-hydroxyphenyl)-<NUM>-oxo-<NUM>,<NUM>-dihydroquinoline-<NUM>-carboxamide; <NUM>); LUMA = lumacaftor ((<NUM>-(<NUM>-(<NUM>-(<NUM>,<NUM>-difluorobenzo[d][<NUM>,<NUM>]dioxol-<NUM>-yl)cyclopropane carboxamido)-<NUM>-methylpyridin-<NUM>-yl)benzoic acid, <NUM>); Cmp <NUM> = Compound <NUM> (N-trans-<NUM>-(<NUM>-((R)-<NUM>-hydroxyethyl)-<NUM>,<NUM>,<NUM>-oxadiazol-<NUM>-yl)cyclobutyl)-<NUM>-phenylisoxazole-<NUM>-carboxamide, <NUM>); Cmp <NUM> = Compound <NUM> (sodium <NUM>-((<NUM>R)-<NUM>-(tetrahydro-<NUM>-pyran-<NUM>-yl)ethoxy)-<NUM>-methyl-<NUM>-(<NUM>-methyl-<NUM>-benzofuran-<NUM>-yl)quinoline-<NUM>-carboxylate, <NUM>); Cmp <NUM> = Compound <NUM> (N-(<NUM>-hydroxy-<NUM>,<NUM>-bis(trimethylsilyl)phenyl)-<NUM>-oxo-<NUM>,<NUM>-dihydroquinoline-<NUM>-carboxamide, <NUM>).

Claim 1:
A compound represented by
<CHM>
or a pharmaceutically acceptable salt thereof,
for use in a method of treating a disease associated with decreased cystic fibrosis transmembrane conductance regulator (CFTR) activity in a patient in need thereof, the method comprising administering said compound in combination with compounds:
<CHM>
or a pharmaceutically acceptable salt thereof, and
<CHM>
wherein the disease is selected from the group consisting of cystic fibrosis, congenital bilateral absence of vas deferens (CBAVD), acute, recurrent, or chronic pancreatitis, disseminated bronchiectasis, asthma, allergic pulmonary aspergillosis, chronic obstructive pulmonary disease (COPD), chronic sinusitis, dry eye disease, protein C deficiency, A-β-lipoproteinemia, lysosomal storage disease, type <NUM> chylomicronemia, mild pulmonary disease, lipid processing deficiencies, type <NUM> hereditary angioedema, coagulation-fibrinolyis, hereditary hemochromatosis, CFTR-related metabolic syndrome, chronic bronchitis, constipation, pancreatic insufficiency, hereditary emphysema, Sjogren's syndrome, familial hypercholesterolemia, I-cell disease/pseudo-Hurler, mucopolysaccharidoses, Sandhof/Tay-Sachs, Crigler-Najjar type II, polyendocrinopathy/hyperinsulemia, Diabetes mellitus, Laron dwarfism, myleoperoxidase deficiency, primary hypoparathyroidism, melanoma, glycanosis CDGtype <NUM>, congenital hyperthyroidism, osteogenesis imperfecta, hereditary hypofibrinogenemia, ACT deficiency, Diabetes insipidus (DI), neurophyseal DI, nephrogenic DI, Charcot-Marie Tooth syndrome, Perlizaeus-Merzbacher disease, Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, progressive supranuclear palsy, Pick's disease, Huntington's disease, spinocerebellar ataxia type I, spinal and bulbar muscular atrophy, dentatorubral pallidoluysian, myotonic dystrophy, hereditary Creutzfeldt-Jakob disease (due to prion protein processing defect), Fabry disease, cholestatic liver disease (primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC)), and Straussler-Scheinker syndrome.