RU2785889C1 - Method for treatment of disorders associated with melanocortin 4 receptor path - Google Patents

Abstract

FIELD: medicine; therapy.

SUBSTANCE: invention relates to medicine, namely to therapy; it can be used for the treatment of a disorder characterized by hypermethylation of POMC gene in a subject. An agonist of a melanocortin 4 receptor (hereinafter – MC4R), having the formula Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH₂ (SEQ ID NO: 140), is administered as a drug at a daily dose from 0.1 mg to 10 mg.

EFFECT: method provides effective treatment of a patient with POMC deficiency, suffering from severe obesity and hyperphagia, due to administration of MC4R receptor agonist.

50 cl, 3 dwg, 6 tbl, 6 ex

Description

BACKGROUND OF THE INVENTION

The melanocortin 4 receptor (MC4R) is a heterotrimeric G-protein coupled receptor that signals by activating adenylate cyclase. MC4R, expressed in the nuclei of the hypothalamus and other nervous and non-nervous tissues, which controls eating behavior and energy homeostasis, integrates the agonistic (anorexigenic) signal of α-melanocyte-stimulating hormone (α-MSH, α-MSH) and the antagonistic orexigenic) signal of the agouti-related peptide (AGPR).

MC4R is part of the leptin-melanocortin pathway, or POMC-MC4R pathway, which includes a number of proteins such as leptin, leptin receptors, pro-opiomelanocortin (POMC), prohormone convertases including PCSK1 and α-MSH, among others. Binding of AGPR to MC4R suppresses MC4R activity, and binding of α-MSH stimulates MC4R. Suppression of receptor activity leads to the generation of an orexigenic signal, while stimulation of receptor activity leads to the generation of an anorexigenic signal. Signals from the MC4R modulate eating behavior through secondary effector neurons.

In humans, the POMC-MC4R hypothalamic pathway is part of a network that regulates appetite and body weight. There is evidence that monogenic defects in this pathway lead to severe early onset obesity. For example, patients with loss-of-function POMC mutations suffer from early-onset severe obesity, hyperphagia, and adrenocorticotropic hormone (ACTH) deficiency. They also have low pigmentation of the skin and body hair. Prader-Willi Syndrome (PWS) is thought to be caused by loss of function of several genes on human chromosome 15, particularly in the 15q11-q13 region, which affects one or more genes in the POMC-MC4R pathway. PWS patients suffer from severe hyperphagia, which leads to severe obesity and other complications. There are currently no approved treatments for obesity and hyperphagia associated with disorders associated with genetic defects in the POMC-MC4R pathway, such as PWS and obesity associated with the null POMC genotype. Deficiency of MSH, a POMC cleavage product, and MC4R ligand, is responsible for the earlier onset of obesity and hyperphagia in these disorders associated with defects in the POMC-MC4R pathway. There is a need for a therapy, such as MHC replacement therapy, that provides an effective treatment for obesity and hyperphagia associated with disorders associated with genetic defects in the POMC-MC4R pathway while causing fewer safety concerns.

BRIEF DESCRIPTION OF THE INVENTION

In one aspect, provided herein is a method for treating Prader-Willi Syndrome (PWS) in a subject in need thereof, comprising:

administration of a melanocortin 4 receptor agonist (MC4R) at a daily dosage of approximately 0.1 mg (eg 0.1 mg +/- 5%) to approximately 10 mg (eg 10 mg +/- 5%),

wherein said agonist is an MC4R agonist as described herein, e.g. said agonist is

(R ² R ³ ) -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -A ¹⁰ -R ¹ (I),

where:

A ¹ is Acc, HN-(CH ₂ ) _m -C(O), L- or D-amino acid or removed;

A ² is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Asp, or Glu;

A ³ is Gly, Ala, β-Ala, Gaba, Aib, D-amino acid or removed;

A ⁴ is His, 2-Pal, 3-Pal, 4-Pal, Taz, 2-Thi, 3-Thi or (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁵ is D-Phe, D-1-Nal, D-2-Nal, D-Trp, D-Bal, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, L- Phe or D-(Et)Tyr;

A ⁶ is Arg, hArg, Dab, Dap, Lys, Orn or HN-CH((CH ₂ ) _n -N(R ⁴ R ⁵ ))-C(O);

A ⁷ is Trp, 1-Nal, 2-Nal, Bal, Bip, D-Trp, D-2-Nal, D-Bal or D-Bip;

A ⁸ is Gly, D-Ala, Acc, Ala, 13-Ala, Gaba, Apn, Ahx, Aha, HN-(CH ₂ ) _s -C(O) or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Dab, Dap, Orn, or Lys;

A ¹⁰ is Acc, HN-(CH ₂ ) _t -C(O), L- or D-amino acid or removed;

R ¹ is OH or NH ₂ ;

each of R ² and R ³ , independently at each occurrence, is selected from the group consisting of H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₁ -C ₃₀ )acyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )alkyl, substituted ( C ₁ -C ₃₀ )heteroalkyl, substituted (C ₁ -C ₃₀ )acyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, substituted aryl(C ₁ -C ₃₀ )alkyl and substituted aryl(C ₁ -C ₃₀ )acyl;

R ⁴ and R ⁵ are each independently H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₁ -C ₄₀ )acyl, (C ₂ - C ₄₀ )alkenyl, (C ₂ -C ₄₀ )alkynyl, aryl(C ₁ -C ₄₀ )alkyl, aryl(C ₁ -C ₄₀ )acyl, substituted (C ₁ -C ₄₀ )alkyl, substituted by (C ₁ -C ₄₀ )heteroalkyl, substituted (C ₁ -C ₄₀ )acyl, substituted (C ₂ -C ₄₀ )alkenyl, substituted (C ₂ -C ₄₀ )alkynyl, substituted aryl(C ₁ -C ₄₀ )alkyl, substituted aryl(C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl or -C(NH)-NH ₂ ;

m is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

n is independently 1, 2, 3, 4, or 5 each time it occurs;

s is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

t is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

each of X ¹ , X ² , X ³ , X ⁴ and X ⁸ independently each time it occurs is H, F, Cl, Br, I, (C _1-10 )alkyl substituted with (C _1-10 )alkyl, (C _2-10 )alkenyl, substituted (C _2-10 )alkenyl, (C _2-10 )alkynyl, substituted (C _2-10 )alkynyl, aryl, substituted aryl, OH, NH ₂ , NO ₂ or CN,

with the provision of treatment for PWS.

In embodiments, the subject has, or is identified as having, a loss-of-function mutation in region 15q11-q13 of chromosome 15.

In embodiments, the subject has or is identified as having a mutation (eg, a loss-of-function mutation) in the MAGEL2 gene.

In embodiments, the daily dosage is from 0.1 mg to 10 mg. In embodiments, the daily dosage is from about 0.1 mg to about 7.5 mg. In embodiments, the daily dosage is from about 0.1 mg to about 5 mg. In embodiments, the daily dosage is from about 0.1 mg to about 2.5 mg. In embodiments, the daily dosage is from about 0.1 mg to about 2 mg. In embodiments, the daily dosage is from about 0.1 mg to about 1 mg. In embodiments, the daily dosage is from about 0.2 mg to about 10 mg. In embodiments, the daily dosage is from about 0.2 mg to about 7.5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 2.5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 2 mg. In embodiments, the daily dosage is from about 0.2 mg to about 1.5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 1 mg. In embodiments, the daily dosage is from about 0.3 mg to about 10 mg. In embodiments, the daily dosage is from about 0.3 mg to about 7.5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 2.5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 2 mg. In embodiments, the daily dosage is from about 0.3 mg to about 1.5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 1 mg. In embodiments, the daily dosage is from about 0.25 mg (eg, 0.25 mg) to about 0.5 mg (eg, 0.5 mg). In embodiments, the daily dosage is from about 0.5 mg (eg, 0.5 mg) to about 0.75 mg (eg, 0.75 mg). In embodiments, the daily dosage is about 0.25 mg (eg, 0.25 mg). In embodiments, the daily dosage is about 0.5 mg (eg, 0.5 mg). In embodiments, the daily dosage is from about 0.75 mg (eg, 0.75 mg) to about 1.25 mg (1.25 mg). In embodiments, the daily dosage is about 1 mg (eg, 1 mg). In embodiments, the daily dosage is from about 1.25 mg (eg, 1.25 mg) to about 2 mg (eg, 2 mg). In embodiments, the daily dosage is about 1.5 mg (eg, 1.5 mg). In embodiments, the daily dosage is about 2 mg (eg, 2 mg).

In embodiments, said method comprises administering the agonist in a dosage unit suitable for administration by injection, eg subcutaneous injection, to subjects.

In embodiments, said dosage unit contains about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, or 2 mg of the agonist.

In embodiments, said dosage unit is in a delivery device, e.g., a syringe (e.g., a prefilled syringe), an implantable device, a needleless hypodermic injection device, an infusion pump (e.g., an implantable infusion pump), or an osmotic delivery system.

In embodiments, the agonist is administered subcutaneously, for example by subcutaneous injection.

In embodiments, the agonist is administered every day for at least 3 weeks, e.g., at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 weeks or more, or at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 or 12 months or more or at least 1, 2, 3, 4 years or more.

In embodiments, the subject is obese, such as severely obese.

In embodiments, the subject is obese with early onset.

In embodiments, the subject suffers from hyperphagia.

In embodiments, the subject has a body mass index (BMI) greater ^than 25 kg/m , 44, 45, 46, 47, 48, 49, 50 kg/m ² or more) before the administration of the agonist, for example, at the time when the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater ^than 35 kg/m kg/m ² or more) prior to administration of the agonist, for example at the time the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater ^than 40 kg/m kg/m ² or more) prior to administration of the agonist, for example at the time the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater than 45 kg/m ² (e.g., ≥46, 47, 48, 49, 50, 51, 52, 53, 54, 55 kg/m ² or greater) prior to administration of the agonist , for example, at the moment when he is prescribed an agonist, or at the time of the first administration.

In embodiments, the subject has a BMI greater than the 85th-95th percentile prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the subject has had one or more failed therapies, such as exercise, diet, or behavioral therapies, prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the body weight of the subject after administration of the agonist is lower than before administration of the agonist.

In embodiments, administration of the agonist results in a reduction in the subject's weight compared to the subject's pre-treatment weight of about 1 kg to 3 kg after 1 week of treatment, or about 1 kg to 6 kg after 2 weeks of treatment, or about 2 kg to 12 kg after 4 weeks of treatment, or approximately 4 kg to 24 kg after 8 weeks of treatment, or approximately 8 kg to 48 kg after 16 weeks of treatment.

In embodiments, administration of the agonist results in weight loss in the subject at a rate of about 1-2 kg/week, e.g., about 2 kg/week, e.g., over 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4 -8 weeks of treatment or more, 8-16 weeks of treatment or more, 16-32 weeks or more, or 32-64 weeks or more.

In embodiments, administration of the agonist results in a reduction in hunger (e.g., lower Likert hunger score, e.g., at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 points lower) in the subject compared to the subject's level of hunger before treatment, e.g., results in the elimination of hunger (e.g., a score of 0 on the Likert scale of hunger) in the subject, e.g., after 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4-8 weeks of treatment or more, or 8-16 weeks of treatment or more.

In embodiments, administration of the agonist does not result in a detectable/significant reduction in basal metabolic energy (resting, REE) in the subject, e.g., over 24 hours, one week, or 30 days, or more, e.g., compared to a control REE value (e.g., , REE in a specified subject prior to treatment or a predetermined REE, e.g., in subjects with a similar pre-treatment BMI, e.g. when expressed as REE per kg lean body mass).

In embodiments, administration of the agonist results in an increase in basal metabolic energy (REE) in the subject, e.g., for 24 hours, one week, or 30 days, or more, e.g. or compared to a predetermined REE, e.g., in subjects with a similar pre-treatment BMI, expressed as REE per kg lean body mass, e.g., after reaching a similar level of weight loss due to fasting).

In embodiments, administration of the agonist results in a reduction in the subject's food intake compared to a control (e.g., the subject's pre-treatment food intake), e.g., where the food intake is food intake during the day, or food intake over 24 hours or one week.

In embodiments, administration of the agonist results in a reduction in food intake of at least 100 kcal, e.g., at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475, 500, 525, 550, 575, 600, 1000 kcal or more, compared to a control (e.g., the subject's food intake prior to treatment or a predetermined level of food intake), e.g., where food intake is food intake during day or food intake over 24 hours or one week.

In embodiments, administration of the agonist results in a reduction in food intake of at least 5 kcal/kg/day, such as 5, 10, 20, 30, 40, 50, 60, 70, 80, or 90, or more kcal/kg/day . In embodiments, said reduction in food intake is a reduction from baseline in food intake. In embodiments, said reduction in food intake is at least 100 kcal/kg/day, for example, for a pediatric subject of about 1 year of age. In embodiments, said reduction in food intake is at least 40 kcal/kg/day, eg, for a subject in the pediatric category, eg, late adolescence.

In embodiments, administration of the agonist results in a reduction in the subject's waist circumference compared to a control (e.g., the subject's pre-treatment waist circumference), as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks, or more after the start of treatment.

In embodiments, administration of the agonist results in a reduction in waist circumference of at least 2 cm (e.g., at least 2, 3, 4, 5, 6, 7, 8, 9, 10 cm, or greater) in the subject compared to a control ( for example, the waist circumference of the specified subject before treatment), as measured 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, administration of the agonist does not result in a detectable increase in the subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to the subject's pre-treatment blood pressure, as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, administration of the agonist results in a decrease in the subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to the subject's pre-treatment blood pressure, as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, administration of the agonist results in a decrease in the subject's systolic blood pressure of at least 3 mmHg. Art. (e.g., at least 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7 mmHg or greater) compared to the subject's pre-treatment blood pressure measured 1, 2, 3, 4 , 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, administration of the agonist results in a decrease in the subject's diastolic blood pressure of at least 4 mmHg. Art. (e.g., at least 4, 7, 7.5, 8, 8.5, 9, 9.5, 10 mm Hg or more) compared to the subject's pre-treatment blood pressure as measured 1, 2, 3, 4, 5 , 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the subject is a mammal, such as a human.

In embodiments, the agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140).

In embodiments, the method further includes obtaining information about the genotype of the subject, for example, obtaining information about the genotype of the 15q11-q13 region of chromosome 15 or the MAGEL2 gene.

In embodiments, the agonist is administered in response to detection of a specific sequence, such as a mutation, in the 15q11-q13 region of chromosome 15 or in the MAGEL2 gene.

In embodiments, the information is obtained directly, for example, from a sample (eg, a blood, serum, urine, or tissue (eg, biopsy) sample) taken from a subject.

In embodiments, said specific sequence, such as a mutation, is detected in a nucleic acid by a method selected from one or more of: nucleic acid hybridization based assay, amplification based assay, RFLP-PCR assay, real-time PCR, sequencing, screening analysis, fluorescence in situ hybridization (FISH), multicolor fluorescence in situ hybridization (MFISH) spectral karyotyping, comparative genomic hybridization, in situ hybridization , PCR with sequence specific primers (SSP), HPLC or mass spectrometric genotyping.

In embodiments, said specific sequence, such as a mutation, is detected in a subject.

In embodiments, said specific sequence, such as a mutation, is detected in a nucleic acid molecule or polypeptide in a sample taken from a subject.

In embodiments, the sample contains cells from blood, serum, urine, or tissue (eg, biopsy) from the subject.

In embodiments, the information is obtained from another party, whereby, for example, said other party is a subject, caregiver, physician, endocrinologist, hospital, clinic, third party payer, insurance company, or government agency.

In embodiments, the method includes:

based on the presence or absence of a particular sequence, such as a mutation, in a subject, one or more of:

(1) identifying or selecting the subject as having Prader-Willi syndrome (PSW); and/or

(2) identifying or selecting said subject as a subject likely to or likely not to respond to the agonist.

In embodiments, the presence of said specific sequence, such as a mutation, is detected in the subject, and based on this determination, the method includes identifying the subject as having Prader-Willi Syndrome (PWS).

In embodiments, the presence of said specific sequence, such as a mutation, is detected in a subject, and based on this determination, the method includes identifying said subject as a subject that is likely to or will not respond to an agonist.

In embodiments, the subject is a subject with PWS or a subject identified as a subject with PWS.

In one aspect, provided herein is a method for treating a disorder in a subject in need thereof, comprising:

administration of a melanocortin 4 receptor agonist (MC4R) at a daily dosage of approximately 0.1 mg (eg 0.1 mg +/- 5%) to approximately 10 mg (eg 10 mg +/- 5%),

where the violation is selected from:

(i) Prader-Willi syndrome (PSW);

(ii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the POMC gene;

(iii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the PCSK1 gene;

(iv) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the MAGEL2 gene;

(v) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the leptin receptor gene;

(vi) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the leptin gene;

(vii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the 5-HT2c receptor gene;

(viii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the nescient 2 (NhHL2) helix-loop-helix protein gene;

(ix) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the prohormone convertase gene;

(x) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the carboxypeptidase E (CPE) gene;

(xi) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the single-minded 1 (SIM1) gene;

(xii) a disorder characterized by hypermethylation of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, containing one or more methylated cytosines, eg, 5'methylcytosine); or

(xiii) a disorder characterized by a defect in the POMC-MC4R pathway other than:

(a) a heterozygous POMC mutation characterized by the presence of one functional POMC allele and one non-functional POMC allele,

(b) a heterozygous leptin mutation characterized by the presence of one functional leptin allele and one non-functional leptin allele,

(c) mutations in the melanocortin receptor (MC4R) (eg, a loss-of-function mutation), or

(d) prohormone convertase mutations (eg, loss-of-function mutations);

wherein said agonist is an MC4R agonist as described herein, e.g., the agonist is

(R ² R ³ ) -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -A ¹⁰ -R ¹ (I),

where:

A ¹ is Acc, HN-(CH ₂ ) _m -C(O), L- or D-amino acid or removed;

A ² is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Asp, or Glu;

A ³ is Gly, Ala, β-Ala, Gaba, Aib, D-amino acid or removed;

A ⁴ is His, 2-Pal, 3-Pal, 4-Pal, Taz, 2-Thi, 3-Thi or (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁵ is D-Phe, D-1-Nal, D-2-Nal, D-Trp, D-Bal, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, L- Phe or D-(Et)Tyr;

A ⁶ is Arg, hArg, Dab, Dap, Lys, Orn or HN-CH((CH ₂ ) _n -N(R ⁴ R ⁵ ))-C(O);

A ⁷ is Trp, 1-Nal, 2-Nal, Bal, Bip, D-Trp, D-2-Nal, D-Bal or D-Bip;

A ⁸ is Gly, D-Ala, Acc, Ala, 13-Ala, Gaba, Apn, Ahx, Aha, HN-(CH ₂ ) _s -C(O) or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Dab, Dap, Orn, or Lys;

A ¹⁰ is Acc, HN-(CH ₂ ) _t -C(O), L- or D-amino acid or removed;

R ¹ is OH or NH ₂ ;

each of R ² and R ³ , independently at each occurrence, is selected from the group consisting of H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₁ -C ₃₀ )acyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )alkyl, substituted ( C ₁ -C ₃₀ )heteroalkyl, substituted (C ₁ -C ₃₀ )acyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, substituted aryl(C ₁ -C ₃₀ )alkyl and substituted aryl(C ₁ -C ₃₀ )acyl;

R ⁴ and R ⁵ are each independently H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₁ -C ₄₀ )acyl, (C ₂ - C ₄₀ )alkenyl, (C ₂ -C ₄₀ )alkynyl, aryl(C ₁ -C ₄₀ )alkyl, aryl(C ₁ -C ₄₀ )acyl, substituted (C ₁ -C ₄₀ )alkyl, substituted (C ₁ -C ₄₀ )heteroalkyl, substituted (C ₁ -C ₄₀ )acyl, substituted (C ₂ -C ₄₀ )alkenyl, substituted (C ₂ -C ₄₀ )alkynyl, substituted aryl(C ₁ -C ₄₀ )alkyl, substituted aryl(C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl or -C(NH)-NH ₂ ;

m is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

n is independently 1, 2, 3, 4, or 5 each time it occurs;

s is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

t is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

each of X ¹ , X ² , X ³ , X ⁴ and X ⁸ independently each time it occurs is H, F, Cl, Br, I, (C _1-10 )alkyl substituted with (C _1-10 )alkyl, (C _2-10 )alkenyl, substituted (C _2-10 )alkenyl, (C _2-10 )alkynyl, substituted (C _2-10 )alkynyl, aryl, substituted aryl, OH, NH ₂ , NO ₂ or CN.

In embodiments, the subject has one or more mutations, for example, one or more of the genes described herein.

In embodiments, the disorder is Prader-Willi Syndrome (PWS).

In embodiments, the subject has, or is identified as having, a loss-of-function mutation in the paternal allele of chromosome 15 region 15q11-q13.

In embodiments, the subject has or is identified as having a mutation, eg, a loss-of-function mutation, in the MAGEL2 gene.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the POMC gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional POMC allele and one non-functional POMC allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two different non-functional POMC alleles, eg, has a POMC genotype null genotype.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a homozygous POMC genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the PCSK1 gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional PCSK1 allele and one non-functional PCSK1 allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional PCSK1 alleles, eg, has a PCSK1 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a homozygous PCSK1 genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the MAGEL2 gene.

In embodiments, the subject is, or is identified as being, a heterozygous carrier of the mutation(s), e.g., has one functional MAGEL2 allele and one non-functional MAGEL2 allele, including subjects in which the remaining functional allele is "silenced" by maternal imprinting, resulting in the subject being the subject. with zero function MAGEL2.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two mutated non-functional MAGEL2 alleles, eg, has a MAGEL2 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a MAGEL2 genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the leptin receptor gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional leptin receptor allele and one non-functional leptin receptor allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two non-functional leptin receptor alleles, eg, has a leptin receptor genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a leptin receptor genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the leptin gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional leptin allele and one non-functional leptin allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two non-functional leptin alleles, eg, has a leptin genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a leptin genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the 5-HT2c receptor gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional 5-HT2c receptor allele and one non-functional 5-HT2c receptor allele.

In embodiments, the subject is, or identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional 5-HT2c receptor alleles, eg, has a 5-HT2c receptor genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a null genotype for the 5-HT2c receptor.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the helix-loop-helix nescient 2 (NhHL2) protein gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional NhHL2 allele and one non-functional NhHL2 receptor allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional NhHL2 alleles, eg, has an NhHL2 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a NhHL2 genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the prohormone convertase gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional prohormone convertase allele and one non-functional prohormone convertase allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two non-functional prohormone convertase alleles, eg, has a prohormone convertase genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a prohormone convertase genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the carboxypeptidase E (CPE) gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional CPE allele and one non-functional CPE allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two non-functional CPE alleles, eg, has a CPE genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a CPE genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the single-minded 1 (SIM1) gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional SIM1 allele and one non-functional SIM1 allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional SIM1 alleles, eg, has a SIM1 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a null SIM1 genotype.

In embodiments, the disorder is characterized by a hypermethylated POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine).

In embodiments, the disorder is characterized by a POMC-MC4R pathway defect other than:

(a) a heterozygous POMC mutation characterized by the presence of one functional POMC allele and one non-functional POMC allele,

(b) a heterozygous leptin mutation characterized by the presence of one functional leptin allele and one non-functional leptin allele,

(c) a heterozygous melanocortin 4 receptor (MC4R) mutation characterized by the presence of one functional MC4R allele and one non-functional MC4R allele, or

(d) prohormone convertase mutations (eg loss-of-function mutations).

In embodiments, the daily dosage is from 0.1 mg to 10 mg. In embodiments, the daily dosage is from about 0.1 mg to about 7.5 mg. In embodiments, the daily dosage is from about 0.1 mg to about 5 mg. In embodiments, the daily dosage is from about 0.1 mg to about 2.5 mg. In embodiments, the daily dosage is from about 0.1 mg to about 2 mg. In embodiments, the daily dosage is from about 0.1 mg to about 1 mg. In embodiments, the daily dosage is from about 0.2 mg to about 10 mg. In embodiments, the daily dosage is from about 0.2 mg to about 7.5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 2.5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 2 mg. In embodiments, the daily dosage is from about 0.2 mg to about 1.5 mg. In embodiments, the daily dosage is from about 0.2 mg to about 1 mg. In embodiments, the daily dosage is from about 0.3 mg to about 10 mg. In embodiments, the daily dosage is from about 0.3 mg to about 7.5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 2.5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 2 mg. In embodiments, the daily dosage is from about 0.3 mg to about 1.5 mg. In embodiments, the daily dosage is from about 0.3 mg to about 1 mg. In embodiments, the daily dosage is from about 0.25 mg (eg, 0.25 mg) to about 0.5 mg (eg, 0.5 mg). In embodiments, the daily dosage is from about 0.5 mg (eg, 0.5 mg) to about 0.75 mg (eg, 0.75 mg). In embodiments, the daily dosage is about 0.25 mg (eg, 0.25 mg). In embodiments, the daily dosage is about 0.5 mg (eg, 0.5 mg). In embodiments, the daily dosage is from about 0.75 mg (eg, 0.75 mg) to about 1.25 mg (1.25 mg). In embodiments, the daily dosage is about 1 mg (eg, 1 mg). In embodiments, the daily dosage is from about 1.25 mg (eg, 1.25 mg) to about 2 mg (eg, 2 mg). In embodiments, the daily dosage is about 1.5 mg (eg, 1.5 mg). In embodiments, the daily dosage is about 2 mg (eg, 2 mg).

In embodiments, said method comprises administering the agonist in a dosage unit suitable for administration by injection, eg subcutaneous injection, to a subject.

In embodiments, said dosage unit contains about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, or 2 mg of the agonist.

In embodiments, said dosage unit is in a delivery device, e.g., a syringe (e.g., a prefilled syringe), an implantable device, a needleless hypodermic injection device, an infusion pump (e.g., an implantable infusion pump), or an osmotic delivery system.

In embodiments, the agonist is administered subcutaneously, for example by subcutaneous injection.

In embodiments, the agonist is administered daily for at least 3 weeks, e.g., at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 , 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 weeks or more, or at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months or more, or at least 1, 2, 3, 4 years or more.

In embodiments, the subject is obese, such as severely obese.

In embodiments, the subject is obese with early onset.

In embodiments, the subject suffers from hyperphagia.

In embodiments, the subject has a body mass index (BMI) greater ^than 25 kg/m , 44, 45, 46, 47, 48, 49, 50 kg/m ² or more) before the administration of the agonist, for example, at the time when the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater ^than 35 kg/m kg/m ² or more) prior to administration of the agonist, for example at the time the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater ^than 40 kg/m kg/m ² or more) prior to administration of the agonist, for example at the time the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater than 45 kg/m ² (e.g., ≥46, 47, 48, 49, 50, 51, 52, 53, 54, 55 kg/m ² or greater) prior to administration of the agonist , for example, at the moment when he is prescribed an agonist, or at the time of the first administration.

In embodiments, the subject has a BMI greater than the 85th-95th percentile prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the subject has already had one or more failed therapies, such as exercise, diet, or behavioral therapies, prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the body weight of the subject after administration of the agonist is lower than before administration of the agonist.

In embodiments, administration of the agonist results in a reduction in the subject's weight compared to the subject's pre-treatment weight of about 1 kg to 3 kg after 1 week of treatment, or about 1 kg to 6 kg after 2 weeks of treatment, or about 2 kg to 12 kg after 4 weeks of treatment, or approximately 4 kg to 24 kg after 8 weeks of treatment, or approximately 8 kg to 48 kg after 16 weeks of treatment.

In embodiments, administration of the agonist results in weight loss in the subject at a rate of about 1-2 kg/week, e.g., about 2 kg/week, e.g., over 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4 -8 weeks of treatment or more, 8-16 weeks of treatment or more, 16-32 weeks or more, or 32-64 weeks or more.

In embodiments, administration of the agonist results in a reduction in hunger (e.g., lower Likert hunger score, e.g., at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 points lower) in the subject compared to the subject's level of hunger before treatment, e.g., results in the elimination of hunger (e.g., a score of 0 on the Likert scale of hunger) in the subject, e.g., after 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4-8 weeks of treatment or more, or 8-16 weeks of treatment or more.

In embodiments, administration of the agonist does not result in a detectable/significant reduction in basal metabolic energy (REE) in the subject, e.g., over 24 hours, one week, or 30 days, or more, e.g., compared to a control REE value (e.g., with REE in a specified subject prior to treatment or a predetermined REE, e.g., in subjects with a similar pre-treatment BMI, e.g. expressed as REE per kg lean body mass).

In embodiments, administration of the agonist results in an increase in basal metabolic energy (REE) in the subject, e.g., for 24 hours, one week, or 30 days, or more, e.g. or compared to a predetermined REE, e.g., in subjects with a similar pre-treatment BMI, expressed as REE per kg lean body mass, e.g., after reaching a similar level of weight loss due to fasting).

In embodiments, administration of the agonist results in a reduction in the subject's food intake compared to a control (e.g., the subject's pre-treatment food intake), e.g., where the food intake is food intake during the day, or food intake over a 24 hour or one week period.

In embodiments, administration of the agonist results in a reduction in food intake of at least 100 kcal, e.g., at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475, 500, 525, 550, 575, 600, 1000 kilocalories or more compared to the control (e.g., the subject's pre-treatment food intake or a predetermined food intake level), where, for example, food intake is food intake during the day or food intake over 24 hours or one week.

In embodiments, administration of the agonist results in a reduction in food intake of at least 5 kcal/kg/day, such as 5, 10, 20, 30, 40, 50, 60, 70, 80, or 90, or more kcal/kg/day . In embodiments, said reduction in food intake is a reduction from baseline in food intake. In embodiments, said reduction in food intake is at least 100 kcal/kg/day, for example, for a pediatric subject of about 1 year of age. In embodiments, said reduction in food intake is at least 40 kcal/kg/day, eg, for a subject in the pediatric category, eg, late adolescence.

In embodiments, administration of the agonist results in a reduction in the subject's waist circumference compared to a control (e.g., the subject's pre-treatment waist circumference), as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks, or more after the start of treatment.

In embodiments, administration of the agonist results in a reduction in waist circumference of at least 2 cm (e.g., at least 2, 3, 4, 5, 6, 7, 8, 9, 10 cm, or greater) in the subject compared to a control ( for example, the waist circumference of the specified subject before treatment), as measured 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, administration of the agonist does not result in a detectable increase in the subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to the subject's pre-treatment blood pressure, as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, administration of the agonist results in a decrease in the subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to the subject's pre-treatment blood pressure, as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, administration of the agonist results in a decrease in the subject's systolic blood pressure of at least 3 mmHg. Art. (e.g., at least 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7 mmHg or greater) compared to the subject's pre-treatment blood pressure measured 1, 2, 3, 4 , 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, administration of the agonist results in a decrease in the subject's diastolic blood pressure of at least 4 mmHg. Art. (e.g., at least 4, 7, 7.5, 8, 8.5, 9, 9.5, 10 mm Hg or more) compared to the subject's pre-treatment blood pressure as measured 1, 2, 3, 4, 5 , 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the subject is a mammal, such as a human.

In embodiments, the agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140).

In embodiments, the method includes obtaining information about the genotype of the subject, for example, obtaining information about the genotype, for example, mutations in:

POMC gene;

the PCSK1 gene;

gene MAGEL2;

leptin receptor gene;

leptin gene;

the 5-HT2c receptor gene;

in the helix-loop-helix protein gene nescient 2 (NhHL2);

prohormone convertase gene;

the carboxypeptidase E (CPE) gene;

gene single-minded 1 (SIM1); or

POMC-MC4R pathway gene.

In embodiments, an agonist is administered in response to detection of a particular sequence, such as a mutation, in a gene described herein.

In embodiments, the method includes obtaining information about the methylation status of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine).

In embodiments, the agonist is administered in response to the detection of hypermethylation

In embodiments, information is obtained directly from, for example, a sample (eg, a blood, serum, urine, or tissue sample (eg, biopsy) taken from a subject.

In embodiments, said specific sequence, such as a mutation, is detected in a nucleic acid by a method selected from one or more of: nucleic acid hybridization based assay, amplification based assay, RFLP-PCR assay, real-time PCR, sequencing, screening analysis, fluorescence in situ hybridization (FISH), multicolor fluorescence in situ hybridization (MFISH) spectral karyotyping, comparative genomic hybridization, in situ hybridization , PCR with sequence specific primers (SSP), HPLC or mass spectrometric genotyping.

In embodiments, a specific sequence, such as a mutation, is detected in a subject.

In embodiments, said specific sequence, such as a mutation, is detected in a nucleic acid molecule or polypeptide in a sample taken from a subject.

In embodiments, methylation status, e.g., hypermethylation, e.g., methylated cytosine, is detected by a method selected from one or more of: PCR methylation-specific mass spectrometry, bisulfite-treated DNA sequencing, HpaII small fragment enrichment by ligase PCR, chromatin immunoprecipitation on-chip (ChIP-on-chip), genome scanning for restriction markers, immunoprecipitation of methylated DNA, molecular break lights method, DNA methyltransferase activity, methyl-sensitive Southern blotting, or melting assay with high resolution.

In embodiments, the subject exhibits hypermethylation, such as methylated cytosine.

In embodiments, hypermethylation, eg, methylated cytosine, is detected in a nucleic acid molecule in a sample taken from a subject.

In embodiments, the sample contains cells from blood, serum, urine, or tissue (eg, biopsy) from the subject.

In embodiments, the information is obtained from another party, whereby, for example, said other party is a subject, caregiver, physician, endocrinologist, hospital, clinic, third party payer, insurance company, or government agency.

In embodiments, the identification of a certain sequence is the result of cooperation with the other party.

In embodiments, the method includes:

depending on the determination of the presence or absence of (a) a particular sequence, such as a mutation, and/or (b) hypermethylation in the subject, one or more of:

(1) identifying or selecting the subject as having Prader-Willi syndrome (PSW);

(2) identifying or selecting the subject as having a disorder characterized by one or more mutations in the POMC gene, such as POMC deficiency;

(3) identifying or selecting the subject as having a disorder characterized by one or more mutations in the PCSK1 gene, such as PCSK1 deficiency;

(4) identifying or selecting the subject as having a disorder characterized by one or more mutations in the MAGEL2 gene, eg MAGEL2 deficiency;

(5) identifying or selecting the subject as having a disorder characterized by one or more mutations in the leptin receptor gene, eg, leptin receptor deficiency;

(6) identifying or selecting the subject as having a disorder characterized by one or more mutations in the leptin gene, such as leptin deficiency;

(7) identifying or selecting the subject as having a disorder characterized by one or more mutations in the 5-HT2c receptor gene, eg, 5-HT2c receptor deficiency;

(8) identifying or selecting the subject as having a disorder characterized by one or more mutations in the NhHL2 gene, such as NhHL2 deficiency;

(9) identifying or selecting the subject as having a disorder characterized by one or more mutations in the prohormone convertase gene, eg prohormone convertase deficiency;

(10) identifying or selecting the subject as having a disorder characterized by one or more mutations in the CPE gene, eg CPE deficiency;

(11) identifying or selecting the subject as having a disorder characterized by one or more mutations in the SIM1 gene, eg SIM1 deficiency;

(12) identifying or selecting the subject as having a disorder characterized by a hypermethylated POMC gene, eg, POMC deficiency;

(13) identifying or selecting the subject as having a disorder characterized by one or more mutations in the POMC-MC4R pathway gene, such as a deficiency in the POMC-MC4R pathway; and/or

(14) identifying or selecting said subject as a subject likely to or likely not to respond to the agonist.

In embodiments, the presence of a particular sequence, such as a mutation, is detected in the subject (e.g., mutations in MAGEL2 and/or mutations in the paternal allele of region 15q11-q13 of chromosome 15), and based on this determination, the method includes identifying the subject as having Prader- Willie (SPV).

In embodiments, the presence of a particular sequence, such as a mutation (e.g., a mutation in the POMC gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the POMC gene, such as deficiency POMC.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the PCSK1 gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the PCSK1 gene, such as deficiency PCSK1.

In embodiments, the presence of a specific sequence, such as a mutation (e.g., a mutation in a leptin receptor gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the leptin receptor gene, e.g. , leptin receptor deficiency.

In embodiments, the presence of a particular sequence, such as a mutation (such as a mutation in the leptin gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the leptin gene, such as a deficiency leptin.

In embodiments, the presence of a specific sequence, such as a mutation (e.g., a mutation in the 5-HT2c receptor gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the 5-HT2c receptor gene. -HT2c, for example, 5-HT2c receptor deficiency.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the NhHL2 gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the NhHL2 gene, such as deficiency NhHL2.

In embodiments, the presence of a specific sequence, such as a mutation (e.g., mutations in the prohormone convertase gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the prohormone convertase gene, such as deficiency prohormone convertase.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the CPE gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the CPE gene, such as a deficiency CPE.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the SIM1 gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the SIM1 gene, such as deficiency SIM1.

In embodiments, the presence of a specific sequence, e.g., a mutation (e.g., a mutation in a gene described herein) is detected in a subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the pathway gene. POMC-MC4R, for example, is deficient in the POMC-MC4R pathway.

In embodiments, the subject is determined to have hypermethylation in the POMC gene, and based on this determination, the method includes identifying the subject as having a disorder characterized by a hypermethylated POMC gene, such as POMC deficiency.

In embodiments, the presence of a certain sequence, such as a mutation, or hypermethylation, is detected in a subject, and based on this determination, the method includes identifying said subject as a subject that is likely to or will not respond to an agonist.

In embodiments, the subject is a subject with PWS or a subject identified as a subject with PWS or a disorder characterized by one or more mutations in the POMC, PCSK1, MAGEL2, leptin receptor, leptin, 5-HT2c receptor, NhHL2, prohormone convertase, CPE, SIM1 gene or another POMC-MC4R pathway gene, such as POMC-MC4R pathway deficiency.

In one aspect, provided herein is a method for treating a disorder selected from:

(i) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the PCSK1 gene;

(ii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the MAGEL2 gene;

(iii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the leptin receptor gene;

(iv) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the 5-HT2c receptor gene;

(v) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the nescient 2 (NhHL2) helix-loop-helix protein gene;

(vi) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the carboxypeptidase E (CPE) gene;

(vii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the single-minded 1 (SIM1) gene;

(viii) a disorder characterized by hypermethylation of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine);

(ix) a disorder characterized by a defect in the POMC-MC4R pathway other than:

(a) a POMC mutation, for example a heterozygous POMC mutation characterized by the presence of one functional POMC allele and one non-functional POMC allele,

(b) a leptin mutation, for example, a heterozygous leptin mutation characterized by the presence of one functional leptin allele and one non-functional leptin allele,

(c) mutations in the melanocortin 4 receptor (MC4R), or

(d) prohormone convertase mutations;

(x) a disorder characterized by a homozygous POMC mutation (eg, a loss-of-function mutation), eg, characterized by a null POMC genotype;

(xi) a disorder characterized by a complex heterozygous POMC mutation (eg, characterized by the presence of two non-functional alleles), eg, characterized by a null POMC genotype;

(xii) a disorder characterized by a homozygous mutation (eg, a loss-of-function mutation), eg, characterized by a leptin genotype null;

(xiii) a disorder characterized by a complex heterozygous mutation of leptin (e.g., characterized by the presence of two non-functional alleles) e.g., characterized by a null leptin genotype,

in a subject in need, comprising administering a melanocortin 4 receptor (MC4R) agonist,

wherein said agonist is an MC4R agonist described herein, for example, is

(R ² R ³ ) -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -A ¹⁰ -R ¹ (I),

where:

A ¹ is Acc, HN-(CH ₂ ) _m -C(O), L- or D-amino acid or removed;

A ² is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Asp, or Glu;

A ³ is Gly, Ala, β-Ala, Gaba, Aib, D-amino acid or removed;

A ⁴ is His, 2-Pal, 3-Pal, 4-Pal, Taz, 2-Thi, 3-Thi or (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁵ is D-Phe, D-1-Nal, D-2-Nal, D-Trp, D-Bal, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, L- Phe or D-(Et)Tyr;

A ⁶ is Arg, hArg, Dab, Dap, Lys, Orn or HN-CH((CH ₂ ) _n -N(R ⁴ R ⁵ ))-C(O);

A ⁷ is Trp, 1-Nal, 2-Nal, Bal, Bip, D-Trp, D-2-Nal, D-Bal or D-Bip;

A ⁸ is Gly, D-Ala, Acc, Ala, 13-Ala, Gaba, Apn, Ahx, Aha, HN-(CH ₂ ) _s -C(O) or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Dab, Dap, Orn, or Lys;

A ¹⁰ is Acc, HN-(CH ₂ ) _t -C(O), L- or D-amino acid or removed;

R ¹ is OH or NH ₂ ;

each of R ² and R ³ , independently at each occurrence, is selected from the group consisting of H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₁ -C ₃₀ )acyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )alkyl, substituted ( C ₁ -C ₃₀ )heteroalkyl, substituted (C ₁ -C ₃₀ )acyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, substituted aryl(C ₁ -C ₃₀ )alkyl and substituted aryl(C ₁ -C ₃₀ )acyl;

R ⁴ and R ⁵ are each independently H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₁ -C ₄₀ )acyl, (C ₂ - C ₄₀ )alkenyl, (C ₂ -C ₄₀ )alkynyl, aryl(C ₁ -C ₄₀ )alkyl, aryl(C ₁ -C ₄₀ )acyl, substituted (C ₁ -C ₄₀ )alkyl, substituted by (C ₁ -C ₄₀ )heteroalkyl, substituted (C ₁ -C ₄₀ )acyl, substituted (C ₂ -C ₄₀ )alkenyl, substituted (C ₂ -C ₄₀ )alkynyl, substituted aryl(C ₁ -C ₄₀ )alkyl, substituted aryl(C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl or -C(NH)-NH ₂ ;

m is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

n is independently 1, 2, 3, 4, or 5 each time it occurs;

s is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

t is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

each of X ¹ , X ² , X ³ , X ⁴ and X ⁸ independently each time it occurs is H, F, Cl, Br, I, (C _1-10 )alkyl substituted with (C _1-10 )alkyl, (C _2-10 )alkenyl, substituted (C _2-10 )alkenyl, (C _2-10 )alkynyl, substituted (C _2-10 )alkynyl, aryl, substituted aryl, OH, NH ₂ , NO ₂ or CN.

In embodiments, the disorder is characterized by a homozygous POMC mutation (eg, loss of the mutation), eg, characterized by a null POMC genotype.

In embodiments, the disorder is characterized by a compound heterozygous POMC mutation (eg, characterized by the presence of two non-functional alleles), eg, characterized by a null POMC genotype.

In embodiments, the mutations are those described herein, for example, p.Lys51Term g.A6851>T and p.Arg145ProfsX12 g.7134delG.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the PCSK1 gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional PCSK1 allele and one non-functional PCSK1 allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional PCSK1 alleles, eg, has a PCSK1 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a null PCSK1 genotype.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the MAGEL2 gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional MAGEL2 allele and one non-functional MAGEL2 allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional MAGEL2 alleles, eg, has a MAGEL2 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a MAGEL2 genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the leptin receptor gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional leptin receptor allele and one non-functional leptin receptor allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two non-functional leptin receptor alleles, eg, has a leptin receptor genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a leptin receptor genotype null.

In embodiments, the disorder is characterized by a homozygous mutation (eg, loss of mutation), eg, characterized by a leptin genotype null.

In embodiments, the disorder is characterized by a compound heterozygous mutation of leptin (eg, characterized by the presence of two non-functional alleles), eg, characterized by a leptin genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the 5-HT2c receptor gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional 5-HT2c receptor allele and one non-functional 5-HT2c receptor allele.

In embodiments, the subject is, or identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional 5-HT2c receptor alleles, eg, has a 5-HT2c receptor genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a null genotype for the 5-HT2c receptor.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the helix-loop-helix nescient 2 (NhHL2) protein gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional NhHL2 allele and one non-functional NhHL2 receptor allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional NhHL2 alleles, eg, has an NhHL2 genotype null.

In embodiments, the subject is, or is identified as being, a homozygous carrier of the mutation(s), eg, has a NhHL2 genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the carboxypeptidase E (CPE) gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional CPE allele and one non-functional CPE allele.

In embodiments, the subject is or is identified as being a carrier of complex heterozygous mutation(s), eg, has two non-functional CPE alleles, eg, has a CPE genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a CPE genotype null.

In embodiments, the disorder is characterized by one or more mutations (eg, loss-of-function mutations) in the single-minded 1 (SIM1) gene.

In embodiments, the subject is or is identified as being a heterozygous carrier of the mutation(s), eg, has one functional SIM1 allele and one non-functional SIM1 allele.

In embodiments, the subject is, or is identified as being, a carrier of complex heterozygous mutation(s), eg, has two non-functional SIM1 alleles, eg, has a SIM1 genotype null.

In embodiments, the subject is or is identified as being a homozygous carrier of the mutation(s), eg, has a null SIM1 genotype.

In embodiments, the disorder is characterized by a hypermethylated POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine).

In embodiments, the subject has or is identified as having a hypermethylated CpG island in the POMC gene, such as at the intron 2-exon 3 border of the POMC gene.

In embodiments, the disorder is characterized by a defect in the POMC-MC4R pathway other than a POMC mutation, eg, a heterozygous POMC mutation characterized by the presence of one functional POMC allele and one non-functional POMC allele.

In embodiments, the disorder is characterized by a defect in the POMC-MC4R pathway other than a leptin mutation, eg, a heterozygous leptin mutation characterized by the presence of one functional leptin allele and one non-functional leptin allele.

In embodiments, the disorder is characterized by a defect in the POMC-MC4R pathway other than an MC4R mutation, such as a heterozygous melanocortin 4 receptor (MC4R) mutation characterized by the presence of one functional MC4R allele and one non-functional MC4R allele.

In embodiments, the disorder is characterized by a defect in the POMC-MC4R pathway other than a prohormone convertase mutation.

In embodiments, said method comprises administering the agonist in a dosage unit suitable for administration by injection, eg subcutaneous injection, to a subject.

In embodiments, said dosage unit contains about 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, or 2 mg of the agonist.

In embodiments, said dosage unit is in a delivery device, e.g., a syringe (e.g., a prefilled syringe), an implantable device, a needleless hypodermic injection device, an infusion pump (e.g., an implantable infusion pump), or an osmotic delivery system.

In embodiments, the agonist is administered subcutaneously, for example by subcutaneous injection.

In embodiments, the agonist is administered daily for at least 3 weeks, e.g., at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 or more, or at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months or more, or at least 1, 2, 3, 4 years or more.

In embodiments, the subject is obese, such as severely obese.

In embodiments, the subject is obese with early onset.

In embodiments, the subject suffers from hyperphagia.

In embodiments, the subject has a body mass index (BMI) greater ^than 25 kg/m , 44, 45, 46, 47, 48, 49, 50 kg/m ² or more) before the administration of the agonist, for example, at the time when the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater ^than 35 kg/m kg/m ² or more) prior to administration of the agonist, for example at the time the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater ^than 40 kg/m kg/m ² or more) prior to administration of the agonist, for example at the time the agonist is prescribed or at the time of the first administration.

In embodiments, the subject has a body mass index (BMI) greater than 45 kg/m ² (e.g., ≥46, 47, 48, 49, 50, 51, 52, 53, 54, 55 kg/m ² or greater) prior to administration of the agonist , for example, at the moment when he is prescribed an agonist, or at the time of the first administration.

In embodiments, the subject has a BMI greater than the 85th-95th percentile prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the subject has already had one or more failed therapies, such as exercise, diet, or behavioral therapies, prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the body weight of the subject after administration of the agonist is lower than before administration of the agonist.

In embodiments, administration of the agonist results in a reduction in the subject's weight compared to the subject's pre-treatment weight of about 1 kg to 3 kg after 1 week of treatment, or about 1 kg to 6 kg after 2 weeks of treatment, or about 2 kg to 12 kg after 4 weeks of treatment, or approximately 4 kg to 24 kg after 8 weeks of treatment, or approximately 8 kg to 48 kg after 16 weeks of treatment.

In embodiments, administration of the agonist results in weight loss in the subject at a rate of about 1-2 kg/week, e.g., about 2 kg/week, e.g., over 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4 -8 weeks of treatment or more, 8-16 weeks of treatment or more, 16-32 weeks or more, or 32-64 weeks or more.

In embodiments, administration of the agonist results in a reduction in hunger (e.g., lower Likert hunger score, e.g., at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 points lower) in the subject compared to the subject's level of hunger before treatment, e.g., results in the elimination of hunger (e.g., a score of 0 on the Likert scale of hunger) in the subject, e.g., after 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4-8 weeks of treatment or more, or 8-16 weeks of treatment or more.

In embodiments, administration of the agonist does not result in a detectable/significant reduction in basal metabolic energy (REE) in the subject, e.g., over 24 hours, one week, or 30 days, or more, e.g., compared to a control REE value (e.g., with REE in a specified subject prior to treatment or a predetermined REE, e.g., in subjects with a similar pre-treatment BMI, e.g. expressed as REE per kg lean body mass).

In embodiments, administration of the agonist results in an increase in basal metabolic energy (REE) in the subject, e.g., for 24 hours, one week, or 30 days, or more, e.g. or compared to a predetermined REE, e.g., in subjects with a similar pre-treatment BMI, expressed as REE per kg lean body mass, e.g., after reaching a similar level of weight loss due to fasting).

In embodiments, administration of the agonist results in a reduction in the subject's food intake compared to a control (e.g., the subject's pre-treatment food intake), whereby, for example, food intake is food intake during the day, or food intake over a period of 24 hours or one weeks.

In embodiments, administration of the agonist results in a reduction in food intake of at least 100 kcal, e.g., at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475, 500, 525, 550, 575, 600, 1000 kilocalories or more compared to the control (e.g., the subject's pre-treatment food intake or a predetermined food intake level), where, for example, food intake is food intake during the day or food intake over 24 hours or one week.

In embodiments, administration of the agonist results in a reduction in food intake of at least 5 kcal/kg/day, such as 5, 10, 20, 30, 40, 50, 60, 70, 80, or 90, or more kcal/kg/day . In embodiments, said reduction in food intake is a reduction from baseline in food intake. In embodiments, said reduction in food intake is at least 100 kcal/kg/day, for example, for a pediatric subject of about 1 year of age. In embodiments, said reduction in food intake is at least 40 kcal/kg/day, eg, for a subject in the pediatric category, eg, late adolescence.

In embodiments, administration of the agonist results in a reduction in the subject's waist circumference compared to a control (e.g., the subject's pre-treatment waist circumference), as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks, or more after the start of treatment.

In embodiments, administration of the agonist results in a reduction in waist circumference of at least 2 cm (e.g., at least 2, 3, 4, 5, 6, 7, 8, 9, 10 cm, or greater) in the subject compared to a control ( for example, the waist circumference of the specified subject before treatment), as measured 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, administration of the agonist does not result in a detectable increase in the subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to the subject's pre-treatment blood pressure, as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, administration of the agonist results in a decrease in the subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to the subject's pre-treatment blood pressure, as measured at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, administration of the agonist results in a decrease in the subject's systolic blood pressure of at least 3 mmHg. Art. (e.g., at least 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7 mmHg or greater) compared to the subject's pre-treatment blood pressure measured 1, 2, 3, 4 , 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, administration of the agonist results in a decrease in the subject's diastolic blood pressure of at least 4 mmHg. Art. (e.g., at least 4, 7, 7.5, 8, 8.5, 9, 9.5, 10 mm Hg or more) compared to the subject's pre-treatment blood pressure as measured 1, 2, 3, 4, 5 , 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the subject is a mammal, such as a human.

In embodiments, the agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140).

In embodiments, the method includes obtaining information about the genotype of the subject, for example, obtaining information about the genotype, for example, mutations in:

POMC gene;

the PCSK1 gene;

gene MAGEL2;

leptin receptor gene;

leptin gene;

the 5-HT2c receptor gene;

in the helix-loop-helix protein gene nescient 2 (NhHL2);

the carboxypeptidase E (CPE) gene; or

gene single-minded 1 (SIM1).

In embodiments, an agonist is administered in response to detection of a particular sequence, such as a mutation, in a gene described herein.

In embodiments, the method includes obtaining information about the methylation status of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine).

In embodiments, the agonist is administered in response to the detection of hypermethylation

In embodiments, the information is obtained directly, for example, from a sample (eg, a blood, serum, urine, or tissue (eg, biopsy) sample) taken from a subject.

In embodiments, said specific sequence, such as a mutation, is detected in a nucleic acid by a method selected from one or more of: nucleic acid hybridization based assay, amplification based assay, RFLP-PCR assay, real-time PCR, sequencing, screening analysis, fluorescence in situ hybridization (FISH), multicolor fluorescence in situ hybridization (MFISH) spectral karyotyping, comparative genomic hybridization, in situ hybridization , PCR with sequence specific primers (SSP), HPLC or mass spectrometric genotyping.

In embodiments, a specific sequence, such as a mutation, is detected in a subject.

In embodiments, said specific sequence, such as a mutation, is detected in a nucleic acid molecule or polypeptide in a sample taken from a subject.

In embodiments, methylation status, e.g., hypermethylation, e.g., methylated cytosine, is detected by a method selected from one or more of: PCR methylation-specific mass spectrometry, bisulfite-treated DNA sequencing, HpaII small fragment enrichment by ligase PCR, chromatin immunoprecipitation on-chip (ChIP-on-chip), genome scanning for restriction markers, methylated DNA immunoprecipitation, molecular break lights, DNA methyltransferase activity, methyl-sensitive Southern blotting, or melting assay with high resolution.

In embodiments, the subject exhibits hypermethylation, such as methylated cytosine.

In embodiments, hypermethylation, eg, methylated cytosine, is detected in a nucleic acid molecule in a sample taken from a subject.

In embodiments, the sample contains cells from blood, serum, urine, or tissue (eg, biopsy) from the subject.

In embodiments, the information is obtained from another party, whereby, for example, said other party is a subject, caregiver, physician, endocrinologist, hospital, clinic, third party payer, insurance company, or government agency.

In embodiments, the identification of a certain sequence is the result of cooperation with the other party.

In embodiments, the detection of hypermethylation is the result of cooperation with the other party.

In embodiments, the method includes:

depending on the determination of the presence or absence of (a) a particular sequence, such as a mutation, and/or (b) hypermethylation in the subject, one or more of:

(1) identifying or selecting a subject as having a disorder characterized by one or more mutations in the PCSK1 gene, such as PCSK1 deficiency;

(2) identifying or selecting a subject as having a disorder characterized by one or more mutations in the MAGEL2 gene, eg MAGEL2 deficiency;

(3) identifying or selecting a subject as having a disorder characterized by one or more mutations in the leptin receptor gene, eg, leptin receptor deficiency;

(4) identifying or selecting a subject as having a disorder characterized by one or more mutations in the 5-HT2c receptor gene, eg, 5-HT2c receptor deficiency;

(5) identifying or selecting a subject as having a disorder characterized by one or more mutations in the NhHL2 gene, eg NhHL2 deficiency;

(6) identifying or selecting a subject as having a disorder characterized by one or more mutations in the CPE gene, eg CPE deficiency;

(7) identifying or selecting a subject as having a disorder characterized by one or more mutations in the SIM1 gene, eg SIM1 deficiency;

(8) identifying or selecting a subject as having a disorder characterized by a hypermethylated POMC gene, such as POMC deficiency;

(9) identifying or selecting the subject as having a disorder characterized by one or more mutations in the POMC-MC4R pathway gene, such as a deficiency in the POMC-MC4R pathway;

(10) identifying or selecting a subject as having a disorder characterized by a defect in the POMC-MC4R pathway other than a POMC mutation;

(11) identifying or selecting a subject as having a disorder characterized by a defect in the POMC-MC4R pathway other than a leptin mutation;

(12) identifying or selecting a subject as having a disorder characterized by a defect in the POMC-MC4R pathway other than an MC4R mutation;

(13) identifying or selecting a subject as having a disorder characterized by a defect in the POMC-MC4R pathway other than a prohormone convertase mutation;

(14) identifying or selecting a subject as having a disorder characterized by a homozygous POMC mutation;

(15) identifying or selecting a subject as having a disorder characterized by a complex heterozygous POMC mutation;

(16) identifying or selecting a subject as having a disorder characterized by a homozygous leptin mutation;

(17) identifying or selecting a subject as having a disorder characterized by a complex heterozygous leptin mutation; and/or

(18) identifying or selecting said subject as a subject likely to or likely not to respond to the agonist.

In embodiments, the presence of a specific sequence, such as a mutation (eg, a mutation in MAGEL2), is detected in the subject, and based on this determination, the method includes identifying the subject as having Prader-Willi Syndrome (PWS).

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the PCSK1 gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the PCSK1 gene, such as deficiency PCSK1.

In embodiments, the presence of a specific sequence, such as a mutation (e.g., a mutation in a leptin receptor gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the leptin receptor gene, e.g. , leptin receptor deficiency.

In embodiments, the presence of a specific sequence, such as a mutation (e.g., a mutation in the 5-HT2c receptor gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the 5-HT2c receptor gene. -HT2c, for example, 5-HT2c receptor deficiency.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the NhHL2 gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the NhHL2 gene, such as deficiency NhHL2.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the CPE gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the CPE gene, such as a deficiency CPE.

In embodiments, the presence of a specific sequence, such as a mutation (such as a mutation in the SIM1 gene), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the SIM1 gene, such as deficiency SIM1.

In embodiments, the presence of a certain sequence, such as a mutation (e.g., a mutation in a gene described herein), is detected in a subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by one or more mutations in the pathway gene. POMC-MC4R, for example, is deficient in the POMC-MC4R pathway.

In embodiments, the subject is determined to have hypermethylation in the POMC gene, and based on this determination, the method includes identifying the subject as having a disorder characterized by a hypermethylated POMC gene, such as POMC deficiency.

In embodiments, the presence of a certain sequence, e.g., a mutation (e.g., a homozygous POMC mutation), is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by a homozygous POMC mutation, e.g., POMC deficiency.

In embodiments, the presence of a certain sequence, e.g., a mutation (e.g., heterozygous heterozygous POMC mutation) is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by a heterozygous POMC mutation, e.g., POMC deficiency.

In embodiments, the presence of a certain sequence, e.g., a mutation (e.g., a homozygous leptin mutation) is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by a homozygous leptin mutation, e.g., leptin deficiency.

In embodiments, the presence of a specific sequence, e.g., a mutation (e.g., heterozygous heterozygous leptin mutation) is detected in the subject, and based on this determination, the method includes identifying the subject as having a disorder characterized by a heterozygous leptin complex mutation, e.g., leptin deficiency.

In embodiments, the presence of a certain sequence, such as a mutation, or hypermethylation, is detected in a subject, and based on this determination, the method includes identifying said subject as a subject that is likely to or will not respond to an agonist.

In embodiments, the subject has or is identified as having a disorder characterized by one or more mutations in the PCSK1, MAGEL2, leptin receptor, 5-HT2c receptor, NhHL2, prohormone convertase, CPE, SIM1, or other POMC-MC4R pathway gene, e.g. POMC-MC4R.

In embodiments, the subject has or is identified as having a disorder characterized by a homozygous or compound heterozygous mutation in one or more of a POMC gene and a leptin gene, such as POMC deficiency or leptin deficiency.

In one aspect, a dosage unit of the agonist described herein is provided, wherein said dosage unit comprises 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6 , 1.7, 1.8, 1.9 or 2 mg agonist.

In embodiments, said dosage unit contains 0.5 mg of the agonist.

In embodiments, said dosage unit contains 1.0 mg of the agonist.

In embodiments, said dosage unit contains 1.5 mg of the agonist.

In embodiments, said dosage unit is suitable for injection, eg subcutaneous injection.

In embodiments, said dosage unit is in a delivery device suitable for injection, eg subcutaneous injection.

In embodiments, said dosage unit is in a syringe or pen-type device suitable for injection, eg subcutaneous injection.

In embodiments, the agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140).

In one aspect, a method for evaluating a subject is provided, comprising:

obtaining information that identifies a subject as having or not having a certain sequence, such as a mutation, in the 15q11-q13 region of chromosome 15 or in the MAGEL2 gene,

moreover, identifying a subject as having the indicated mutation indicates that the patient is more likely to improve symptoms after treatment with an MC4R agonist (for example, an agonist, MC4R described herein), and identifying a patient as not having a mutation in the 15q11-q13 region of chromosome 15 or in gene MAGEL2, indicates that it is less likely to improve symptoms after treatment with an MC4R agonist, such as the MC4R agonist described herein.

In another aspect, a method for evaluating a subject is provided, comprising:

obtaining information that identifies a subject as having or not having a specific sequence, such as a mutation, in one or more of:

POMC gene;

the PCSK1 gene;

gene MAGEL2;

leptin receptor gene;

leptin gene;

5-HT2c receptor gene;

helix-loop-helix protein gene nescient 2 (NhHL2);

carboxypeptidase E (CPE) gene; or

gene single-minded 1 (SIM1);

wherein identifying a subject as having said defined sequence, such as a mutation, indicates that the patient is more likely to improve symptoms following treatment with an MC4R agonist (e.g., an MC4R agonist described herein), and identifying a subject as not having said defined sequence , for example, mutations, indicates that it is less likely to improve symptoms after treatment with an MC4R agonist, such as the MC4R agonist described herein.

In accordance with any of the methods described herein, improved symptoms include one or more of:

(a) weight loss;

(b) reduction in waist circumference;

(c) reduced levels of hunger;

(d) reduced food intake; and/or

(e) no decrease or increase in basal metabolic energy expenditure.

In embodiments, said mutation is a loss-of-function mutation.

In embodiments, said mutation is a homozygous mutation, eg, a homozygous loss-of-function mutation.

In embodiments, said mutation is a heterozygous mutation.

In embodiments, the heterozygous mutation is a compound heterozygous mutation (eg, characterized by the presence of two non-functional alleles).

In embodiments, a heterozygous mutation is characterized by the presence of one functional and one non-functional allele.

In embodiments, the method further includes submitting a report to the other party, wherein, for example, said other party is a subject, caregiver, doctor, oncologist, hospital, clinic, third party payer, insurance company, or government agency.

In embodiments, said report is in electronic form, web form, or paper form.

In embodiments, the report indicates the presence or absence of a mutation in a subject, optionally including the identifier of the subject from which the information was obtained.

In implementation options, the report contains:

information about the genotype (eg, the presence or absence of a particular sequence, such as a mutation) of the subject;

prognosis information or proposed treatment options, such as MC4R agonists;

information about the likely efficacy of any treatment option, for example, an MC4R agonist, the acceptability of any treatment option, and whether that treatment option is recommended for the subject; and/or

information about, or recommendations for, the use of a specified treatment option (eg, an MC4R agonist).

In embodiments, the agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140).

In one aspect, a method for selecting a subject having Prader-Willi Syndrome (PWS) is provided, comprising:

obtaining information about the genotype of the subject, for example, obtaining information about the genotype of the paternal allele of the 15q11-q13 region of chromosome 15 or the MAGEL2 gene;

and the specified stage of obtaining includes determining the presence or absence of a certain sequence, for example, a mutation in the paternal allele region 15q11-q13 chromosome 15 or gene MAGEL2; and

wherein the presence of said specific sequence, for example, indicates that the patient has PWS (identification).

In one aspect, a method is provided for selecting a subject deficient in the POMC-MC4R pathway, comprising:

(i) obtaining information about the genotype of the subject, for example, obtaining information about the genotype, for example, mutations in:

POMC gene;

the PCSK1 gene;

gene MAGEL2;

leptin receptor gene;

leptin gene;

the 5-HT2c receptor gene;

in the helix-loop-helix protein gene nescient 2 (NhHL2);

the carboxypeptidase E (CPE) gene; or

gene single-minded 1 (SIM1);

wherein the presence of said defined sequence, for example, indicates that the patient is deficient in the POMC-MC4R pathway (identification); or

(ii) obtaining information about the methylation status of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine).

Moreover, the presence of hypermethylation in the POMC intron indicates that the subject is deficient in the POMC-MC4R pathway.

According to any method described herein, in embodiments, the method further comprises administering to the subject a melanocortin 4 receptor (MC4R) agonist, such as the agonist described herein, such as setmelanotide.

In embodiments, said mutation is a loss-of-function mutation.

In embodiments, said mutation is a homozygous mutation, eg, a homozygous loss-of-function mutation.

In embodiments, said mutation is a heterozygous mutation.

In embodiments, said heterozygous mutation is a compound heterozygous mutation (eg, characterized by the presence of two different non-functional alleles).

In embodiments, a heterozygous mutation is characterized by the presence of one functional one non-functional allele. In embodiments, the agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140).

Also provided herein is the use of an MC4R agonist, such as the MC4R agonist described herein, in the treatment or manufacture of a medicament for the treatment of Prader-Willi Syndrome (PWS), wherein the MC4R agonist is administered at a daily dosage of approximately 0.1 mg (e.g., 0.1 mg +/- 5%) to about 10 mg (eg 10 mg +/- 5%).

Also provided herein is the use of an MC4R agonist, such as the MC4R agonist described herein, in the treatment of or in the manufacture of a medicament for the treatment of a disorder selected from:

(i) Prader-Willi syndrome (PSW);

(ii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the POMC gene;

(iii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the PCSK1 gene;

(iv) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the MAGEL2 gene;

(v) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the leptin receptor gene;

(vi) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the leptin gene;

(vii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the 5-HT2c receptor gene;

(viii) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the nescient 2 (NhHL2) helix-loop-helix protein gene;

(ix) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the prohormone convertase gene;

(x) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the carboxypeptidase E (CPE) gene;

(xi) a disorder characterized by one or more mutations (eg, loss-of-function mutations) in the single-minded 1 (SIM1) gene;

(xii) a disorder characterized by hypermethylation of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, containing one or more methylated cytosines, eg, 5'methylcytosine); or

(xiii) a disorder characterized by a defect in the POMC-MC4R pathway other than:

(a) a heterozygous POMC mutation characterized by the presence of one functional POMC allele and one non-functional POMC allele,

(b) a heterozygous leptin mutation characterized by the presence of one functional leptin allele and one non-functional leptin allele,

(c) mutations in the melanocortin receptor (MC4R) (eg, a loss-of-function mutation), or

(d) prohormone convertase mutations (eg, a loss-of-function mutation).

Optionally, said agonist is administered at a daily dosage of about 0.1 mg (eg 0.1 mg +/- 5%) to about 10 mg (eg 10 mg +/- 5%).

Additional implementation options in accordance with any method described herein include the following.

In embodiments, the MC4R agonist is a compound of Formula I, where:

A ¹ is A6c, Arg, D-Arg, Cha, D-Cha, hCha, Chg, D-Chg, Gaba, Ile, Leu, hLeu, Met, β-hMet, 2-Nal, D-2-Nal, Nip, Nle, Oic, Phe, D-Phe, hPhe, hPro, Val or deleted;

A ² is Asp, Cys, D-Cys, hCys, D-hCys, Glu, Pen, or D-Pen;

A ³ is D-Abu, Aib, Ala, β-Ala, D-Ala, D-Cha, Gaba, D-Glu, Gly, D-Ile, D-Leu, D-Tle, D-Val or deleted;

A ⁴ is His or 3-Pal;

A ⁵ is D-Bal, D-1-Nal, D-2-Nal, D-Phe, D-Trp or D-(Et)Tyr;

A ⁶ is Arg or hArg;

A ⁷ is Bal, Bip, 1-Nal, 2-Nal, Trp, D-Trp;

A ⁸ is A6c, D-Ala, Aha, Ahx, Ala, β-Ala, Apn, Gaba, Gly, or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Lys, Pen, or D-Pen;

A ¹⁰ represents Thr or deleted,

wherein at least one of A ³ or A ⁸ is removed, but not both, or a pharmaceutically acceptable salt of such a compound.

In embodiments, the MC4R agonist is not adrenocorticotropic hormone (ACTH).

In embodiments, the MC4R agonist is not melanotan-II (MT-II) (Ac-Nle-cyclo[Asp-His-D-Phe-Arg-Trp-Lys]-NH ₂ ) (SEQ ID NO: 562).

In embodiments, the MC4R agonist contains 8 amino acids or more.

In embodiments, the MC4R agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is hydantoin(C(O)-(Arg-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 500) or its pharmaceutically acceptable salt.

In embodiments, the MC4R agonist is a D-Phe-Arg-Trp tripeptide (SEQ ID NO: 560) or a pharmaceutical salt thereof.

In embodiments, the MC4R agonist is a peptide that includes D-Phe-Arg-Trp (SEQ ID NO: 560), or a pharmaceutical salt thereof.

In embodiments, the MC4R agonist is a peptide that includes an acetylated tripeptide Ac-D-Phe-Arg-Trp-NH ₂ (SEQ ID NO: 561), or a pharmaceutical salt thereof.

In embodiments, the MC4R agonist is c[hydantoin(C(O)-(Glu-D-Ala))-His-D-Phe-Arg-Trp-Dap]-NH ₂ (SEQ ID NO: 496) or its pharmaceutical acceptable salt.

In embodiments, the MC4R agonist is hydantoin(C(O)-(Nle-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 501) or its pharmaceutically acceptable salt.

In embodiments, the MC4R agonist is hydantoin(C(O)-(Gly-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-NH ₂ SEQ ID NO: 506) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is hydantoin(C(O)-(Ala-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 507 ) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is hydantoin(C(O)-(D-Arg-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 515 ) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is hydantoin(C(O)-(Gly-D-Arg))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 535 ) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is hydantoin(C(O)-(Gly-Arg))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 531) or its pharmaceutically acceptable salt.

In embodiments, the MC4R agonist is Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ (SEQ ID NO: 468) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ (SEQ ID NO: 470) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ (SEQ ID NO: 471) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-β-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ (SEQ ID NO: 472) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Aib-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ (SEQ ID NO: 473) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is c[hydantoin(C(O)-(Asp-Aic))-D-2-Nal-Arg-Trp-Lys]-NH ₂ (SEQ ID NO: 492) or a pharmaceutically acceptable salt thereof .

In embodiments, the MC4R agonist is c[hydantoin(C(O)-(Asp-A6c))-D-2-Nal-Arg-Trp-Lys]-NH ₂ (SEQ ID NO: 489) or a pharmaceutically acceptable salt thereof .

In embodiments, the MC4R agonist is Ac-Arg-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 139) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-NH ₂ (SEQ ID NO: 36) or a pharmaceutically acceptable salt thereof.

In embodiments, the MC4R agonist is D-Phe-c(Cys-His-D-Phe-Arg-Bip-β-Ala-D-Cys)-Thr-NH ₂ (SEQ ID NO: 81) or a pharmaceutically acceptable salt thereof .

In embodiments, the MC4R agonist is D-Phe-c(Cys-His-D-Phe-hArg-Bip-β-Ala-D-Cys)-Thr-NH ₂ (SEQ ID NO: 83) or a pharmaceutically acceptable salt thereof .

In embodiments, the MC4R agonist is D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-NH ₂ (SEQ ID NO: 84) or its a pharmaceutically acceptable salt.

In embodiments, the MC4R agonist is D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-NH ₂ (SEQ ID NO: 82) or its a pharmaceutically acceptable salt.

In embodiments, an MC4R agonist is any MC4R agonist described in US 2014/0329743 A1, which is incorporated herein by reference.

In embodiments, the MC4R agonist is any MC4R agonist described in WO2014/144260 A1, incorporated herein by reference.

Unless otherwise indicated, all technical and scientific terms have the meaning normally given to them by those of ordinary skill in the art to which this invention belongs. Although methods and materials similar or equivalent to those described herein may be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents and other references mentioned in this document are hereby incorporated by reference in their entirety. In addition, the materials, methods, and examples are for illustrative purposes only and are not intended to be construed as limiting. Headings, subheadings, and elements marked with numbers or letters, such as (a), (b), (i), etc., are for the sole purpose of facilitating the reading process. The use of headings or elements denoted by numbers or letters in this document does not imply that steps or elements must be implemented in alphabetical order, or that steps or elements are necessarily different from each other. Other features, objects, and advantages of the invention will become apparent from the description and drawings, as well as from the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

The following detailed description of the preferred embodiments of the present invention can be better understood when read in conjunction with the accompanying drawings. For purposes of illustrating the invention, the drawings show the presently preferred embodiments. However, it should be understood that the present invention is not limited to the specific arrangement and devices used in these embodiments, as shown in the drawings.

FIG. 1A and FIG. 1B are graphs showing the effect on suppression of cumulative food intake after treatment with setmelanotide (RM-493 at 0.1 mg/kg (mpk)) versus baseline neutral mice in Magel2 genotype null mice (Magel2) and wild-type mice. (W.T.). FIG. 1A is an enlarged version of the tab of FIG. 1B and shows the total food intake during t 3 h after drug administration. FIG. 1B shows the total food intake during the night.

FIG. 2 is a set of graphs showing the change in body weight in wild-type humans after 2 or 4 weeks of treatment with setmelanotide.

FIGURES 3A-D show food intake over time in wild type or db/db genotype mice ( db~ diabetes) treated with neutral vehicle or setmelanotide.

FIGURES 3A and 3D are a set of graphs showing food intake as a function of time in wild type or db/db genotype mice ( db~ diabetes) at various concentrations of setmelanotide.

FIGURES 3E and 3F are graphs summarizing the effect on food intake over time in wild-type (FIG. 3E) or db/db (FIG. 3F) mice treated with neutral vehicle or 0.0554 mpk, 0.137 mpk, 0.344 mpk or 1.37 mpk of setmelanotide.

DETAILED DESCRIPTION OF THE INVENTION

The present disclosure is based at least in part on the discovery that targeting defects in the POMC-MC4R pathway, e.g., targeting defects upstream of the MC4R, using an MC4R agonist as replacement therapy results in significant weight loss, reduced hunger, and/or ensuring an increase in energy expenditure in subjects with obesity. The present disclosure is also based in part on the finding that the response (e.g., decreased body weight and/or hunger and/or increased energy expenditure) in obese subjects having a defect (e.g., a genetic defect) in one or more genes is higher than the MC4R in of the POMC-MC4R pathway, per agonist is likely to be significantly higher than in obese subjects without such a defect. For example, as described herein, subjects with a non-functional Magel2 gene (e.g., obese with Magel2 genotype null) may respond significantly better (e.g., by reducing food intake) to exposure to an MC4R agonist than obese subjects who do not have this genetic disorders (eg, obesity with wild-type genotype).

Also, as described herein, subjects with a non-functional POMC gene (e.g., obese, POMC genotype null) showed a significantly stronger response (e.g., reduced body weight and/or hunger and/or increased energy expenditure) to an MC4R agonist. than obese subjects without such a genetic disorder (eg, obese with wild-type POMC genotype). Specifically, the MC4R agonist produced a weight loss of approximately 2-2.5 kg per week for 26 weeks of treatment (total weight loss was approximately 36 kg after 26 weeks, corresponding to approximately 23% of baseline body weight). This weight loss in a POMC deficient subject is more than 2-fold higher than that observed in wild type (i.e., normal genotype) obese patients (who experience weight loss after treatment with an MC4R agonist corresponding to approximately 0.6-0.9 kg per week for 2-4 weeks). In addition, greater weight loss in POMC-deficient subjects persisted for a longer period of time with no apparent reduction in sensitivity.

The significant weight loss and duration of weight loss observed in POMC deficient patients is not only significantly greater than that observed in wild-type obese patients treated with an MC4R agonist, but also significantly greater than that observed in obese subjects treated currently present on the therapeutic market. In clinical trials, commercially available therapies such as Belviq® (lorcaserin HCl tablets), Qsymia® (ximia) (extended release phentermine and topiramate capsules), Contrave® (contrave: naltrexone HCl + bupropion HCl extended release tablets) ) and Saxenda® (saxenda: injectable liraglutide) at prescribed doses after one year of treatment resulted in a placebo-adjusted weight loss in obese subjects of less than 5 kg. Hypersensitivity of subjects deficient in the POMC-MC4R pathway (e.g., subjects deficient in POMC) to an MC4R agonist, e.g., the MC4R agonist described herein, is unexpected, as long-term weight loss in obese patients is thought to have a limit of about 5%, as subjects appear to become desensitized and adapt to the effects of therapy, it is thought to be through physiological and compensatory changes, which include reduced energy expenditure as the subject loses weight. Surprisingly, this limit for sustained weight loss was not observed in POMC deficient subjects, in whom weight loss was significantly greater than 5% even after 13-26 weeks of treatment.

Without wishing to be bound by theory, an MC4R agonist such as setmelanotide can replace a missing MC4R signaling step in subjects having a genetic defect in the POMC-MC4R pathway (e.g., genetic disorders such as PWS and POMC-null obesity). Accordingly, it is believed that an MC4R agonist such as setmelanotide may provide even greater efficacy in such patient populations than in populations with normal obesity (eg, wild-type genotype). Accordingly, the methods and compositions described herein provide an optimized approach for restoring MC4R pathway function in subjects with genetic disorders (e.g., genetic defects in one or more POMC-MC4R pathway genes), such as PWS, POMC genotype null, and obesity. with a null genotype for PCSK, providing a reduction in hyperphagia and obesity observed in these subjects. Provided herein are methods for treating a subject having a genetic defect in one or more of the POMC-MC4R pathway genes, as well as methods for identifying/selecting subjects that have such defects and/or subjects that are likely to respond to an MC4R agonist (e.g., with more likely to respond to an MC4R agonist than wild-type obese subjects).

Definitions

As used herein, "about" and "approximately" generally refer to the average tolerable degree of error for the quantity being measured, given the nature or accuracy of the measurements. Examples of error rates are within 20 percent (%), typically within 10%, and more commonly within 5% of a given value or range of values.

As used herein, the terms "obtain" or "acquisition" refers to providing access to a physical object or value , such as a numerical value, or information (eg, information about a sequence or mutation status therein) about a genotype, or nucleic acid, or polypeptide, by " direct acquisition" or "indirect acquisition" of a specified physical object, value, or information. "Direct acquisition" means performing some physical process ( eg, performing a physical or synthetic process) to obtain a physical object, value, or information. "Indirect acquisition" refers to the receipt of a physical object, value, or information from another party or from another source ( for example, from a third-party laboratory that directly obtains the specified physical object, value, or information). Directly obtaining a physical object involves performing a process that involves a physical change in a physical substance, such as a starting material. Examples of changes include obtaining a physical object from two or more starting materials, separating or fragmenting a substance, separating or purifying a substance, combining two or more separate objects into a mixture, performing a chemical reaction that includes the destruction or formation of a covalent or non-covalent bond. Direct acquisition of value or information involves performing a process that involves a physical change in a sample or other substance. Examples include performing an analytical process that involves a physical change in a substance, such as a sample, analyte, or reagent (sometimes referred to herein as "physical analysis"), performing an analytical method, such as a method that includes one or more of the following: separation or purification of a substance, for example, an analyte or its fragment or other derivative, from another substance; combining the analyte, or a fragment or other derivative thereof, with another substance, such as a buffer, solvent or chemical reaction agent, or changing the structure of the analyte, its fragment or other derivative, for example, by breaking or forming covalent or non-covalent bonds between the first and the second atom of the analyte, or by changing the structure of the reagent, or its fragment or other derivative, for example, by breaking or forming covalent or non-covalent bonds between the first and second atom of the reagent.

As used herein, the term "obese" refers to a subject having a body mass index (BMI) in the ranges defined as "obese" by the Centers for Disease Control (see, for example, URL.cdc.gov/obesity/defining.html and www. .cdc.gov/obesity/childhood/defining.html, accessed 19 August 2015) or according to the National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. BMI is obtained by dividing the subject's weight, eg in kilograms (kg), by the square of the subject's height, eg, in meters (m). For example, an adult with a BMI of 30 kg/ ^m2 or higher is considered obese. For example, an adult with a BMI between 25.0 and 29.9 kg/m ² is considered overweight, an adult with a BMI between 18.5 and 24.9 kg/m ² is considered normal or healthy weight, and an adult with a BMI less than 18.5 kg/m ² is considered underweight. For example, an adult who is 5 feet 9 inches tall and weighs 203 pounds or more is considered obese. For children and adolescents, an obese person is defined as having a BMI greater than the 85th to ^{95th percentile} for children and adolescents of the same age and sex.

A "severely obese" subject or a "severely obese" subject refers to a subject with a BMI of 35 kg/m ² or greater, such as 40 kg/m ² or greater. For example, the weight of a subject with severe obesity is more than 100% above the ideal (normal, healthy) body weight.

As used herein, "early onset", e.g., as in the case of early onset obesity, refers to the onset (e.g., the first manifestation of one or more symptoms of a disorder, e.g., the disorder described herein, e.g., obesity, PWS, obesity has zero POMC genotype) that occurs in the subject before adulthood, such as during childhood, such as when the subject is under 18 years of age or younger (for example, the subject's age is 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1 year or less, or in adolescence, such as when the child is under the age of 12 or when the child is under the age of 6).

In the present text, the term "metabolic syndrome" refers to a group of symptoms that coexist with and increase the risk of coronary heart disease, stroke, and type 2 diabetes. According to the American Heart Association and the National Heart, Lung, and Blood Institute, metabolic syndrome, also called syndrome X) is defined if a subject has three or more of the following:

1) blood pressure is equal to or higher than 130/85 mm Hg. Art.,

2) fasting blood sugar (glucose) equal to or higher than 100 mg/dl,

3) big waist circumference (length around the waist):

- men - 40 inches or more,

- women - 35 inches or more,

4) low HDL cholesterol:

- men - below 40 mg / dl,

- women - below 50 mg / dl,

5) triglyceride levels equal to or greater than 150 mg/dL.

Metabolic syndrome can be diagnosed by examining blood pressure, blood glucose, HDL cholesterol, LDL cholesterol, total cholesterol, and triglyceride levels.

As used herein, the term "agonist" refers to any chemical compound, natural or synthetic, which, upon interaction ( eg, binding) with its target, eg, MC4R, increases MC4R signaling activity above baseline. An agonist can be a superagonist ( i.e., a compound that is capable of inducing a higher maximal response than an endogenous target receptor agonist and, accordingly, has an efficacy of more than 100%), a full agonist ( i.e., a compound that causes maximum response after occupancy and activation of the receptor) or a partial agonist ( i.e., a compound that activates receptors but is not capable of eliciting a maximum response of the receptor system).

As used herein, "treatment" includes achieving one or more of the following: weight loss (as measured, for example, by body mass index (BMI) and/or body weight), e.g., compared to a control (e.g., body weight up to treatment or a defined body weight value), a reduction in the subject's waist circumference, e.g., compared to a control (e.g., pre-treatment waist circumference or a predetermined waist circumference), a reduction in hunger, e.g., compared to a control (e.g., hunger before treatment or a predetermined hunger level), an increase in basal metabolic energy expenditure (REE), for example, compared to control (for example, with a pre-treatment REE or a predetermined REE), a decrease in food intake, for example, compared with a control level (for example, to treatment or predetermined food intake), alleviation or improvement of the clinical symptom or indicators associated with the disorder described herein, such as obesity, PWV, POMC genotype null obesity, e.g., type II diabetes, prediabetic state, blood hemoglobin A1C (Hb1Ac) above 6%, hyperinsulinemia, hyperlipidemia, lack of insulin sensitivity or glucose intolerance, delay, suppression or preventing the progression of obesity and/or obesity-related symptoms, or partially or completely delaying, suppressing or preventing the onset of obesity or obesity-related symptoms. Delaying, suppressing, or preventing the progression of obesity includes, for example, delaying, suppressing, or preventing a subject of normal weight from becoming obese. In embodiments, the control is a parameter value measured prior to treatment with an MC4R agonist described herein, or a predetermined value. The term "treatment" further includes partial or complete reduction in the risk of coronary heart disease, stroke, and type 2 diabetes associated with the metabolic syndrome, as well as alleviation or improvement of the clinical symptom or signs of the metabolic syndrome associated with the metabolic syndrome, such as one or more of the five indicators listed above. For example, the term "treatment" includes delaying, suppressing, or preventing the progression of parameters associated with the metabolic syndrome, including insulin resistance, glucose clearance, and cardiovascular disease parameters, including heart rate and blood pressure.

As used herein, "suppression" (inhibition) or "suppresses" (inhibits) may comprise a decrease in a certain parameter, such as the parameter described herein. For example, this term includes the inhibition of any parameter, for example, activity, constituting at least 5%, 10%, 20%, 30%, 40% or more. Accordingly, inhibition need not be 100%.

"Prophylactic treatment" refers to treatment before the onset of obesity in order to prevent, suppress or reduce the severity of its manifestations.

In the present text, the term "subject" refers to a mammal, such as a human. The subject may also be an animal in need of veterinary treatment, such as companion animals (eg, dogs, cats, etc.), farm animals (eg, cows, sheep, pigs, horses, etc.), and laboratory animals. (eg rats, mice, guinea pigs, etc.).

As used herein, the term "mutation" may refer to the nucleotide sequence of a gene or fragment thereof that is changed from the wild type sequence. For example, a mutation may include a point mutation, a frameshift mutation, a missense mutation, an inversion, a deletion, an insertion, a shortening, a chromosomal translocation. In embodiments, the mutation results in a gene or gene fragment encoding a non-functional protein, a protein with reduced activity (or a partially functional protein), or a protein with altered activity. For example, a "loss of function" mutation refers to a mutation that results in a gene or gene fragment that encodes a non-functional protein whose activity is substantially reduced compared to its wild-type counterpart (e.g., non-functional protein activity is less than 10%, 9%, 8 %, 7%, 6%, 5%, 4%, 3%, 2%, 1% or less of the activity of its wild-type counterpart). For example, a mutation causing "partial loss of function" refers to a mutation that results in a gene or gene fragment encoding a partially functional protein whose activity is reduced compared to its wild-type counterpart (for example, the activity of a partially functional protein is less than 50% and more 10% of the activity of its wild-type counterpart).

As used herein, "heterozygous" refers to the presence in a subject of two different alleles (having different nucleotide sequences) for a given gene. In some embodiments, "heterozygous mutation" may refer to the presence of a mutation on one allele for a given gene and the absence of a mutation on another allele of the same gene in a subject (eg, one mutant allele and one wild-type allele for a given gene). In other embodiments, a "heterozygous mutation" may be a "composite heterozygous" mutation, which refers to the presence of a mutation (e.g., a loss-of-function mutation or a partial loss-of-function mutation) on one allele for a given gene of another mutation. (eg a loss-of-function mutation or a partial loss-of-function mutation) on a different allele of the same gene (eg two different alleles each mutated, eg non-functional or partially functional). In embodiments where the complex heterozygous mutation includes two non-functional alleles, the genotype may be a null genotype or a functionally deficient genotype (deficient genotype).

As used herein, "homozygous" refers to the presence of two identical alleles for a given gene. In some embodiments, "homozygous mutation" refers to the presence of two mutant alleles for a given gene, where the two mutant alleles are identical.

As used herein, "genotype null" refers to the presence in a subject of two non-functional alleles of any gene.

As used herein, "dosage unit" refers to a physically discrete unit intended to be administered to a subject being treated as unit doses. Each unit contains a certain amount of active compound, calculated in such a way as to provide the desired therapeutic effect, in combination with the required pharmaceutical carrier.

As used herein, "dosage" refers to the amount or amount of a therapeutic agent. In some embodiments, a dosage is the amount administered to a subject in a single administration, such as in a single injection, a single infusion, or a single administration of one or more dosage units. In embodiments, the dosage is the amount administered to the subject in multiple doses, such as multiple injections, multiple infusions, or multiple administrations of one or more dosage units. In other embodiments, dosage may refer to the total amount administered to a subject in a given period of time, such as per day. In such examples, the dosage is usually referred to as "daily dosage" or dosage expressed as the value of the amount per day.

As used herein, "hunger" or "level" refers to a subject's appetite, desire to consume food, or perceived need for food. In embodiments, a subject's hunger or level of hunger can be quantified using a scale that measures hunger. In embodiments, the hunger scale gives a higher hunger score to a subject who feels intolerable hunger more frequently (eg, often or always) and a lower score to a subject who feels intolerable hunger less frequently (eg, sometimes or never). See, for example, Sibilia. Psychologicol Topics 19 (2010), 2, 341-354. For example, you can use the Linkert hunger scale, which gives scores from 0 to 10 points (0=no hunger, 10=very hungry). In other examples, the Linkert scale can be used, which gives scores from 1 to 4 points, where a subject who never feels unbearable hunger is rated 1, a subject who sometimes feels unbearable hunger is rated 2, a subject who often feels unbearable hunger , scores a 3, and a subject who always feels intolerable hunger scores a 4. See above.

POMC-MC4R Path

The melanocortin system, which includes melanocortins (MC, MC), agouti and agouti-related proteins, and their receptors, integrates hormonal, metabolic, and neural signals to control energy homeostasis and regulate appetite, energy expenditure, and body weight. Melanocortins, which include alpha-melanocyte-stimulating hormone (α-MSH), β-MSH, γ-MSH, and ACTH, are a family of peptide hormones derived from a precursor protein called pro-opiomelanocortin (POMC). Activation of the MC4 receptor (MC4R) in the POMC-MC4R pathway increases energy expenditure and food intake. See, for example, Fan et al. Nature 1997; 385:165-68. The POMC-MC4R pathway includes a number of proteins such as melanocortins (MC, MK), MC4 receptor (MC4R), POMC, subtilisin/kexin type 1 proprotein convertase (PCSK1, also referred to as PC1/3), MAGE-like protein 2 (MAGEL2), leptin receptor (leptin-R), leptin, G-protein coupled 5-hydroxytryptamine (serotonin) 2C receptor (5-HT2c receptor), helix-loop-helix protein nescient 2 (NhHL2, also called NSCL2), prohormone convertase, carboxypeptidase E (CPE) and single-minded 1 (Sim1) protein, which together contribute to the regulation of energy homeostasis, for example, through the regulation of appetite and energy expenditure. MC4R and other components of the POMC-MC4R pathway play a significant role in weight regulation. There is evidence that a mutation in the MC4R gene leads to severe obesity with early onset. It is believed that other genetic defects in the POMC-MC4R pathway may lead to severe obesity with early onset.

MC4R

hMC4R is a protein encoded by the genomic sequence having GenBank accession number CH471077.2.

Mutations in the MC4R receptor are a concomitant cause of severe obesity in children. It has been noted that the number of carriers of MC4R mutations in the population with the onset of obesity in adolescence is about 2.5%, with a maximum prevalence of 6% observed among children with severe obesity. Humans with MC4R mutations show a more or less similar phenotype, as has been described for mice with mutations in the MC4R gene. Individuals with MC4R deficiency exhibit hyperphagia, hyperinsulinemia, increased fat mass as well as lean body mass, increased bone mineral density, and linear increases in growth rate, with no change in cortisone, gonadotropin, thyroid, or sex steroid levels. In contrast to the MC4R deletion, hyperphagia and hyperinsulinemia in human subjects tend to decrease with age. As in MC4R knockout mice, the heterozygous carrier phenotype is the average of the homozygous carrier phenotypes. The observed hyperphagia, determined after a test meal, is less pronounced than in people with a leptin deficiency. The severity of MC4R dysfunction observed in in vitro assays is predictive of the food eaten at a test meal by a subject carrying that particular mutation and correlates with the onset and severity of obesity manifestations (phenotype). At least 90 different MC4R mutations have been associated with obesity, and additional MC4R mutations are likely to be found resulting in a similar obesity phenotype.

Examples of MC4R mutations that cause obesity in humans are described, for example, in Farooqi et al., The Journal of Clinical Investigation , July 2000, V. 106(2), pp. 271-279 and Vaisse et al., The Journal of Clinical Investigation , July 2000, V. 106(2), pp. 253-262, the relevant portions of which are incorporated herein by reference).

Additional mutations that have the potential to cause obesity in humans include R18H, R18L, S36Y, P48S, V50M, F51L, E61K, I69T, D90N, S94R, G98R, I121T, A154D, Y157S, W174C, G181D, F202L, A219 V, I226T . agonists, and the endogenous agouti-related protein antagonist.” Biochemistry, 2010 June 8; 49(22):4583-600, the relevant portions of which are incorporated herein by reference.

Additional examples of mutations that have the potential to cause obesity in humans include the mutations listed in the OMIM (Online Human Mendelian Inheritance) Database of Human Genes and Genetic Disorders, accession number 155541 (MC4R) (more precisely, accession numbers 155541.0001- 155541.0023) at the URL https://omim.org/entry/155541. Representative examples include 4-BP DEL, NT631; 4-BP INS, NT732; TYR35TER, ASP37VAL, SER58CYS, ILE102SER, ASN274SER, 1-BP INS, 112A, 4-BP DEL, 211CTCT, ILE125LYS, ALA175THR, ILE316SER, TYR287TER, ASN97ASP, 15-BP DEL (δ88-92 codons), and SER127LEU. Relevant portions of the OMIM database are incorporated herein by reference.

Additional examples of mutations in MC4R are described in Lee. Annals Acad. Med. 38.1(2009):34-44.

In exemplary embodiments, the MC4R mutation results in a delay in MC4R signaling activity.

Mutations in the genomic sequence encoding the MC4R can be determined by methods known to those of ordinary skill in the art. For example, a genomic sequence can be cloned using nucleotide primers such as, for example, those described in Farooqi et al., The Journal of Clinical Investigation, July 2000, V. 106(2), pp. 271-279 and Vaisse et al et al., The Journal of Clinical Investigation, July 2000, V. 106(2), pp. 253-262, and clone the sequence of interest using commercially available sequencers and software.

MC4R activity can be measured by methods known to those of ordinary skill in the art. For example, it is possible to transiently transfect cells with cloned MC4R DNA, bring the transfected cells into contact with an MC4R agonist ( e.g., α-MSH), and measure the intracellular level of cAMP, the MC4R second messenger, as measured in the electrochemiluminescence assay described, for example, in the source, Roubert et al., Journal of Endocrinology (2010) 207, pp. 177-183. Decreased MC4R signaling can be ascertained by comparing the intracellular level of cAMP produced in response to a given agonist by wild-type MC4R with that produced by mutant MC4R.

POMC (POMK)

POMC is a component of the POMC-MC4R pathway that operates above MC4R. POMC is a precursor protein that is cleaved by prohormone conkertases to form a number of peptide hormones (eg, alpha-MSH, ACTH, beta-endorphin, and enkephalin). Convertases that process POMC polypeptides include prohormone convertase 1 (PC1, also called PC1/3 or PCSK1), prohormone convertase 2 (PC2), carboxypeptidase E (CPE), peptidyl-α-amidating monooxygenase (PAM), N-acetyltransferase (N-AT ) and prolyl carboxypeptidase (PRCP).

The POMC gene is located on the human chromosome 2p23.3 and the gene sequence is held in the GenBank accession number NG_008997.1 and is incorporated herein by reference. An example of a POMC variant X1 mRNA transcript nucleic acid is available from GenBank accession number XM_011532917.1 and is incorporated herein by reference. An exemplary amino acid sequence of the X1 isoform of human POMC is contained in the GenBank Accession Number XP_011531219.1 and is incorporated herein by reference. An exemplary human POMC variant 1 mRNA transcript nucleic acid is contained in GenBank accession number NM_001035256.1 and is incorporated herein by reference. An example of the amino acid sequence of the human POMC pro-protein is contained in the GenBank accession number NP_001030333.1. An example nucleic acid mRNA transcript of human POMC variant 2 is held in GenBank under accession number NM_000939.2 and is incorporated herein by reference. An example of the amino acid sequence of the human POMC pre-protein is contained in the GenBank accession number NP_000930.1.

Pro-opiomelanocortin neurons that express POMC produce an anorexigenic effect in which secretion of POMC neuropeptides from pro-opiomelanocortin neurons reduces food intake. Loss-of-function mutations in the POMC gene have been reported to cause obesity, red hair, and adrenal insufficiency. For example, defects in POMC (eg, loss-of-function mutation(s) or hypermethylation) have been associated with obesity and d-ACTH deficiency. See, for example, Mendiratta et al. Intl. J. Ped. Endocrinol. 2011:5, and Kuehnen et al. PLoS Genetics. 8.3(2012):e1002543. There is evidence that a homozygous substitution of cytosine for adenosine at codon 231 (c.231C > A) produces a premature termination codon that causes loss of POMC function, which is associated with severe weight gain, congenital adrenal insufficiency, and hypoglycemia. See, for example, Mendiratta et al. Intl. J. Ped. Endocrinol. 2011:5. In embodiments, examples of mutations in POMC are described in Lee. Annals Acad. Med. 38.1(2009):34-44.

In embodiments, examples of mutations in POMC are described in Table 1 below. Embodiments provide for homozygous and/or heterozygous (e.g., compound heterozygous) mutations from Table 1.

Table 1

Examples of heterozygous variants leading to loss of POMC function (POMC+/-) A source Function Cys28Phe J Clin Endo 2008; 93; 4494 Leu37Phe J Clin Endo 2008; 93; 4494
Cell Met. 2006; 3; 135 His143GLu Cell Met. 2006; 3; 135 loss of alpha-MSH function Phe144Leu Ped Res. 2008; 63; 2; 211 loss of alpha-MSH function Tyr221Cys Cell Met. 2006; 3; 135
Cell Met. 2006; 3; 135
cell met. 2006; 3; 141 loss of beta-MSH function Pro231Leu Clin Chem 2005; 51(8); 1358 Probable loss of beta-MSH function Arg236Gly Hum Mol Gen. 2002; eleven; 1997
Hum Mol Gen. 2002; eleven; 1997 Loss of beta-endorphin function Glu244X Clin Chem 2005; 51(8); 1358 *Numbering of amino acids corresponds to the numbering in the protein containing the signal peptide, as described by Takahashi et al. 1981 Febs Letters 135(1)97.
X stands for early termination.

In some embodiments, such as those shown in Table 1, the amino acid sequence of POMC is the sequence described by Takahashi et al. 1981 Febs Letters 135(1)97 and copied below (the 26-amino acid signal peptide is underlined).

MPRSCCSRSG ALLLALLLQA SMEVRG WCLE SSQCQDLTTE SNLLECIRAC KPDLSAETPM FPGNGDEQPL TENPRKYVMG HFRWDRFGRR NSSSSGSSGA GQKREDVSAG EDCGPLPEGG PEPRSDGAKP GPREGKRSYS MEHFRWGKPV GKKRRPVKVY PNGAEDESAE AFPLEFKREL TGQRLREGDG PDGPADDGAG AQADLEHSLL VAAEKKDEGP YRMEHFRWGS PPKDKRYGGF MTSEKSQTPL VTLFKNAIIK NAYKKGE (SEQ ID NO: 563)

In some embodiments such as those shown in Table 1, the nucleotide sequence of the POMC gene is the sequence described by Takahashi et al. Nucl Acids Res. 1983, 11(19)6847, such as found in GenBank accession number V01510.1 and copied below.

1 ctgctcttca cagcatcacc ctctccccat ttaatggttt aggttaacag gactttttcc

61 ttgaggcttg ggacacggaa gggagcctcc cctaaaccag gcccttggag agcaggcccc

121 aggggagcag tgcaactcac cttcacaccc acaagacggc tcctgacttc tgctccctcc

181 tcccctcccc aaagtggaac agagagaata tgattcccca cgacttccac atcacagttt

241 ccaaacaatg gggaaatcgg aggcctcccc gtgtgcagac ggtgatattt accgccaaat

301 gcgaaccagg cagatgccag ccccagcacg cacgcaggta acttcaccct cgcctcaacg

361 acctcagagg ctgcccggcc tgccccacac gggggtgcta agcctcccgc ccgttctaag

421 cggagaccca acgccatcca taattaagtt cttcctgagg gcgagcggcc aggtgcgcct

481 tcggcaggac agtgctaatt ccagcccctt tccagcgcgt ctccccgcgc tcgtcccccg

541 tctggaagcc cccctcccac gccccgcggc cccccttccc ctggcccggg gagctgctcc

601 ttgtgctgcc gggaaggtca aagtcccgcg cccaccagga gagctcggca agtatataag

661 gacagaggag cgcgggacca agcggcggcg aaggaggggga agaagagccg cgaccgagag

721 aggccgccga gcgtccccgc cctcagagag cagcctcccg agacaggtaa gggcgcagcg

781 tgggggaccc gtgctctttc cccgggatcc cctgtccccg tcctcgcgat gcagtcggcc

841 ggctccggct ccgaaggcgg acctgggcgc ctctggctct ccgcggtccc gagttctcga

901 caaactttct gcgccgactg cggcatgaga agccgccagt agctgagctg gagggcccac

961 gtccggcccc tgggcggacg gccgcgaagc tgcaggcgct gtctccaggg agccggcggc

1021 ctcctctccc ccaggggctc gcggcggtcc ggaggctccg agagcttgct aggaggtctt

1081 gggacaaccc ggtctttttt tttttttttg agacggagtt tcgctcttgt tgcccatgct

1141 ggagagcaaa ggggtgatct ctgctcaccg caaccttcgc ctcccggggtt caagcgattc

1201 tcctgcttca gcctcccgag tagctgggat tacaggcatg cgccaccacg cccggctaat

1261 ttttgtattt ttagtagtga cggagtttct ccatgttggt caggctggtc tcaaactccc

1321 gacaacaggt gatccgcccg ccttggcccc ccaaagttct ggcattacag gcgcgagcca

1381 ccgccccgg ccagcccggt cttttagtat ctcttgctcc cagtttccag gataggtgtc

1441 acatcttgaa agtcaaattc catacacgct atcgcaaatt aatgttggaa acggggcagc

1501 agagaaaagg ataaaagtca taatgaacgc cctgccttcc ggatttttc ggattcagac

1561 ccctgaatcc ttgtttcctt gcccacctta gcgcacccga ggtggccgcg ctatgataat

1621 tacatgataa ctgggtcaat tacaatgcag aatagttgggg tctcttctct ccaagaccta

1681 gctggggtta aaaacaggtg gccggggcgg gagctgtcct agatcctgaa acgcactgtc

1741 tagtttcgga tgccctcaac agaaccgggg tggacggttt atggcgcaga tcctgggttg

1801 agggcacggg cagccatttg gaatgatcaa ggctcaggta aggggcgttt ccagcgaagg

1861 aggacagtc cacttggcat ttggattccc caaattcttc atgtttaaat ggggcaggga

1921 gggttcttac agaatggctg gaggagcca aggaaaataa aagtgtgtgt ggattttttt

1981 tgtgtgtgtg tcagtttata aactctgcac agattatggc cactttaatg acttactgtt

2041 cctttgatgc ttttgttata ggactcgatg catgtatgtc atggtgtaag gacaaaactc

2101 ggcccctgtg ctcctctaat ctttacaaaa ggtcatggcc agcgtgcagt tttacagtaa

2161 caagcaaaat gatttgttga gctcatagag agcccctcac acctatgaag ttctaataag

2221 tgtagttcta ctataaagtt aatctcagga tgagcaaatt tcaagtttct atttttccag

2281 agctttccat ttttggatta taatactttc cctacttaaa aaagcacaac atttgatatt

2341 tccccaataa tttgttgctt taaaaatgac acaaaaggta ctatttgttc attgtagaga

2401 actgaaaata cacataagca aatacacata cacataagca aaatatacaa tacaaacaca

2461 agaccatctt tcagggaaga atctgaagtt ttagcaatag cagccatcta accagtttag

2521 caacagaata taagctctga gagggtggga gtgaatatgt taccacattg tacaacacag

2581 cacatagggc ataaggaggg gaaatgctct ctggggcttt ccaggaaggc ctgaagtcat

2641 tgcttctagc aaatggaaat cactccagag tagttatctt tgacaagaat tgaaatataa

2701 ttgagggaac tatcagacct gtaagatttt gttttttcct ttactaatat gttactttac

2761 atttgcattt ggtgacatac gtaactacca ttttctgtg actgtaacat ctgggcattt

2821 ttcagagcta aatgtgctat ggtcaacttg gagctttaat ctaattgcct ggtccaccaa

2881 gttctggctg tgtacttgaa tagatcactg gcagggtaca atgggaacag cctgtccctt

2941 ggagccagga gaggacacca aggttgacca aagctcgttc agttgcccct ttagccgaag

3001 cgcacctggg ccagtcactg gctgccagtg ccatctaatg gctgctctga aaatgctcag

3061 ccttgcccgg caacccttca gaagctagca ccgtgcaggc ccagcgcctg gggaataggg

3121 cgagggtggg gtagagagaa ggaagtggcc tcctgaagta gaaatcagcg cttcagagga

3181 ctttcacttc caaagcctcc cctatataaa aaagatttgg cccacgcctc cccaaatgag

3241 agatttattt taggcaaact tattttaaaa tgccagcgtt cattaggagt gacaagacac

3301 ttagtcatcc acgctttaat gtgaattact tttctcatct aattacattt ctttctagca

3361 gctggctgag aagatcttct gaaatccaaa atgattgtag ggttggcggt gagctgatct

3421 ccggcctcga ggtggcttca gggggcccac ctggttaagg gaaatttggc agtgcgaggg

3481 tagtgctgga gagaggggtg ggtacagggg gctagggggca ccatggatgc cccctcctta

3541 ctgtcccctg gtgtcttgac ctcagcttct gcccacaggc acttgctgga ttctccaaaa

3601 gtatctgcag tggctgttcc accaggaggt aattcccttc tggtctcttt cccctccaca

3661 tctgcatcct cttcaaatcc tgccatttca gaccacattt gagagctcta gagaacaaga

3721 catctgacac gtgacgtgtc cagagatga gccagatttc aaagaactga gatctgcttt

3781 aaaaacgaag ctctccaaag ttactggagt ctgggtaata gtgatcacca gagtaatttg

3841 tgtgcaggac atcaaatcag gctgctcgaa atgctgccta aattggccag tggttttatt

3901 tgcttttctg tcaacctaat attcatagga aatagagttt cagaggaatg ataggatcct

3961 ggtggaataa aaagggaaaa gaccatcttg agcaggagtt tcagggtcct ccgtttttcc

4021 caagttactt tcactcctga gatcttgcat gttagaacta cagcttaatg tagtgaaata

4081 ggaaagttct ctgttaggag cttagcctta ccttgtcatg gacattaaag taattgtctc

4141 tctttgggct tcaattttcc catctctcat gggaagggct gaaccaagca atccccaaaa

4201 tagcttccag ccttaacctt tttagggggtc tcgtttaaat agaagataac agggaaatgg

4261 tcacagttta cccaggtcca ttccctcctc cttatcacaa cttataccac cgctgtactg

4321 cacacctcct ttctcagcat tgctgctgtc cttaaaatgc ctttaactcc acaagagt

4381 gtgttgttaa tgttggctca aggtccttcc tggtgagtgg ccaacattgt tttgctcctt

4441 gcaggggtcc caccaatctt gtttgcttct gcagagcctc agcctgcctg gaagatgccg

4501 agatcgtgct gcagccgctc gggggccctg ttgctggcct tgctgcttca ggcctccatg

4561 gaagtgcgtg gctggtgcct ggagagcagc cagtgtcagg acctcaccac ggaaagcaac

4621 ctgctggtac gtgggccatg actgccatct tggcttagac attagatggg actggagctg

4681 ggaaagctca aaagaaaagg gtgtggggaa agggaaattc attcccagtg ataggcgtga

4741 ttcaatccag ggcaggagca aaactttgca gtgaagtaag aaatgggaga agaaatcagg

4801 gaaggaagca gcttcaggga gaggggttga gtccacaatt tctgcttggt tatccttact

4861 tcttgcccca tcttttatgg agaccttgaa ccctttaagc tagagatggt gctataagag

4921 caataatgga cccctcaatc tattctgtac tttacatctt tagcttccca aactattcct

4981 ttttaagaag ctcatatcac ttgccatttt cattccatat ttcttaccct tttatctact

5041 accggttgca aaaccagcca ggtagttctt caaatcatct ctggaagaag gaaaaaccag

5101 gggccctttt ttttttttct ttaattggtg ccaaatgtct catgtttatt ctggaggact

5161 ggccttctgc tgtgttcctc tacagtcttt ccagagcatg tgaaggcctt tgcatcaggc

5221 aggagctccc tccaggtcac cacagggtgt atgtatctgc ctgtgggggg tgtgtgtgtg

5281 tgtgtgttgg ggggcataaa tgagtaatga tgccaaatcc agagattaaa aggcacactg

5341 agaccaggcg agatggctca tggctgtaat cccagcactt ttagatgcta aggtgggagg

5401 attgcttgag cccagggatt caagacaagc ctgggcaaca tagtgagacc tccacttcta

5461 caaaaaataa aaaagttagc cagatgtggt ggcatgtgcc tgtagtccta gctacttggg

5521 aggttcactt gaggccagga gtctgacgac acagtaagct atgatcacac cattgcactc

5581 cagtctgggt aacagaatga gaccttgtct caaaacaaaa caaaatgaaa caaacaaaca

5641 aacaaacccc catactgtta gtgtcagtga cgggaatttt aatcttgttg ccatcacctg

5701 gcaggtgctg aggtggaat gtacataact acattctgtg tattttgtca atgcagaagc

5761 tgagttaagg tgaagataga atgaggtcct caaagacaca gaccagtttt catgtgtaat

5821 ataaaataga aacaaagagc ccaggggatt ctgtgagttc cagtttggaa agacccaaga

5881 gtctcttgac ttgagacacc cacagcacag ctcaccaggg agggtgcact ggacacagtc

5941 aggacccatg ggttctagac ccagttttga ggtgtgggac cttgaccagg tcctatcacc

6001 tctctgagtc tcctgtttca ctatctgtcc acgggagggg agtgtaaatt agttttttcc

6061 attgttaacg ttccacagag ttgtaattct gaacacctgg agtaggcaat gtccagctca

6121 acagagtggg taggatcctt ttatttttctc ctttgctatt cccaagaaag agagcagcca

6181 gtgagctttt catcttttta tcactgaaaa ctcaaggctg cagcctatgc agccattttc

6241 ctaagctaat atgtaccaca atagagtcct ctagggacaa ggagcagaga cacaggttcc

6301 acagacggtg caatggaaat aacgctagct ttccacccct ccctccagtc agaatgagat

6361 tacagggaaa taagcttgcc ccagagctca ctgggggatc tctcagaaat cagctcagaa

6421 gtcgtgaaag aaccaaggtg cagttttgga ggcttagtgc agagatggag ctggggtagg

6481 gcataaagta ggttttccat cactgaggta aggttgaggc attatttttt attttttgtt

6541 tatttattta ttttttttgag acggagtctc gctctatcac ccaggctgga gtgcagtggc

6601 gcgatctccc ctcactgcaa gctccacctc ccaggttcac acaggttgaa gcattattaa

6661 aaatatgttt aaaaatatgg gccctagtag ccagacttct atcacctgga gagattatcc

6721 cccaaatttc agccccactc ccctcctgga cttgaattaa accatatgta tttattcaat

6781 attcttttta tttatttatt tatttttttg agacggagtc ttgctctgtt gccctggctg

6841 gagtgtggag tgcagtggtg tgatcttggc tcactgcaac ctctacctcc caggttcaag

6901 cggttctcct gcctcaggct ccagagtagc tgggattaca ggcgcccgcc accacaccca

6961 gcttatttat ttatttatac tagagatggt atttcaccat agttggccag gctggtcttg

7021 aactcctgac ctcatgtgat ctgcctgcct tggcctccca aagtgctggg attataggtg

7081 tgagccacca tgcccggccc tcaatattca ttaagtgcca acaactacca cccgtctgcc

7141 tttcttggag ccactccttt atgtcaggca tatgacagta agactttggt cctgttcaca

7201 aaagctaggg gtggctagat ggctagacaa accatggaat gggatgggaa gtgtgttgca

7261 gttgccagca gaagcatgaa ggggatggga caaaagaggc ggtggcaaga tcttagatgc

7321 ccacgagtgc caagaaagca ggtgggcaga cctgctctgt agggaggcct cgacgcttga

7381 cacgcccgac actgtgccct gtgtcctcgg cacgtggcga gggcggccag ggcctaggcg

7441 cagtgacggg cgcggcagcc gggccggggt gcggggcacg ggctgccctc atgccctcgc

7501 gtcttccccc aggagtgcat ccgggcctgc aagcccgacc tctcggccga gactcccatg

7561 ttcccgggaa atggcgacga gcagcctctg accgagaacc ccgggaagta cgtcatgggc

7621 cacttccgct gggaccgatt cggccgccgc aacagcagca gcagcggcag cagcggcgca

7681 gggcagaagc gcgaggacgt ctcagcgggc gaagactgcg gcccgctgcc tgagggcggc

7741 cccgagcccc gcagcgatgg tgccaagccg ggcccgcgcg agggcaagcg ctcctactcc

7801 atggagcact tccgctgggg caagccggtg ggcaagaagc ggcgcccagt gaaggtgtac

7861 cctaacggcg ccgaggacga gtcggccgag gccttccccc tggagttcaa gagggagctg

7921 actggccagc gactccggga gggagatggc cccgacggcc ctgccgatga cggcgcaggg

7981 gcccaggccg acctggagca cagcctgctg gtggcggccg agaagaagga cgagggcccc

8041 tacaggatgg agcacttccg ctggggcagc ccgcccaagg acaagcgcta cggcggtttc

8101 atgacctccg agaagagcca gacgcccctg gtgacgctgt tcaaaaacgc catcatcaag

8161 aacgcctaca agaagggcga gtgagggcac agcgggcccc agggctaccc tcccccagga

8221 ggtcgacccc aaagcccctt gctctcccct gccctgctgc cgcctcccag cctggggggt

8281 cgtggcagat aatcagcctc ttaaagctgc ctgtagttag gaaataaaac ctttcaaatt

8341 tcacatccac ctctgacttt gaatgtaaac tgtgtgaata aagtaaaaat acgtagccgt

8401 caaataacag cagcatggat cggaggagca cagtggtttc catgcggtag gatatttcac

8461 aggacttagt gagcgtgaaa ggaaaatgtg cttcctgccc ccacccccaa atggatcttc

8521 gagggatcag atagtttggg tgaaggcaca gggtggctcc agcacctcta ggatggccgt

8581 attttccaca cactccactg agtgggagac tgctcagcta gcacacgtgt aaaggcagga

8641 ttcctgcaag agtgaccc (SEQ ID NO: 564)

In some embodiments, examples of mutations in POMC, such as resulting in homozygous POMC deficiency, are described, for example, in the references shown in Table 2, each of which is incorporated herein by reference.

table 2

A source Aslan et al. International Journal of Obesity (2014) 38, 148-151 Krude et al. J Clin Endocrinol Metab 88: 4633-4640, 2003) Krude et al. Nature genetics, V 19 (June) 1998; 155-157. Darcan S et al. Transient Salt Wasting in POMC-deficiency. Exp Clin Endocrinol Diabetes 2010; 118:281-283 Mendiratta et al. International Journal of Pediatric Endocrinology 2011, 2011:5 Farooqi et al. Diabetes 2006; 55(9): 2549-2553 Clement et al. JCEM 2008; 93(12): 4955-4962. Krude H, Grüters A: Implications of Proopiomelanocortin (POMC) mutations in humans: the POMC deficiency syndrome. Trends in Endocrinology and Metabolism 2000, 11(1):15-22. Hung et al. J Ped Endocrinol Metabol 2012; 25(1-2): 175-179 Ozen et al. J Ped Endocrinol Metabol 2015; 28(5-6): 691-694 Cirillo G, et al., Br J Dermatol. 2012;167:1393-5 Samuels J Clin End Met, 2013, 98(2); 736-742

Additionally, hypermethylation of the POMC gene has been associated with obesity in children. See, for example, Kuehnen et al. PLoS Genetics. 8.3(2012):e1002543. A variant with hypermethylation in the CpG island at the intron 2-exon 3 border of the POMC gene is strongly associated with obesity compared to normal weight children. See above. Exon 3 of POMC is believed to be involved in binding to the P300 transcriptional enhancer, and hypermethylation in exon 3 reduces the expression of the POMC transcript. See above.

In other embodiments, exemplary mutations in POMC include one or more of the mutations described in one or more of the following sources: Aslan, Int J Obes (Lond). Jan 2014;38(1):148-51; Krude, Nature 1998; nineteen; 155-157; Krude, Jclin Res Metab 2003.88(10); 4633-4640; Samuels, J Clin Endocrin Metab, 2013; 98(2); 736-742; Clement, J Clin Endocrin Metab., 2008; 93(12); 4955-4962; Creemers, J Clin Endocr Metab, 2008, 93(11); 4494-4499; Cirillo, British Assoc Derm, 2012, 167; 1390-1400; ESPE poster Barcelona 2015, R Marina et al.; Farooqi, Diabetes 2006; 55; 2549-2553; Mendiratta, Int J Pediatr Endocrinol. 2011;2011:5; A Meloni, et al., ESPE Poster Barcelona 2015; Hinney, J Clin Endocrin Metab, 1998, 10; 3737-3741; Lee, Cell Metabol., 2006; 3; 135-140 (PLOF); Dubern, Pediatric Res. 2008; 63(2); 211-216; Philippe et al. Int. J. Obes. 39.2.(2015):295-302; Bieberman, 2006; 3; 141-146; or Buono, Clin Chem, 2005; 51(8); 1358-1364; Challis, Hum. Mol. Genet. 11(17): 1997; Hum. Mol. Genet. 11(17): 1998, each of which is incorporated herein by reference in its entirety.

PCSK1

Subtilisin/kexin proprotein convertase type 1 (PCSK1, also referred to as PC1/3) is an enzyme that acts upstream of MC4R in the POMC-MC4R pathway to process (cleave) prohormones such POMC into their mature forms.

There is evidence that a heterozygous nonsense variant in PCSK1 (p.Arg80*), which encodes a polypeptide truncated to less than two of 14 exons, is associated with obesity in humans. See, for example, Philippe et al. Intl. J. Obesity 39.2(2015):295-302.

The PCSK1 gene is located in humans at the cytogenetic position 5q15-q21. The sequence of the human PCSK1 gene is contained in the GenBank accession number NG_021161.1 and is incorporated herein by reference. An example nucleic acid variant 1 transcript of human PCSK1 is contained in the GenBank accession number NM_000439.4 (see, for example, Hsiao et al. Gene 533 (1), 32-37 (2014)) and is incorporated herein by reference. An exemplary amino acid sequence of human PCSK1 isoform 1 is available from GenBank Accession Number NP_000430.3 and is incorporated herein by reference. An example nucleic acid variant 2 transcript of human PCSK1 is held in the GenBank accession number NM_001177875.1 and is incorporated herein by reference. An exemplary amino acid sequence of human PCSK isoform 2 is available from GenBank under accession number NP_001171346.1 and is incorporated herein by reference.

In some embodiments, examples of mutations in PCSK1, such as resulting in homozygous PCSK1 deficiency, are described, for example, in the references shown in Table 3, each of which is incorporated herein by reference.

Table 3

A source Jackson et al. (Cambridge). Nature Genetics 1997:16(June):303-306 O'Rahilly et al. NEJM 1995:333:1386-1390 Jackson et al. J. Clin. Invest. 112:1550-1560 (2003). doi:10.1172/JCI200318784 Farooqi et al. J Clin Endocrinol Metab. 92: 3369-3373, 2007 Martin et al. Gastroenterology 2013;145:138-148 Yourshaw et al. J Pediatr Gastroenterol Nutr. Dec 2013; 57(6): 759-767 Frank et al. (Farooqi). Molecular Genetics and Metabolism 110 (2013) 191-194 Wilschanski et al. PLOS One Oct. 2014; DOI: 10.1371/Journal.pone.0108878

In some embodiments, examples of mutations in PCSK1, such as resulting in heterozygous PCSK1 deficiency, are described, for example, in the references listed in Table 4, each of which is incorporated herein by reference.

Table 4

Examples of heterozygous variants leading to loss of PCSK1 function (PCSK1+/-) A source Function Met125Ile
Thr175Met
Asn180Ser
Tyr181His
Gly262Arg
Ser325Asn
Thr558Ala Diabetes 2012, V 61: 383 complete loss of function Asn221Asp
Gln665E-S690Thr Nature genetics 2008, 40(8): 943 Influences PCSK1 binding to Ca2+

In other embodiments, an exemplary mutation in PCSK1 includes one or more of the mutations described in one or more of the following: Martin, Gastroenterology 145:138-48, 2013; Creemers, Diabetes 61:383, 2012; Jackson, Nature Gen.: July 16, 1997, p. 303; Martin, Gastroenterology 145:138-48, 2013; Blanco et al. Endrocrinology 156:3625-37, 2015; Jackson, J. Clin. Investigation 112:1550-51, 2003; Benzino, Nat. Genetics 8: 943, 2008; Yourshaw, Gastroenterology 57(6):759, 2013; Faroqi, J. Clin. Endocrinol. & Metab. 92:3369-73, 2007; Pickett, PLoS One 8:e55065, 2013; Bohours-Nouet, EXPE Poster at Barcelona 2015 PSW meeting; Graeme et al., Mol. Gen. Metabol. 110:191-94, 2013; Blanco et al. Endrocrinology 155:3434-47, 2014; Wilschansky PLoS ONE 9: 108878, 2014; Frank, Mol.Gen Metabol. 2013; and Harter J. Pediatr. Gastroentrol Nutr. 2015, each of which is hereby incorporated by reference in its entirety.

MAGEL2

It is believed that MAGEL2 (melanoma antigen (MAGE) of the L2 family or MAGE-like protein 2) is involved in the ubiquitin ligase activity of E3 zinc finger ubiquitin protein ligases, and possibly in the regulation of circadian rhythms. MAGEL2 is a member of the MAGE family of proteins that are involved in pathways that modulate protein degradation, protein modification, transcription, and cytoskeletal rearrangements. See, for example, Mercer et al. PLoS Genetics 9.1(2013):e1003207.

In mice, MAGEL2 is expressed in the hypothalamus, including the arcuate nucleus, which controls energy homeostasis. There is evidence that mice lacking expression of the MAGEL2 gene (mice has a null genotype for MAGEL2) gain weight poorly at an early age, after which they become obese and gain weight. See, for example, Mercer et al. PLoS Genetics 9.1(2013):e1003207. There is evidence that adult mice without MAGEL2 (has a null genotype for MAGEL2) demonstrate defective anorexigenic responses and defective responses of POMC neurons to leptin. See, for example, Pravdivyi et al. Hum. Mol. Genet. 2015, 1-8. MAGEL2-deficient mice (MAGEL2 genotype null mice) also have reduced alpha-MSH levels in the paraventricular nucleus of the hypothalamus. See above. In embodiments, examples of MAGEL2 mutations, such as mutations resulting in loss of MAGEL2 function, are described in Schaaf et al. Nat Genet. 2013 Nov;45(11):1405-8. doi: 10.1038/ng.2776. Epub 2013 Sep 29; and Soden et al. Sci Transl Med. 2014 Dec 3;6(265):265ra168, each of which is incorporated herein by reference.

MAGEL2 is one of a group of genes that are inactivated in Prader-Willi syndrome (PWS). Inactivating mutations in MAGEL2 have been found in children with signs of PWS. See above. There is evidence of a heterozygous mutation c.1652delT (p.Val551fs) in MAGEL2 (NM_019066.4) in a 13 year old subject. See, for example, Schaaf et al. Nat. Genet. 45.11(2013):1405-09. A heterozygous mutation c.1802delC (p.Pro601fs) has also been reported in an 8 year old subject. See above. A heterozygous mutation c.3181_3182delAT (p.Ile1061fs) has also been reported in a 5 year old subject. See above. A c.3124C>T (p.Gln1024*) mutation has also been reported in a 19 year old human subject. See above. The SPV is described in more detail below.

The human MAGEL2 gene sequence is provided in NG_016776.1, and is incorporated herein by reference. An example of a MAGEL2 human transcript nucleic acid sequence is NM_019066.4, incorporated herein by reference. An example amino acid sequence for human MAGEL2 is NP_061939.3, incorporated herein by reference.

Leptin and the leptin receptor (leptin-R)

Leptin is an adipocyte-produced hormone whose action suppresses hunger and thus regulates energy homeostasis, food intake, body weight, and glucose homeostasis. Leptin acts upstream of MC4R in the POMC-MC4 pathway by binding to the leptin receptor (leptin-R, also called LEP-R, OB-R, or CD295). POMC neurons are involved in leptin-mediated activity in the brain, and one of the effects of leptin binding to the leptin receptor is the stimulation of POMC expression. See, for example, Varela et al. EMBO Reports 13.12(2012):1079-86. There is evidence that division of leptin-R in POMC neurons leads to obesity, which effect was partially offset by overexpression of the leptin receptor in these mice, which has a null leptin receptor genotype. See above. There is evidence that mutations in leptin (Lep ob/ob (ob~obesity)) or the leptin receptor (Lep db/db (db~diabetes)) are associated with impaired glucose homeostasis and increased body weight in mice. See above. Additionally, fa/fa (fa~fat) genotype rats have been described that are deficient in the leptin receptor. See, for example, Cettour-Rose et al. Endocrinology: 2002; 143(6); 2277-2283.

Examples of mutant (eg, non-functional) leptin variants in humans associated with obesity have been described. A homozygous frameshift mutation that results in a deletion of the guanine nucleotide at codon 133 of the leptin gene has been associated with severe obesity in some severely obese children. See, for example, Montague et al. Nature 387.6636(1997):903-8. A homozygous transversion in leptin (c.298G→T) resulted in an aspartate to tyrosine substitution at amino acid position 100 (p.D100Y) and was associated with early-onset extreme obesity (see, e.g., Wabitsch et al. N. Engl. J. Med. 372.1(2015):47-54). Homozygous Gln223Arg and Lys656Asn mutations in the leptin receptor have been associated with obesity in humans. See, for example, Masuo et al. hypertens. Res. 31.6(2008):1093-100. Additional examples of mutations in leptin/leptin-R are described in Lee. Annals Acad. Med. 38.1(2009):34-44.

In some embodiments, examples of mutations in the leptin receptor (LEPR), for example, resulting in homozygous leptin receptor deficiency, are described, for example, in the references listed in Table 5, each of which is incorporated herein by reference.

Table 5

A source Farooqi et al., New Engl J Med, 356: 237-247; 2007 Clement et al., Nature 392: 398-401, 1998. Montague et al., Nature 387: 903-908, 1997 Farooqi et al., J. Clin. Invest. 110:1093-1103, 2002 Gibson et al., J. Clin. Endocr. Metab. 89: 4821-4826, 2004 Wabitsch et al., New Eng. J. Med. 372:48-54, 2015. Saeed et al., Obesity 2014; 22; 1112-1117 Huvenne et al., J Clin Endocrinol Metab. 2015 Vol 100; issue 5: E757-766

In some embodiments, examples of mutations in the leptin receptor, such as those resulting in homozygous leptin receptor deficiency, are described, for example, in the references listed in Table 6, each of which is incorporated herein by reference.

Table 6

Examples of Loss of LEPR Function in Homozygous (LEPR-/-) Variants A source Function c.2396-1 G>T Obesity 2014; 22(4); 1112 Splicing defect in exon 15 c.1675 G>A Obesity 2014; 22(4); 1112 nonsense mutation p.Cys604Gly
p.Leu786Pro
p.His800_Asn831del
p.Tyr422His
p.Thr711NfsX18
P.535-1G>A
p.166CfsX7 J Clin Endocrinol Metab; 2015; 100(5): E757 probable loss of LEPR function 4-bp del at codon 22
11-bp del at codon 70
66-bp del at codon 514
Trp31X
Ala409Glu
Trp664Arg
His684Pro
1-bp del at codon 15/ Arg612His N Eng J Med. 2007; 356(3): 237 broken LEPR signaling

Examples of human leptin transcript nucleic acid sequences are provided in NM_000230.2 and BC060830.1, which are incorporated herein by reference. Exemplary human leptin precursor amino acid sequences are provided in NP_000221.1, AAH69452.1, AAH69527.1, AAH69323.1, AAH60830.1, which are incorporated herein by reference. Examples of human leptin receptor nucleic acid sequences are available from GenBank under accession numbers U66497.1, U66496.1, U66495.1, U43168.1, NM_001198689.1, NM_001198688.1, NM_001198687.1, NM_001003679.2, NM_00 NM_001003680.3 and incorporated herein by reference. Exemplary human leptin receptor amino acid sequences are contained in GenBank Accession Numbers P48357.2, AAB09673.1, AAC23650.1, AAB07497.1, AAB07496.1, AAB07495.1, AAA93015.1 and incorporated herein by reference.

In other embodiments, an exemplary mutation in LEPR includes one or more of the mutations described in one or more of the following sources: Faroqui et al., N Engl J Med 356:237-24, 2007; Gill et al., Obesity 22:576-84, 2014; Kimber et al., Endocrinol. 149:6043-52, 2008; Huvenne et al. J. Clin. Endo Metab. 100:E757-66, 2015; and Mammes et al., Eur. J. Clin. Inv. 31:398-4004, 2015, each of which is incorporated herein by reference in its entirety.

5H T2c receptor

The G-protein coupled 5-hydroxytryptamine (serotonin) 2C receptor (5-HT2c receptor) is a G protein coupled receptor (GPCR) that binds to the neurotransmitter serotonin. Among other physiological functions, the 5HT2c receptor is involved in the regulation of nutrition. The 5HT2c receptor acts upstream of MC4R in the POMC-MC4R pathway. Stimulation of the 5-HT _2C receptor leads to an increase in POMC levels in the anterior pituitary gland. By binding to serotonin receptors, including the 5HT2c receptor, serotonin increases POMC activity and impairs eating behavior. See, for example, Roepke et al. Am. J Physiol. Endocrinol. Metab. 302.11(2012):E1399-406. There is evidence that 5HT2c receptor agonists reduce nutrition in mice. See, for example, Bickerdike. Curr. top. Med. Chem. 3.8(2003):885-97. Alternative splicing of the receptor is regulated by a small nucleolar RNA (macRNA, snoRNA), SNORD115. In PWS, SNORD115 is inactivated. Without intending to be bound by any theoretical justification, it is believed that the polymorphisms are associated with obesity.

The human 5-HT2c receptor gene sequence is contained in GenBank accession number NG_012082.2 (see, for example, Jahnsen JA et al. Eur. J. Pharmacol. 684 (1-3), 44-50 (2012)) and included to this document by reference. Example nucleic acid sequences of the human 5-HT2c receptor are contained in the GenBank accession numbers NM_001256761.2, NM_001256760.2, NM_000868.3, and are incorporated herein by reference. Exemplary amino acid sequences for the human 5-HT2c receptor are available from GenBank under accession numbers NP_001243690.1, NP_001243689.1, NP_000859.1, incorporated herein by reference.

NhLH2

NhLH2 is a neuronal transcription factor that acts upstream of MC4R in the POMC-MC4R pathway. NhLH2 is a member of the base family of helix-loop-helix (bHLH) transcription factors. NhLH2 is expressed in a number of differentiated adult neurons, including pro-opiomelanocortin neurons and MC4R neurons. NhLH2 expression may be regulated by food intake and leptin levels. See, for example, Good et al. Trends Endocrinol. Metab. 24.8(2013):385-90. In studies in NhLH2 knockout mice, in which gene deletion leads to obesity with onset in adulthood, NhLH2 has been reported to be involved in the regulation of body weight and fertility. See, for example, Good et al. Nat. Genet. 15(1997):397-401. In embodiments, examples of mutations, for example, that result in heterozygous NhLH2 deficiency are described, for example, in Rayyan et al. Gene. 2013;512(1):134-42, incorporated herein by reference.

NhLH2 binds to leptin-regulated transcription factor, signal transducer and activator-3 (Stat-3), thus regulating PCSK1 in response to leptin or food intake. NhLH2 knockout mice have lower levels of PCSK1 than wild-type mice. This results in reduced levels of truncated PCSK1 peptide, such as mature POMC. See, for example, Good et al. Trends Endocrinol. Metab. 24.8(2013):385-90.

Examples of human NhLH2 nucleic acid sequences are contained in the GenBank accession numbers XM_006710666.2, XR_946659.1, NM_001111061.1, NM_005599.3 (see, for example, Al Rayyan et al. Gene 512 (1), 134-142 (2013 )) and are incorporated herein by reference. Examples of human NhLH2 amino acid sequences are contained in the GenBank accession numbers XP_006710729.1, NP_001104531.1, NP_005590.1 and are incorporated herein by reference.

Prohormone convertase

Prohormone convertases are serine proteases that process the precursors of peptide hormones and neuropeptidases. There are several types of prohormone convertases: PCSK1 (also known as PC1, PC3 and PC1/3), PCSK2 (also known as PC2), PCSK3 (also known as furin, pace and PC1), PCSK4 (also known as PC4) , PCSK5 (also known as PC5, PC6, and PC5/6), PCSK6 (also known as PACE4), PCSK7 (also known as PC7, PC8), PCSK8 (also known as site 1 protease, S1P, SKI), and PCSK9 ( also known as NARC-1). Prohormone convertases are responsible for the breakdown of POMC to form alpha-MSH. For example, PC1 cleaves POMC to form pro-ACTH, which is then cleaved by PC2 convertase to form ACTH1-17. See, for example, Pritchard et al. J. Endocrinol. 172(2002):411-21.

It is believed that defective POMC processing can lead to obesity. A patient with complex heterozygous mutations in PC1 exhibited extreme obesity with onset in childhood, abnormal glucose homeostasis, hypofunction of the adrenal cortex, and hypogonadotropic hypogonadism. See above. There is also information about another patient with defective POMC processing. See above.

Examples of PCSK1 sequences are described above. Examples of human PCSK2 nucleic acid sequences are contained in the GenBank accession numbers NM_002594.4 (see, for example, van Wamelen et al. J. Neuropathol. Exp. Neurol. 72 (12), 1126-1134 (2013)), NM_001201529. 2, NM_001201528.1, and incorporated herein by reference. Example amino acid sequences of human PCSK2 are contained in the GenBank accession numbers NP_001188458.1, NP_001188457.1, NP_002585.2 and are incorporated herein by reference. Examples of human PCSK3 nucleic acid sequences are contained in the GenBank accession numbers NM_001289824.1, NM_001289823.1, NM_002569.3, and are incorporated herein by reference. Example amino acid sequences of human PCSK3 are contained in the GenBank accession numbers NP_001276753.1 (see, for example, Dahms et al. ACS Chem. Biol. 9 (5), 1113-1118 (2014)), NP_001276752.1, NP_002560.1 , and incorporated herein by reference. An example of a human PCSK4 nucleic acid is contained in the GenBank accession number NM_017573.4 (see, e.g., Seidah et al. J. Biol. Chem. 288 (30), 21473-21481 (2013)), and is incorporated herein by links. An example of the amino acid sequence of human PCSK4 is held in the GenBank accession number NP_060043.2, and is incorporated herein by reference. The sequence of the human PCSK5 gene is contained in the GenBank accession number NG_029445.1, and is incorporated herein by reference. Examples of human PCSK5 nucleic acid sequences are contained in the GenBank accession numbers NR_120409.1, NM_006200.5, NM_001190482.1 (see, for example, Mbikay et al. Genomics 26 (1), 123-129 (1995)) and are included in this document by reference. Example amino acid sequences of human PCSK5 are contained in the GenBank accession numbers NP_001177411.1, NP_006191.2 and are incorporated herein by reference. The human PCSK6 gene sequence is held in GenBank under accession number NG_030047.3 and is incorporated herein by reference. Examples of human PCSK6 nucleic acid sequences are contained in the GenBank database under accession numbers NM_138325.3, NM_001291309.1, NM_138323.2, NM_138324.2, NM_138322.3, NM_138319.3, NM_002570.4 (see, for example, Tsuji et al. J Biochem 122 (2), 438-452 (1997)) and incorporated herein by reference. An example of a human PCSK7 nucleic acid is contained in the GenBank accession numbers NM_004716.3 (see, for example, Stickel et al. Hum. Mol. Genet. 23 (14), 3883-3890 (2014)) and incorporated herein by reference . An example of the amino acid sequence of human PCSK7 is available from GenBank under accession number NP_004707.2 and is incorporated herein by reference. The sequence of the human PCSK8 gene is held in the GenBank accession number NG_033017.1 and is incorporated herein by reference. An example of a human PCSK8 nucleic acid is contained in the GenBank accession number NM_003791.3 (see, for example, Weiss et al. J. Invest. Dermatol. 134 (1), 168-175 (2014)) and incorporated herein by reference . An example of the amino acid sequence of human PCSK8 is contained in the GenBank accession number NP_003782.1 and is incorporated herein by reference. The sequence of the human PCSK9 gene is held in the GenBank accession number NG_009061.1 and is incorporated herein by reference. Examples of human PCSK9 nucleic acid sequences are listed in GenBank accession numbers XM_011541193.1, NR_110451.1, and NM_174936.3 (see, e.g., Brouwers et al. Clin. Sci. 126 (9), 679-684 (2014)) and incorporated herein by reference. Example amino acid sequences of human PCSK9 are contained in the GenBank accession number XP_011539495.1 and NP_777596.2 and are incorporated herein by reference.

In some embodiments, examples of mutations in prohormone convertase, eg, PCSK1, result in homozygous deficiency, as described, for example, in the references shown in Table 3, each of which is incorporated herein by reference.

In some embodiments, examples of mutations in hormone convertase, eg, PCSK1, eg, those that result in heterozygous deficiency, are described, eg, in the references listed in Table 4, each of which is incorporated herein by reference.

CPE

Carboxypeptidase E (CPE), also called carboxypeptidase H (CPH) or convertase, is an enzyme that catalyzes the release of C-terminal lysine or arginine residues from polypeptides. CPE is involved in the processing of many neuropeptides and peptide hormones. For example, CPE acts downstream of prohormone convertases, and leads to the generation of intermediate peptide precursors with further transformation of polypeptides by removing the C-terminal basic residues, resulting in the formation of mature peptides. For example, CPE is involved in the processing of POMC. CPE mutations are associated with obesity. For example, a morbidly obese female patient was described who had a shortening mutation in the CPE gene (c.76_98del; p.E26RfsX68). See, for example, Alsters et al. PLOS ONE. 10.6(2015):e0131417. In embodiments, examples of mutations in CPE, such as those resulting in homozygous CPE deficiency, are described, for example, in Alsters et al. PloS One. 10.6(2015):e0131417, which is incorporated herein by reference.

An exemplary CPE nucleic acid sequence is contained in GenBank accession number NM_001873.2 (Skalka et al. Oncogene 32 (23), 2836-2847 (2013)) and incorporated herein by reference. An example of the CPE amino acid sequence is available from GenBank under accession number NP_001864.1 and is incorporated herein by reference.

Sim1

Single-minded 1 (Sim1) is a transcription factor involved in the development of the paraventricular nucleus of the hypothalamus, which regulates body weight, energy expenditure, and appetite. Sim1 affects MC4R in the POMC-MC4R path. Loss of Sim1 function (eg, in Sim1+/- and Sim1-/- mice) has been reported to cause hyperphagia, obesity, and increased susceptibility to diet-induced obesity. See, for example, Xi et al. PLOS One. 7.4(2012):e36453. In addition, ablation of neurons in Sim1 mice resulted in obesity caused by increased food intake and reduced energy expenditure. See above. In embodiments, examples of mutations in Sim1, such as resulting in heterozygous Sim1 deficiency, are described, for example, in Bonnefond et al. J. Clin. Invest. 123.7(2013):3037-41, which is incorporated herein by reference.

The human SIM1 gene sequence is held in GenBank under accession number NG_008230.1 and is incorporated herein by reference. Examples of human SIM1 nucleic acid sequences are contained in GenBank accession numbers XM_011536073.1 (see e.g. Ramachandrappa et al. J. Clin. Invest. 123 (7), 3042-3050 (2013)), XM_011536072.1, XM_005267100 .2, NM_005068.2 and incorporated herein by reference. Example amino acid sequences of human SIM1 are contained in the GenBank accession number XP_011534375.1, XP_011534374.1, XP_005267157.1, NP_005059.2 and are incorporated herein by reference.

BBS1-20

BBS1-BBS20 are 20 genes associated with Bardet-Biedl syndrome. Mutation(s) in one or more of the BBS genes has been associated with obesity, blindness, and hearing loss. Mice without the BBS1 gene in the nervous system have been shown to develop obesity. See, for example, Guo et al. PLOS Genetics 12.2(2016):e1005890. In addition, it has been described that heterozygous carriers of mutations in genes are more prone to obesity than control subjects. See, for example, Gupta et al. J. Endocrinol. 203(2009):327-36.

In embodiments of the method described herein, the method includes treating a subject having one or more mutations in one or more BBS1-BBS20 genes. In embodiments, the method described herein comprises the use of an MC4R agonist described herein to treat a subject having one or more mutations in one or more of the BBS1-BBS20 genes. Examples include non-coding variants in one or more BBS genes, such as BBS2, BBS4, and/or BBS6. Some sources have shown, for example, that single nucleotide polymorphisms in BBS6 and BBS4 are associated with obesity in children and adults. See, for example, Gupta et al. J. Endocrinol. 203(2009):327-36.

ALMS1

Alström's syndrome (ALMS) is an autosomal recessive disease associated with blindness, deafness, diabetes and obesity, hyperinsulinemia, and altered glucose metabolism, which can lead to the development of type 2 diabetes at a young age in affected subjects. ALMS is caused by mutations in ALMS1 , a gene that has been mapped to chromosome 2p13. The progression from early-onset obesity to impaired fasting plasma glucose or impaired glucose tolerance and overt diabetes is thought to be caused mainly by progressive failure of β-cell insulin secretion, with no further worsening of insulin resistance with age, even with weight loss (Bettini et al. Pediatr Diabetes 13:59-67, 2012). The identification of ALMS1 as a ciliary protein explains some of the observed phenotypes and their similarities to other ciliopathy, including Bradet-Biedl syndrome.

Nucleic acid sequences associated with Alstrom syndrome, variants of the nucleic acid sequence, the protein encoded by such nucleic acid, and screening methods for testing individuals to determine whether they are carriers of Alstrom syndrome are disclosed, for example, in US patent No. 7,196,171.

In embodiments of the method described herein, the method comprises treating a subject having one or more mutations in one or more alleles of the ALMS1 gene. In embodiments, the method described herein comprises the use of an MC4R agonist described herein to treat a subject having one or more mutations in said gene.

Nucleic acid sequences associated with Alstrom syndrome, variants of the nucleic acid sequence, the protein encoded by such nucleic acid, and screening methods for testing individuals to determine whether they are carriers of Alstrom syndrome are disclosed, for example, in US patent No. 7,196,171.

Pseudohypoparathyroidism (GNAS1 )

In pseudohypoparathyroidism, the body is unable to respond to parathyroid hormone and is associated with obesity and short stature, among other clinical symptoms. The main symptoms are low calcium levels and high blood phosphate levels. Affected patients have cataracts, dental problems, seizures, numbness and/or tetany (muscle twitches and spasms in the feet and hands). Symptoms usually begin to appear in childhood. People with this disorder are also resistant to other hormones such as thyroid-stimulating hormone and gonadotropins. Type 1A is also associated with a group of symptoms known as Albright's hereditary osteodystrophy, which includes short stature, a round face, obesity, and short hand bones. Type 1A pseudohypoparathyroidism is caused by a mutation in the GNAS gene and is inherited in an autosomal dominant fashion. The GNAS1 gene is described in, for example, US20060147936.

In embodiments of the method described herein, the method comprises treating a subject with one or more mutations in one or more alleles of the GNAS1 gene. In embodiments, the method described herein comprises the use of an MC4R agonist described herein to treat a subject having one or more mutations in said gene.

Additional genes

Additional genes that may be used herein include BDNF, MCH1R, MCH, NTRK2, SIM1 ( J Clin Invest. 2013;123(7):3042-3050. doi:10.1172/JCI68016), ENPP1, COH1, CNR1, NPC1 , c-MAF, PTER, FTO, TMEM18 (childhood), SDCCAG8, TNKS/MSRA, GNPDA2 (childhood), NEGr1, INSIG2, KCTD15, NROB2, and 16p11.2 deletions (including the SH2B1 gene).

In embodiments of any method described herein, the method includes treating a subject having one or more mutations in one or more of these genes. In embodiments, the method described herein comprises the use of an MC4R agonist described herein to treat a subject having mutations in one or more of these genes.

Violations

In accordance with the methods and compositions described herein, in some embodiments, an MC4R agonist, e.g., an MC4R agonist described herein, e.g., setmelanotide, is used to treat a disorder, such as a metabolic disorder, e.g., obesity, hyperphagia, or metabolic syndrome.

In embodiments, an agonist, eg, an MC4R agonist described herein, eg, setmelanotide, is used to treat a genetic disorder caused by a deficiency of one or more components of the POMC-MC4R pathway. In embodiments, an MC4R agonist, eg, an MC4R agonist described herein, eg, setmelanotide, is used to treat a genetic disorder such as Prader-Willi syndrome (PWS) or POMC genotype null obesity. In embodiments, an MC4R agonist, e.g., an MC4R agonist described herein, e.g., setmelanotide, is used to treat a genetic disorder associated with a defect in one or more of the following genes: POMC, PCSK1, MAGEL2, leptin-R, leptin, receptor 5-HT2c, NhHL2, prohormone convertase, CPE, MC4R, or Sim1. In embodiments, an MC4R agonist, eg, the MC4R agonist described herein, eg, setmelanotide, is used to treat a genetic disorder associated with hypermethylation of the POMC gene, eg, in the POMC intron.

In embodiments, said genetic disorder is associated with obesity, such as severe obesity, and/or hyperphagia.

Prader-Willi Syndrome (PSW)

Prader-Willi Syndrome (PWS) is a rare genetic disorder that occurs in the United States with an incidence of approximately one in 8,000 to one in 25,000 patients. The hallmark of PWS is severe hyperphagia, an overwhelming physiological need to eat that leads to severe obesity and other complications. Obesity is one of the most significant health hazards in PWS patients, and hyperphagia reduces the ability of PWS patients to live independently, as it necessitates constant costly monitoring of the overeating patient. Without supervision, the patient is likely to die prematurely as a result of suffocation, rupture of the stomach, or from complications caused by morbid obesity. There are currently no approved treatments for obesity and hyperphagia associated with PWS.

Symptoms of PWS include hypotonia in infants with stunted weight gain, rapid weight gain and overeating in childhood, as well as mental retardation, developmental delay, short stature, and hypogonadism. Diagnostic criteria for PWS are described, for example, in Holm et al. Pediatrics 91(1993):398-402.

The genetic factors behind PWS are thought to include loss of function of several genes on chromosome 15 in humans, particularly at 15q11-q13. See, for example, Schaaf et al. Nat. Genet. 45.11(2013):1405-09. Protein-coding genes in this region of the chromosome include MKRN3, MAGEL2, NDN, NPAP1, and SNURF-SNRPN. See above. Examples of MAGEL2-null deficiency are described, for example, in Schaaf et al., and in Soden et al. Sci Transl Med. 2014 Dec 3; 6(265):265ra168, which are incorporated herein by reference. Approximately 70% of patients with PWS have a large deletion (approximately 4 Mb) in the 15q11-q13 region of the paternal chromosome. See, for example, Bervini et al. front. Neuroendocrinol. 34(2014):107-119. Approximately 25% of patients with PWS have maternal uniparental disomy. See above. Mice lacking expression of the MAGEL2 gene show abnormalities in POMC neurons and develop some of the symptoms found in humans with PWS. It is believed that a defect in the MAGEL2 gene (located on chromosome 15 in humans) may impair the function of pro-opiomelanocortin (POMC) neurons, which are key components of the MC4 pathway that normally stimulates satiety by activating downstream MC4 receptors. This violation can block the MC4 pathway.

Without intending to be bound by theory, it is believed that the MC4R agonists described herein, such as setmelanotide, can restore weight and appetite regulation in PWS subjects by bypassing POMC neurons and activating MC4 pathways downstream of the block in that pathway. For example, the melanocortin receptor agonists described herein, such as setmelanotide, may act as replacement therapy for MSH.

Obesity has a POMC genotype null (POMC-null)

Also described as a POMC deficiency syndrome, obese patients with POMC genotype null have homozygous mutations resulting in loss of function in the pro-opiomelanocortin (POMC) genes, resulting in severe obesity with early onset. Patients with POMC-null mutations are severely obese with a body mass index greater than 40 and uncontrolled appetite (severe hyperphagia) beginning in childhood. This genetic disorder may also be associated with hormonal deficiencies such as hypothyroidism, red hair and fair skin are common. This disorder can also be the cause of early death. Obesity POMC genotype null is a very rare genetic disorder, and there are no approved treatments for the obesity and hyperphagia associated with this condition. It is estimated that there are between 50 and 500 patients worldwide who have a POMC genotype null.

Bardet-Biedl Syndrome (BBS, BBS)

In embodiments, the MC4R agonist described herein is used to treat Bardet-Biedl syndrome (BBS, SBB). SBS is a genetically heterogeneous disorder. SBS is a form of Lawrence-Moon-Biedl syndrome and is characterized by obesity, retinopathy, learning disabilities, polydactyly, and hypogenitalism. See, for example, Green et al. New Engl. J. Med. 321(1989):1002-9. Without intending to be bound by any theory, it is believed that GBS is characterized by one or more mutations in one or more of 20 genes (BBS1-BBS20). Most of the SBP genes encode proteins that are considered important for the function, formation and stability of cilia. Eight BBS proteins (BBS1, BBS2, BBS4, BBS5, BBS7, BBS8, BBS9, and BBS18) are thought to form a complex called the BBS-some that mediates transport in the cilia membrane. It is believed that BBS6, BBS10 and BBS12 form a complex with the CCT/TRiC family of group II chaperonins.

It is believed that mutation(s) in the gene(s) causes defects in cilia, eg neuronal cilia, or dysregulation of cilia. It is believed that cilia dysfunction leads to impaired leptin signaling and hyperleptinemia. The role of primary cilia and ciliary proteins in energy homeostasis and obesity-related disorders is described, for example, in Gupta et al. J. Endocrinol. 203(2009):327-36; and Oh et al. Cell Metab. 21.1(2015):21-31. Hyperleptinemia was found in patients with SBS, indicating leptin resistance, while the level of triglycerides, leptin, BP-Z diastolic pressure, and intra-abdominal fat mass in patients with SBS was significantly higher than in controls. See, for example, Feuillan et al. J. Clin. Endocrinol. Metab. 96.3(2011). For example, obesity in BBS-mutated mice is thought to be caused by leptin resistance and defects in leptin receptor transport. See, for example, Berbari et al. Proc. Natl. Acad. sci. USA 110.19(2013):7796-7801. Mice with BBS2, BB4 and BB6 mutations have been shown to be hyperleptinaemic and have reduced food intake in response to leptin. See, for example, Berbari et al. Proc. Natl. Acad. sci. USA 110.19(2013):7796-7801.

Ahlstrom's syndrome

Alström's syndrome (ALMS) is an autosomal recessive disease whose clinical symptoms include severe obesity, hyperinsulinemia, and altered glucose metabolism, which can lead to the development of type 2 diabetes at a young age in affected subjects. ALMS is caused by a mutation in ALMS1 , a gene mapped on chromosome 2p13.

The progression from early-onset obesity to impaired fasting plasma glucose or impaired glucose tolerance and overt diabetes is thought to be caused mainly by progressive failure of β-cell insulin secretion, with no further worsening of insulin resistance with age, even with weight loss (Bettini et al. Pediatr Diabetes 13:59-67, 2012).

results

In embodiments, the methods described herein produce one or more of the following results, including weight loss (e.g., body weight), reduced hunger, no detectable reduction in energy expenditure (e.g., basal metabolic energy expenditure), increased energy expenditure (e.g., basal metabolic energy expenditure). ), reduction in food intake per day/week/month, reduction in waist circumference, no detectable increase in blood pressure, or decrease in blood pressure in the subject, for example, relative to control.

In embodiments, a control is a given parameter measured in a subject prior to administration of an MC4R agonist (MC4R agonist treatment). In embodiments, the control is a predetermined value, such as the mean value of a given parameter across a population of obese individuals, such as those similar in age and gender to the subject, or the value of a given paromer measured in the subject at an earlier point in time (e.g., at previous visit, such as a doctor, healthcare facility, or laboratory).

In embodiments, the outcome (e.g., decrease, increase, no detectable decrease, or no detectable increase in a given parameter) is measured in the subject 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after onset treatment with an MC4R agonist. In other embodiments, an outcome (e.g., decrease, increase, no detectable decrease, or no detectable increase in a given parameter) is measured in the subject over a period of time (e.g., over a period of 1-2 weeks, 2-4 weeks, 4-6 weeks, 6-8 weeks, 8-12 weeks or 12-16 weeks) during treatment.

In embodiments, the methods described herein result in a reduction in weight (e.g., body weight) in a subject compared to a control (e.g., subject's pre-treatment weight or a predetermined value, e.g., mean weight in a population of age-matched obese individuals). and sex with the subject not subjected to therapeutic intervention, or the weight of the subject at a previous visit, eg, at a previous visit). In embodiments, the reduction is from about 1 kg to 3 kg after 1 week of treatment, from about 1 kg to 6 kg after 2 weeks of treatment, from about 2 kg to 12 kg after 4 weeks of treatment, from about 4 kg to 24 kg after 8 weeks of treatment, or approximately 8 kg to 48 kg after 16 weeks of treatment. In embodiments, the reduction occurs at a loss rate of about 1-2 kg/week, e.g., about 2 kg/week, e.g., over 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4-8 weeks of treatment, or more, 8-16 weeks of treatment or 16-32 weeks of treatment or more.

Weight measurements, such as body weight, can be made using standard techniques in the art.

In embodiments, the methods described herein result in a decrease in a subject's hunger level compared to a control (e.g., the subject's pre-treatment hunger level, or a predetermined hunger level, age with the subject, or the subject's hunger level at a previous measurement, such as at a previous visit). In embodiments, the methods described herein result in the elimination of hunger in a subject.

In embodiments, hunger is measured on a scale, such as the Linkert Hunger Scale, which ranges from 0 to and is described here. In embodiments, the methods described herein result in a decrease in a subject's hunger score compared to a control (e.g., the subject's pre-treatment hunger level, or a predetermined hunger level, e.g., the average hunger level of a sex- and age-matched population of obese people with the subject, or the subject's hunger level at a previous measurement, such as at a previous visit). In embodiments, the methods described herein result in a lower Likert hunger score, e.g., a decrease in the score by at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 points, compared to a control (e.g., the subject's hunger level prior to treatment, or a predetermined hunger level, e.g., the mean hunger level of a population of obese people similar in sex and age to the subject, or the subject's hunger level at a previous measurement, such as at a previous visit) . In embodiments, the methods described herein result in a Likert hunger score of 0 after treatment.

In embodiments, a decrease in hunger is measured/observed after 1-2 weeks of treatment or more, 2-4 weeks of treatment or more, 4-8 weeks of treatment or more, or 8-16 weeks of treatment or more.

REE is a measure of a subject's basal metabolic rate and can be determined using methods such as those described in Chen et al. J. Clin. Endocrinol. Metab. 100.4(2015):1639-45. In embodiments, the REE can be determined by placing the subject in an indirect calorimetry chamber (also referred to as a metabolic chamber) at a specific point after treatment (e.g., 3, 4, 5, 6, 7 days, or 1, 2, 3, 4, or over weeks). In embodiments, REEs are measured in 30-minute measurement periods, and in some cases, REE values are averaged over several 30-minute periods to obtain an average REE value. In embodiments, the REE may be determined after a 10-12 hour no food period, at a neutral temperature (eg, approximately 25 degrees C), where the subject is awake in the absence of psychological or physical exertion. In embodiments, REE is measured in units of energy per unit of time (eg, kcal/hour or kcal/day). In embodiments, REE is measured relative to the subject's kg lean mass (eg, REE/kg lean mass), eg, as described in the Examples.

In embodiments, the methods described herein do not result in a change or reduction in energy expenditure, e.g., basal metabolic energy (REE), in a subject over an hour, a day (e.g., 24 hours), a week (e.g., 7 days) or month (e.g., 30 days) compared to a reference REE value (e.g., the pre-treatment REE in a specified subject, or a predetermined REE, e.g., the mean REE of a population of obese people similar in sex and age, and normalized for weight as and for the subject, or with the subject's REE at a previous measurement, e.g., at a previous visit), e.g., when measured after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment.

In embodiments, the methods described herein result in no detectable change or no detectable reduction in energy expenditure, e.g., basal metabolic energy (REE) per kg lean body mass, in a subject over an hour, day (e.g., 24 h), week (e.g., 7 days) or month (e.g., 30 days) compared to a reference REE value (e.g., pre-treatment REE in a specified subject or a predetermined REE, e.g., mean REE of a sex-matched population of obese people and age with the subject, or with the subject's REE at a previous measurement, eg at a previous visit), eg when measured after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment.

In embodiments, the methods described herein result in an increase in energy expenditure, e.g., basal metabolic energy (REE) in a subject for an hour, a day (e.g., 24 hours), a week (e.g., 7 days), or a month (e.g., 7 days). , over 30 days) compared to a reference REE value (e.g., pre-treatment REE in a designated subject or a pre-specified REE, e.g., the mean REE of a population of obese people similar in sex and age, and normalized for weight as well as the subject's scores, or the subject's REE at a previous measurement, eg a previous visit), eg when measured after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment.

In embodiments, the subject's REE increase is at least 20 kcal/day (e.g., at least 20, 30, 40, 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150 kcal/day). day or more), for example, when measured after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment.

In embodiments, the subject's REE increase is at least 2% (e.g., at least 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12 %, 13%, 14%, 15% or more), for example, when measured after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment, compared to the REE in the specified subject before treatment.

In embodiments, the REE in a subject (e.g., an adult subject) after treatment with an MC4R agonist (e.g., after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment) is at least 1800 kcal /day (for example, at least 1800, 1825, 1850, 1875, 1900, 1925, 1950, 1975, 2000, 2025, 2050, 2100, 2150, 2200, 2250, 2300, 2400 kcal/day or more), for example, for an adult subject. In embodiments, the REE in a subject (e.g., a pediatric subject) after treatment with an MC4R agonist (e.g., after 3, 4, 5, 6, 7 days, or 1, 2, 3, 4 or more weeks of treatment) is at least 200 kcal/day (eg, at least 200, 225, 250, 275, 300, 325, 350, 375, 400, 450, 500 kcal/day or more), for example, for pediatric subjects.

In embodiments, the methods described herein result in a reduction in the subject's food intake compared to a control (e.g., the subject's pre-treatment food intake or a predetermined level of food intake, e.g., food intake in an average obese human population or said subject's food intake). at a previous measurement, eg at a previous visit), for example, where food intake is measured as daily food intake or food intake over a 24 hour period or one week. In embodiments, the reduction is at least 100 kcal, e.g., at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 350, 375, 400, 425, 450, 475, 500, 525, 550, 575, 600, 1000 kilocalories or more, for example, for daily food intake or food intake over a period of 24 hours, or one week, or 30 days, or for longer periods of time, for example, for an adult subject . In embodiments, average food intake may decrease from a baseline of equal to or greater than about 100 kcal/kg/day to about 90, 80, 70, 60, 50, 40, 30, 20, or 10 kcal/kg/day or below after treatment with an MC4R agonist, for example, setmelanotide, for example, in a pediatric subject at 1 year of age. In embodiments, mean food intake may decrease from baseline equal to or greater than about 40 kcal/kg/day to about 35, 30, 20, or 10 kcal/kg/day or less following treatment with an MC4R agonist, e.g., setmelanotide, e.g., in a subject of the pediatric category of late adolescence.

Food intake can be determined by standard methods, for example, as described in Rutishauser's source. Pub. Health Nutrition. 8.7A(2005):1100-07.

In embodiments, the methods described herein result in a reduction in the subject's waist circumference compared to a control (e.g., the specified subject's waist circumference prior to treatment, or the subject's waist circumference at a previous measurement, such as a previous visit), as measured after 1, 2 , 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the reduction in waist circumference is at least 2 cm (e.g., at least 2, 3, 4, 5, 6, 7, 8, 9, 10 cm or more) in the subject (e.g., adult subject) compared to control (for example, the waist circumference of the specified subject before treatment or a predetermined value of the waist circumference, for example, the waist circumference of the specified subject of an average population of people with obesity, similar in age and sex, or the waist circumference of the subject at a previous measurement, for example, a previous visit), by measurements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after the start of treatment.

In embodiments, the subject's waist circumference is measured using standard methods. In embodiments, the subject's waist circumference is the maximum value of the subject's transverse circumference, such as around the subject's abdomen. In other embodiments, the subject's waist circumference is measured around the natural waist (eg, between the lower rib and the top of the pelvis), at the level of the navel, or at the narrowest point of the cross section.

In embodiments, the methods described herein result in no detectable increase in blood pressure (e.g., diastolic and/or systolic blood pressure) in a subject compared to control blood pressure (e.g., the subject's pre-treatment blood pressure or a predetermined blood pressure , for example, the blood pressure of an average population of obese people, similar in age and sex, or the blood pressure of the specified subject at a previous measurement, for example, at a previous visit), measured after 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the methods described herein result in a decrease in a subject's blood pressure (e.g., diastolic and/or systolic blood pressure) compared to a control blood pressure (e.g., the subject's pre-treatment blood pressure or a predetermined blood pressure, e.g., blood pressure). pressure of an average population of people with obesity, similar in age and sex, or the blood pressure of the indicated subject at a previous measurement, for example, at a previous visit), as measured after 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the reduction in blood pressure, such as systolic blood pressure, is at least 3 mm Hg. Art. (e.g., at least 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7 mmHg or greater) compared to the subject's pre-treatment blood pressure measured 1, 2, 3, 4 , 5, 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the reduction in blood pressure, such as diastolic blood pressure, is at least 4 mm Hg. Art. (e.g., at least 4, 7, 7.5, 8, 8.5, 9, 9.5, 10 mm Hg or more) compared to the subject's pre-treatment blood pressure as measured 1, 2, 3, 4, 5 , 6, 7, 8, 9, 10 weeks or more after starting treatment.

In embodiments, the methods described herein do not result in any undesirable effect on heart rate or blood pressure.

Subject

In accordance with any of the methods described herein, in some embodiments, the subject is obese, for example, before the administration of the agonist described herein, for example, at the time when the agonist is prescribed to him, or at the time of the first administration of the agonist. In embodiments, the subject is a severely obese subject, a pediatric subject, or an adult patient, for example, prior to administration of the agonist described herein, for example, at the time the agonist is prescribed or at the time of the first administration of the agonist. In embodiments, the subject suffers from hyperphagia, for example, prior to administration of the agonist described herein, for example, at the time the agonist is prescribed or at the time of the first administration of the agonist.

In embodiments, the subject (eg, an adult subject) has a body mass index (BMI) greater than 25 kg/m ² or 30 kg/m ² (eg, ≥ 25, 26, 27, 28, 29, 30, 31, 32, 33 , 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 kg/m ² or more) prior to administration of the agonist, for example, at the time when he is prescribed an agonist, or at the time of the first administration.

In embodiments, the subject (eg, a pediatric subject) has a body mass index (BMI) greater than the 85th-95th percentile prior to agonist administration, eg, at the time the agonist is prescribed or at the time of first administration.

In embodiments, the subject has a body weight of at least about 5 kg, such as at least about 5 kg, 10 kg, 20 kg, 30, 40, 50, 60, 70, 80, 90, 100, 110, 120, 130 , 140,145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 200, 205, 210, 215, 220 kg or more, for example, before the administration of the agonist, for example, at the time when the agonist is prescribed to him, or at the time of first injection. In embodiments, the subject has a body weight of at least 20 kg, at least 60 kg, or at least 100 kg, for example, prior to administration of the agonist, such as at the time the agonist is prescribed or at the time of first administration.

In embodiments, the subject is an adult, such as 18 years of age or older, such as 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 , 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 , 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70 or older.

In embodiments, the subject is a subject in the pediatric category, e.g., aged 18 or younger (e.g., aged 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1 year old or younger.

In embodiments, the subject has or is identified as having a defect, such as a genetic defect or mutation, in one or more of the POMC-MC4R pathway genes. In embodiments, the subject has or is identified as one or more mutations in the POMC, PCSK1, MAGEL2, leptin receptor, leptin, 5-HT2c receptor, NhHL2, pro-hormone confertase, CPE, MC4R, or Sim1 genes, or other genes that interfere with function. POMC-MC4R paths. In embodiments, the subject has or is identified as having a hypermethylated POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine).

In embodiments, the subject suffers from Prader-Willi syndrome.

In embodiments, the subject has, or is identified as having, a loss-of-function mutation in the 15q11-q13 region of chromosome 15, eg, in the paternal allele.

In embodiments, the subject has or is identified as having a mutation (eg, a loss-of-function mutation) in the MAGEL2 gene.

In embodiments, the subject has or is identified as having a POMC genotype null, PCSK1 genotype null, MAGEL2 genotype null, leptin receptor genotype null, leptin genotype null, 5-HT2c receptor genotype null, NhHL2 genotype null, NhHL2 genotype null, prohormone convertase genotype, CPE genotype null, MC4R genotype null, and/or SIM1 genotype null. For example, the subject has or is identified as having a POMC genotype null, obesity is PCSK1 genotype null, obesity is MAGEL2 genotype null, obesity is leptin receptor genotype null, obesity is leptin genotype null, obesity is 5-receptor genotype null. HT2c, obesity is NhHL2 genotype null, obesity is prohormone convertase genotype null, obesity is CPE genotype null, obesity is MC4R genotype null, and/or obesity is SIM1 genotype null.

In embodiments, the subject has or is identified as having the POMC mutation described herein, for example, the POMC mutation described in Table 1. In embodiments, the subject has or is identified as having a mutation in the POMC amino acid sequence selected from one or more of: Cys28Phe , Leu37Phe, His143Glu, Phe144Leu, Tyr221Cys, Pro231Leu, Arg236Gly, or Glu244X, where the amino acid sequence numbering is as described in Takahashi et al. 1981 Febs Letters 135(1)97 (and shown as SEQ ID NO: 563) and corresponds to a protein containing a signal peptide, where X corresponds to early termination.

In embodiments, the subject has or is identified as having the POMC mutation (e.g., a homozygous POMC mutation) described in the reference shown in Table 2. In embodiments, the subject has or is identified as having the POMC mutation (e.g., a heterozygous POMC mutation) described in the reference. shown in Table 1.

In embodiments, said POMC mutation is a homozygous mutation. In embodiments, said POMC mutation is a heterozygous mutation (eg, a compound heterozygous mutation). In embodiments, said POMC mutation is a loss-of-function mutation. In embodiments, said POMC mutation is a partial loss-of-function mutation.

In embodiments, the subject has or is identified as having hypermethylation in the POMC gene, e.g., hypermethylation in exon 3 of the POMC gene, or hypermethylation at the intron 2-exon 3 border of the POMC gene, e.g., hypermethylation in the CpG islet at the intron 2-exon 3 border of the POMC gene .

In embodiments, the subject has or is identified as having a PCSK1 mutation as described herein, e.g., a heterozygous nonsense vaniant (p.Arg80*), a PCSK1 mutation (e.g., a homozygous mutation) as described in the references in Table 3, or a PCSK1 mutation ( e.g., a heterozygous mutation) as described in the reference in Table 4. In embodiments, the subject has or is identified as having a mutation in the PCSK1 amino acid sequence selected from: Met125Ile, Thr175Met, Asn180Ser, Tyr181His, Gly262Arg, Ser325Asn, Thr558Ala, Asn221Asp, Gln665E or S690Thr.

In embodiments, said PCSK1 mutation is a homozygous mutation. In embodiments, said PCSK1 mutation is a heterozygous mutation (eg, a compound heterozygous mutation). In embodiments, said PCSK1 mutation is a loss-of-function mutation. In embodiments, said PCSK1 mutation is a partial loss-of-function mutation.

In embodiments, the subject has or is identified as having the MAGEL2 mutation described herein, e.g. c.1652delT (p.Val551fs), c.1802delC (p.Pro601fs), c.3181_3182delAT (p.Ile1061fs), c.3124C> T (p.Gln1024*), or the mutation described in Schaaf et al. Nat. Genet. 45.11(2013):1405-09 or Soden et al. Sci Transl Med. 2014 Dec 3;6(265):265ra168. In embodiments, said MAGEL2 mutation is a homozygous mutation. In embodiments, said MAGEL2 mutation is a heterozygous mutation (eg, a compound heterozygous mutation). In embodiments, said MAGEL2 mutation is a loss-of-function mutation. In embodiments, said MAGEL2 mutation causes a decrease in function/activity.

In embodiments, the subject has or is identified as having the leptin or leptin receptor mutation described herein. In embodiments, the subject has or is identified as having a leptin mutation as described herein, e.g., a homozygous frameshift mutation that results in a deletion of the guanine nucleotide at codon 133 of the leptin gene, or a homozygous transversion (c.298G→T) that results in replacement of aspartate by tyrosine at amino acid position 100 (p.D100Y). In embodiments, the subject has or is identified as having a leptin-R mutation as described herein, e.g., a Gln223Arg or Lys656Asn mutation, or a mutation (e.g., a homozygous mutation) described in the references in Table 5. In embodiments, the subject has or is identified as having a leptin receptor mutation (e.g., a homozygous leptin receptor mutation) as described in Table 6. In some embodiments, the subject has or is identified as having a leptin receptor mutation selected from: c.2396-1 G>T, c.1675 G>A , p.Cys604Gly, p.Leu786Pro, p.His800_Asn831del, p.Tyr422His, p.Thr711NfsX18, P.535-1G>A, p.166CfsX7, 4-bp del at codon 22, 11-bp del at codon 70, 66 -bp del at codon 514, Trp31X, Ala409Glu, Trp664Arg, His684Pro, 1-bp del at codon 15, or Arg612His.

In embodiments, said leptin or leptin receptor mutation is a homozygous mutation. In embodiments, said leptin or leptin receptor mutation is a heterozygous mutation (eg, heterozygous compound mutation). In embodiments, said leptin or leptin receptor mutation is a loss-of-function mutation. In embodiments, said leptin or leptin receptor mutation is a partial loss-of-function mutation.

In embodiments, the subject has or is identified as having the 5-HT2c receptor mutation described herein. In embodiments, said 5-HT2c receptor mutation is a homozygous mutation. In embodiments, said 5-HT2c receptor mutation is a heterozygous mutation (eg, heterozygous compound mutation). In embodiments, said 5-HT2c receptor mutation is a loss-of-function mutation. In embodiments, said 5-HT2c receptor mutation is a partial loss-of-function mutation.

In embodiments, the subject has, or is identified as having, the NhLH2 mutation described herein, such as that described in Good et al. Nat. Genet. 15(1997):397-401. In embodiments, said NhLH2 mutation is a homozygous mutation. In embodiments, said NhLH2 mutation is a heterozygous mutation (eg, a compound heterozygous mutation). In embodiments, said NhLH2 mutation is a loss-of-function mutation. In embodiments, said NhLH2 mutation is a partial loss-of-function mutation.

In embodiments, the subject has, or is identified as having, the prohormone convertase mutations described herein, for example, as described in Pritchard et al. J. Endocrinol. 172(2002):411-21, or as described in the reference sources in Table 3 or Table 4. In embodiments, the prohormone convertase mutation is a homozygous mutation. In embodiments, the prohormone convertase mutation is a heterozygous mutation (eg, a compound heterozygous mutation). In embodiments, the prohormone convertase mutation is a loss-of-function mutation. In embodiments, the prohormone convertase mutation is a partial loss-of-function mutation.

In embodiments, the subject has or is identified as having the CPE mutation described herein, for example, (c.76_98del; p.E26RfsX68), or as described in Alsters et al. PLOS ONE. 10.6(2015):e0131417. In embodiments, said CPE mutation is a homozygous mutation. In embodiments, said CPE mutation is a heterozygous mutation (eg, a compound heterozygous mutation). In embodiments, said CPE mutation is a loss-of-function mutation. In embodiments, said CPE mutation is a partial loss-of-function mutation.

In embodiments, the subject has or is identified as having the SIM1 mutation described herein, for example, as described in Bonnefond et al. J. Clin. Invest. 123.7(2013):3037-41. In embodiments, said SIM1 mutation is a homozygous mutation. In embodiments, said SIM1 mutation is a heterozygous mutation (eg, a complex heterozygous mutation). In embodiments, said SIM1 mutation is a loss-of-function mutation. In embodiments, said SIM1 mutation is a partial loss-of-function mutation.

In embodiments, the method described herein may include identifying or selecting a subject having a defect, such as a genetic defect or mutation in one or more genes of the POMC-MC4R pathway. In embodiments, the method described herein may include obtaining information about a genotype, a specific sequence, or a mutation. In embodiments, the method described herein may include obtaining genotype information, such as mutations in one or more of the genes POMC, PCSK1, MAGEL2, leptin receptor, leptin, 5-HT2c receptor, NhHL2, prohormone convertase, CPE, MC4R, Sim1, and/or other POMC-MC4R pathway genes. In embodiments, the agonist is administered in response to receiving specific sequence information, such as detection or identification of a specific sequence, such as a mutation, in a gene described herein, one or more of the POMC, PCSK1, MAGEL2, leptin receptor, leptin, 5-HT2c receptor, NhHL2, prohormone convertase, CPE, MC4R, Sim1, and/or other POMC-MC4R pathway genes.

In embodiments, the method described herein may include obtaining information about the methylation status of the POMC gene (eg, hypermethylation in the POMC intron, eg, in the CpG island of the POMC gene, eg, including methylated cytosine, eg, 5'methylcytosine). In embodiments, the agonist is administered in response to the detection of hypermethylation.

In embodiments, the method described herein may include obtaining information about the subject's genotype, for example, obtaining information about the genotype of the 15q11-q13 region of chromosome 15 (eg, in the paternal allele) or the MAGEL2 gene. In embodiments, the agonist is administered in response to detection of a specific sequence, such as a mutation, in the 15q11-q13 region of chromosome 15 (eg, in the paternal allele) or in the MAGEL2 gene.

In embodiments, identifying or selecting a subject as having a specific genotype or a specific sequence, such as a mutation, in a gene may include obtaining information about the specific genotype or sequence, such as a mutation. This kind of information can be obtained in a number of ways, as detailed in the Definitions section.

In some embodiments, the sequence is obtained, for example, by accessing the nucleotide sequence, for example by "direct acquisition" or "indirect acquisition" of the sequence. "Direct acquisition" of a sequence means performing a process ( eg, performing a synthetic or analytical method) that results in a sequence, as in the case of performing a sequencing method ( eg, next generation sequencing (NGS)). "Indirectly obtaining a sequence" refers to obtaining knowledge or information about, or obtaining a sequence from, another party or other source ( for example, a third party laboratory that obtains the sequence directly). The resulting sequence does not have to be the entire sequence, for example, sequencing at least one nucleotide or obtaining information or information that identifies a genotype or a particular sequence, such as a mutation disclosed herein, is a sequence.

In embodiments, the sequence may be obtained directly (directly). Direct sequencing involves performing a process that involves a physical change in a physical entity, such as a starting material such as a tissue sample, such as a blood sample or biopsy, or analysis of an isolated nucleic acid sample ( eg, DNA or RNA). Examples of modifications include obtaining a physical object from two or more starting materials, separating or fragmenting a substance, such as a piece of genomic DNA, separating or purifying a substance ( for example, isolating a nucleic acid sample from their tissue), combining two or more separate objects into a mixture, performing a chemical a reaction that involves breaking or forming a covalent or non-covalent bond. Direct acquisition of a value involves performing a process that involves physically modifying a sample or other substance, as described above.

In some embodiments, obtaining information about a specific genotype or a specific sequence, such as a mutation, may include obtaining a sample, such as from which the genotype or a specific sequence is determined, such as mutations. The term "sample acquisition" as used herein refers to obtaining access to a sample, such as a tissue or nucleic acid sample, by "direct acquisition" or "indirect acquisition" of the sample. "Direct sample acquisition" means performing a process ( eg, performing a physical process such as surgery or extraction) that results in a sample being obtained. "Indirect sample acquisition" refers to the receipt of a sample from another party or from another source ( for example, a third party laboratory that performed the direct sample acquisition). Direct sample acquisition involves performing a process that involves a physical change in a physical substance, such as a starting material such as tissue, such as tissue in a human patient or tissue that has been previously isolated from a patient. Examples of alterations include obtaining a physical object from a starting material, cutting or scraping tissue, separating or purifying a substance ( such as a tissue sample or nucleic acid), combining two separate objects into a mixture, performing a chemical reaction that involves breaking or forming a covalent or non-covalent connections. Direct sample preparation involves performing a process that involves a physical change in the sample or other substance, such as as described above.

In some aspects, this document also provides a method for assessing a subject, for example, the likelihood of responding to an MC4R agonist, for example, the MC4R agonist described herein, for example, setmelanotide. In some embodiments, the method includes obtaining information about the subject's genotype. In embodiments, the method includes obtaining information about the presence or absence of a defect, such as a genetic defect, in one or more POMC-MC4R p pathway genes in a subject.

In embodiments, a subject can be identified as having a defect, such as a mutation, in one or more of the POMC-MC4R pathway genes using the method described herein.

In embodiments, identifying a subject as having a defect, e.g., a genetic defect, e.g., a mutation, indicates that the subject is likely to have a response (e.g., improvement in one or more symptoms) to an MC4R agonist, e.g., an MC4R agonist described in herein, for example, setmelanotide. In embodiments, symptom improvement may include the outcome described herein. For example, improvement in a symptom may include weight loss (eg, body weight), decreased hunger, no detectable reduction in energy expenditure (eg, basal metabolic energy expenditure), increased energy expenditure (eg, basal metabolic energy expenditure), decreased food intake per day/week/ per month, or a decrease in waist circumference, for example, relative to control. In embodiments, identifying a subject having a defect, e.g., a genetic defect, e.g., a mutation, such that such a subject is more likely to respond (or likely to achieve a greater response) to an MC4R agonist, such as the MC4R agonist described herein , e.g., setmelanotide, than in a subject (e.g., an obese subject, e.g., similar in age and/or pre-treatment weight) without a genetic defect in the POMC-MC4R pathway, e.g., an obese subject with the wild-type genotype. In embodiments, a subject that is more likely to achieve a response is more likely to show improvement in one or more symptoms, such as the symptoms described herein, for example, compared to a control, for example, a subject (for example, an obese subject, eg, similar in age and/or pre-treatment weight) without a genetic defect in the POMC-MC4R pathway, eg, an obese subject with the wild-type genotype. In embodiments, a subject who is likely to achieve a greater response is likely to have a greater improvement in symptoms, e.g., the symptoms described herein, e.g., greater weight loss, greater reduction in waist circumference, greater increase in basal metabolic energy expenditure. , greater reduction in food intake, greater reduction in hunger levels, e.g., compared to a control, e.g., a subject (e.g., an obese subject, e.g., close in age and/or pre-treatment weight) without a genetic defect in the POMC-MC4R pathway, e.g. , an obese subject with the wild-type genotype.

In embodiments, the methods described herein further include providing a report indicating the presence or absence of said genetic defect, and in some cases, a subject identifier. In embodiments, the report provides recommendations on possible therapy options, the likely effectiveness of any therapy option, and/or recommendations/instructions for the use of a particular therapy option (e.g., MC4R agonist, e.g., MC4R agonist described herein, e.g., setmelanotide) .

MC4R agonists

Examples of natural MC4R agonists include α-MSH, β-MSH, γ-MSH, and adrenocorticotropic hormone (ACTH) or a functional fragment thereof. Examples of synthetic MC4R agonists are detailed below.

In one embodiment, the agonist used in the methods of the present invention may be any known MC4R agonist. In some embodiments, the MC4R agonist is not adrenocorticotropic hormone (ACTH) or a fragment thereof.

In one embodiment, the MC4R agonist is any of the peptides disclosed in International Application WO2005/000339, which is incorporated herein by reference. In particular, examples include peptides of the following structural formula:

,

,

where

W is Glu, Gln, Asp, Asn, Ala, Gly, Thr, Ser, Pro, Met, Ile, Val, Arg, His, Tyr, Trp, Phe, Lys, Leu, Cya, or absent;

R ¹ is -H, -C(O)CH ₃ , -C(O)(CH ₂ ) _1-4 CH ₃ , -C(O)(CH ₂ ) _1-4 NHC(NH)NH ₂ ,

Tyr-βArg-, Ac-Tyr-β-hArg-, gluconoyl-Tyr-Arg-, Ac-diaminobutyryl-,

Ac-diaminopropionyl-, N-propionyl-, N-butyryl-, N-valeryl-,

N-methyl-Tyr-Arg-, N-glutaryl-Tyr-Arg-, N-succinyl-Tyr-Arg-,

R ⁶ -SO ₂ NHC(O)CH ₂ CH ₂ C(O)-, R ⁶ -SO ₂ NHC(O)CH ₂ CH ₂ C(O)Arg-,

R ⁶ -SO ₂ NHCH ₂ CH ₂ CH ₂ C (O) -, C ₃ -C ₇ cycloalkylcarbonyl, phenylsulfonyl,

C ₈ -C ₁₄ bicyclic arylsulfonyl, phenyl-(CH ₂ ) _q C(O)-, C ₈ -C ₁₄ bicyclic aryl-(CH ₂ ) _q C(O)-,

R ² is -H, -NH ₂ , -NHC(O)CH ₃ , -NHC(O)(CH ₂ ) _1-4 CH ₃ ,

-NH-TyrC(O)CH ₃ , R ⁶ SO ₂ NH-, Ac-Cya-NH-, Tyr-NH-,

HO-(C ₆ H ₅ )-CH ₂ CH ₂ C(O)NH- or CH ₃ -(C ₆ H ₅ )-C(O)CH ₂ CH ₂ C(O)NH-;

R ³ is linear or branched C ₁ -C ₄ alkyl, NH ₂ -CH ₂ -(CH ₂ ) _q -, HO-CH ₂ -,

(CH ₃ ) ₂ CHNH(CH ₂ ) ₄ -, R ⁶ (CH ₂ ) _q -, R ⁶ SO ₂ NH-, Ser, Ile,

q is 0, 1, 2 or 3;

R ⁶ is phenyl or C ₈ -C ₁₄ bicyclic aryl;

m is 1 or 2;

n is 1, 2, 3 or 4;

R ⁹ is (CH ₂ ) _p or (CH ₃ ) ₂ C-;

p is 1 or 2;

R ₁₀ is NH- or absent;

R ⁷ is a 5- or 6-membered heteroaryl or a 5- or 6-membered heteroaryl ring optionally containing an R ⁴ substituent;

R ⁴ is H, linear or branched C ₁ -C ₄ alkyl, phenyl, benzyl or (C ₆ H ₅ )-CH ₂ -O-CH ₂ -;

R ⁸ is phenyl, the phenyl ring optionally having an X or cyclohexyl substituent;

X is H, Cl, F, Br, methyl or methoxy;

R ¹¹ is -C(O) or -CH ₂ ;

R ⁵ is -NH ₂ , -OH, glycinol, NH ₂ -Pro-Ser-, NH ₂ -Pro-Lys-, HO-Ser-,

HO-Pro-Ser-, HO-Lys-, Ser alcohol, Ser-Pro alcohol, Lys-Pro alcohol,

HOCH ₂ CH ₂ -O-CH ₂ CH ₂ NH-, NH ₂ -Phe-Arg-, NH ₂ -Glu-,

NH ₂ CH ₂ RCH ₂ NH-, RHN-, RO-, where R represents C ₁ -C ₄ linear or branched alkyl; and

L represents -SS- or -S-CH ₂ -S-.

Other MC4R agonists include peptides with the following structural formula:

where:

W is a single bond, Glu, Gln, Asp, Asn, Ala, Gly, Thr, Ser, Pro, Met, Ile, Val, Arg, His, Tyr, Trp, or Phe;

R ¹ is -H, -C(O)CH ₃ , -C(O)(CH ₂ ) _1-4 CH ₃ , -C(O)(CH ₂ ) _1-4 -NHC(NH)NH ₂ ,

Tyr-βArg, gluconoyl-Tyr-Arg, Ac-Dab, Ac-Dap, N-succinyl-Tyr-Arg,

N-propionyl, N-valeryl, N-glutaryl-Tyr-Arg, N-butyryl,

R ² is -H, -NH ₂ , -NHC(O)CH ₃ , -NHC(O)(CH ₂ ) _1-4 CH ₃ or -NH-TyrC(O)CH ₃ ;

R ³ is C ₁ -C ₄ straight or branched alkyl, Ser, Ile,

q is 0, 1, 2 or 3;

m is 1 or 2;

p is 1 or 2;

R ⁴ is H or C ₁ -C ₄ linear or branched alkyl;

X is H, Cl, F, Br, methyl or methoxy; and

R ⁵ is -NH ₂ , -OH, glycinol, -Ser-Pro-NH ₂ , -Lys-Pro-NH ₂ , -Ser-OH,

-Ser-Pro-OH, -Lys-Pro-OH -Arg-Phe-NH ₂ , -Glu-NH ₂ , -NHR or -OR,

wherein R is C ₁ -C ₄ linear or branched alkyl.

In yet another embodiment, an MC4R agonist may be represented by the following structural formula:

where

W is Glu, Gln, Asp, Ala, Gly, Thr, Ser, Pro, Met, Ile, Val, Arg, His, Tyr, Trp, Phe, Lys, Leu, Cya, or absent;

R ¹ is -H, -C(O)CH ₃ , -C(O)(CH ₂ ) _1-4 CH ₃ , -C(O)(CH ₂ ) _1-4 NHC(NH)NH ₂ ,

Tyr-βArg-, Ac-Tyr-β-hArg-, gluconoyl-Tyr-Arg-, Ac-diaminobutyryl-,

Ac-diaminopropionyl-, N-propionyl-, N-butyryl-, N-valeryl-,

N-methyl-Tyr-Arg-, N-glutaryl-Tyr-Arg-, N-succinyl-Tyr-Arg-,

R ⁶ -SO ₂ NHC(O)CH ₂ CH ₂ C(O)-, R ⁶ -SO ₂ NHC(O)CH ₂ CH ₂ C(O)Arg-,

R ⁶ -SO ₂ NHCH ₂ CH ₂ CH ₂ C (O) -, C ₃ -C ₇ cycloalkylcarbonyl, phenylsulfonyl,

C ₈ -C ₁₄ bicyclic arylsulfonyl, phenyl-(CH ₂ ) _q C(O)-, C ₈ -C ₁₄ bicyclic aryl-(CH ₂ ) _q C(O)-,

R ² is -H, -NH ₂ , -NHC(O)CH ₃ , -NHC(O)(CH ₂ ) _1-4 CH ₃ ,

-NH-TyrC(O)CH ₃ , R ⁶ SO ₂ NH-, Ac-Cya-NH-, Tyr-NH-,

HO-(C ₆ H ₅ )-CH ₂ CH ₂ C(O)NH- or CH ₃ -(C ₆ H ₅ )-C(O)CH ₂ CH ₂ C(O)NH-;

R ³ is C ₁ -C ₄ straight or branched alkyl, NH ₂ -CH ₂ -(CH ₂ ) _q -, HO-CH ₂ -,

(CH ₃ ) ₂ CHNH(CH ₂ ) ₄ -, R ⁶ (CH ₂ ) _q -, R ⁶ SO ₂ NH-, Ser, Ile,

q is 0, 1, 2 or 3;

R ⁶ is phenyl or C ₈ -C ₁₄ bicyclic aryl;

m is 1 or 2;

p is 1 or 2;

R ⁴ is H, C ₁ -C ₄ linear or branched alkyl, phenyl, benzyl or (C ₆ H ₅ )-CH ₂ -O-CH ₂ -;

X is H, Cl, F, Br, methyl or methoxy; and

R ⁵ is -NH ₂ , -OH, glycinol, NH ₂ -Pro-Ser-, NH ₂ -Pro-Lys-, HO-Ser-,

HO-Pro-Ser-, HO-Lys-, -Ser alcohol, Ser-Pro alcohol, Lys-Pro alcohol,

HOCH ₂ CH ₂ -O-CH ₂ CH ₂ NH-, NH ₂ -Phe-Arg-, NH ₂ -Glu-,

NH ₂ CH ₂ RCH ₂ NH- or RO-, wherein R is C ₁ -C ₄ linear or branched alkyl.

Дополнительные примеры агонистов MC4R, которые можно применять для реализации настоящего изобретения приведены в WO2011104378, WO2011104379, WO201060901, WO200887189, WO200887188, WO200887187, WO200887186, US20110065652, WO2010144341, WO2010144344, WO201065799, WO201065800, WO201065801, WO201065802, WO201037081, WO2009152079, WO2009151383, US20100311648, US20100280079, Wo201081666, Wo201034500, WO200910299, WO200811665, Wo201052256, Wo201052255, Wo201126015, US20100120783, Wo201096854, US20100190793, Wo201025142 and Wo20157592 Additional examples of MC4R agonists that can be used to implement the present invention are given in US patent No. 8,263,608; US Pat. No. 8,247,530; US Pat. No. 8,114,844; and US Pat. No. 7,968,548. The full texts of these publications are incorporated herein by reference.

In one embodiment, the MC4R agonist is a D-Phe-Arg-Trp tripeptide (SEQ ID NO: 560) or a pharmaceutical salt thereof. In another example, the agonist is any peptide that includes SEQ ID NO: 560 or a pharmaceutical salt thereof. In yet another example, the MC4R agonist is an acetylated tripeptide Ac-D-Phe-Arg-Trp-NH ₂ (SEQ ID NO: 561) or a pharmaceutical salt thereof.

In one embodiment, MC4R agonists are Formula (I) agonists, or a pharmaceutically acceptable salt, hydrate, solvate, or prodrug of such an agonist (see International Patent Application Publication WO 2007/008704, incorporated herein by reference in its entirety):

(R ² R ³ ) -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -A ¹⁰ -R ¹ (I).

In formula (I):

A ¹ is Acc, HN-(CH ₂ ) _m -C(O), L- or D-amino acid or removed;

A ² is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Asp, or Glu;

A ³ is Gly, Ala, β-Ala, Gaba, Aib, D-amino acid or removed;

A ⁴ is His, 2-Pal, 3-Pal, 4-Pal, Taz, 2-Thi, 3-Thi or (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁵ is D-Phe, D-1-Nal, D-2-Nal, D-Trp, D-Bal, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, L- Phe or D-(Et)Tyr;

A ⁶ is Arg, hArg, Dab, Dap, Lys, Orn or HN-CH((CH ₂ ) _n -N(R ⁴ R ⁵ ))-C(O);

A ⁷ is Trp, 1-Nal, 2-Nal, Bal, Bip, D-Trp, D-2-Nal, D-Bal or D-Bip;

A ⁸ is Gly, D-Ala, Acc, Ala, 13-Ala, Gaba, Apn, Ahx, Aha, HN-(CH ₂ ) _s -C(O) or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Dab, Dap, Orn, or Lys;

A ¹⁰ is Acc, HN-(CH ₂ ) _t -C(O), L- or D-amino acid or removed;

R ¹ is OH or NH ₂ ;

each of R ² and R ³ , independently at each occurrence, is selected from the group consisting of H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₁ -C ₃₀ )acyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )alkyl, substituted ( C ₁ -C ₃₀ )heteroalkyl, substituted (C ₁ -C ₃₀ )acyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, substituted aryl(C ₁ -C ₃₀ )alkyl and substituted aryl(C ₁ -C ₃₀ )acyl;

R ⁴ and R ⁵ are each independently H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₁ -C ₄₀ )acyl, (C ₂ - C ₄₀ )alkenyl, (C ₂ -C ₄₀ )alkynyl, aryl(C ₁ -C ₄₀ )alkyl, aryl(C ₁ -C ₄₀ )acyl, substituted (C ₁ -C ₄₀ )alkyl, substituted by (C ₁ -C ₄₀ )heteroalkyl, substituted (C ₁ -C ₄₀ )acyl, substituted (C ₂ -C ₄₀ )alkenyl, substituted (C ₂ -C ₄₀ )alkynyl, substituted aryl(C ₁ -C ₄₀ )alkyl, substituted aryl(C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl or -C(NH)-NH ₂ ;

m is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

n is independently 1, 2, 3, 4, or 5 each time it occurs;

s is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

t is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

each of X ¹ , X ² , X ³ , X ⁴ and X ⁸ independently each time it occurs is H, F, Cl, Br, I, (C _1-10 )alkyl substituted with (C _1-10 )alkyl, (C _2-10 )alkenyl, substituted (C _2-10 )alkenyl, (C _2-10 )alkynyl, substituted (C _2-10 )alkynyl, aryl, substituted aryl, OH, NH ₂ , NO ₂ or CN.

In exemplary embodiments of Formula (I) agonists:

(I) if R⁴ represents (C_one-C₄₀)acyl, aryl(C_one-C₄₀)acyl substituted with (C_one-C₄₀)acyl, substituted aryl(C_one-C₄₀)acyl, (C_one-C₄₀)alkylsulfonyl or -C(NH)-NH₂, then R^fiverepresents H or (C_one-C₄₀)alkyl, (C_one-C₄₀)heteroalkyl, (C₂-C₄₀)alkenyl, (C₂-C₄₀)alkynyl, aryl(C_one-C₄₀)alkyl substituted with (C_one-C₄₀)alkyl substituted with (C_one-C₄₀)heteroalkyl substituted (C₂-C₄₀)alkenyl, substituted (C₂-C₄₀)alkynyl or substituted aryl(C_one-C₄₀)alkyl;

(II) if R ² is (C ₁ -C ₃₀ )acyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )acyl, or substituted aryl(C ₁ -C ₃₀ )acyl, then R ³ is H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl , substituted (C ₁ -C ₃₀ )alkyl, substituted (C ₁ -C ₃₀ )heteroalkyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, or substituted aryl(C ₁ -C ₃₀ ) alkyl;

(III) one or both of A ³ and A ⁸ must be present in said compound;

(IV) if A ² is Cys, D-Cys, hCys, D-hCys, Pen or D-Pen, then A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen or D-Pen;

(V) if A ² is Asp or Glu, then A ⁹ is Dab, Dap, Orn or Lys;

(VI) if A^eight is Ala or Gly, then A^one is not NIe; and

(VII) if A ¹ is removed, then R ² and R ³ cannot both be H.

In one embodiment, the agonists used in the methods described herein are compounds of Formula I, where:

A ¹ is A6c, Arg, D-Arg, Cha, D-Cha, hCha, Chg, D-Chg, Gaba, Ile, Leu, hLeu, Met, β-hMet, 2-Nal, D-2-Nal, Nip, Nle, Oic, Phe, D-Phe, hPhe, hPro, Val or deleted;

A ² is Asp, Cys, D-Cys, hCys, D-hCys, Glu, Pen or D-Pen;

A ³ is D-Abu, Aib, Ala, β-Ala, D-Ala, D-Cha, Gaba, D-Glu, Gly, D-Ile, D-Leu, D-Tle, D-Val or deleted;

A ⁴ is His or 3-Pal;

A ⁵ is D-Bal, D-1-Nal, D-2-Nal, D-Phe, D-Trp or D-(Et)Tyr;

A ⁶ is Arg or hArg;

A ⁷ is Bal, Bip, 1-Nal, 2-Nal, Trp, D-Trp;

A ⁸ is A6c, D-Ala, Aha, Ahx, Ala, β-Ala, Apn, Gaba, Gly, or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Lys, Pen or D-Pen;

A ¹⁰ represents Thr or deleted,

wherein at least one of A ³ or A ⁸ is removed, but not both, or pharmaceutically acceptable salts of such compounds.

In some embodiments, the agonists of Formula (I) that can be used in the practice of the invention described herein are compounds of the following formula, or a pharmaceutically acceptable salt of such a compound:

SEQ ID NO: 1

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-β-Ala-Lys)-NH ₂ ;

SEQ ID NO: 2

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-A6c-Lys)-NH ₂ ;

SEQ ID NO: 3

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Ahx-Cys)-NH ₂ ;

SEQ ID NO: 4

D-Phe-c(Cys-His-D-Phe-Arg-Trp-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 5

D-Phe-c(Cys-His-D-Phe-Arg-Trp-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 6

D-Phe-c(Cys-His-D-Phe-Arg-Trp-Gaba-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 7

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-NH ₂ ;

SEQ ID NO: 8

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Apn-Lys)-NH ₂ ;

SEQ ID NO: 9

Ac-A6c-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-NH ₂ ;

SEQ ID NO: 10

Ac-D-2-Nal-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-NH ₂ ;

SEQ ID NO: 11

Ac-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-NH ₂ ;

SEQ ID NO: 12

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-NH ₂ ;

SEQ ID NO: 13

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 14

Ac-Nle-c(Cys-β-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 15

Ac-Nle-c(Cys-Gaba-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 16

Ac-Nle-c(Cys-Aib-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 17

Ac-Nle-c(Cys-Gly-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 18

Ac-Nle-c(D-Cys-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 19

Ac-Nle-c(D-Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 20

Ac-Nle-c(D-Cys-β-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 21

Ac-Nle-c(D-Cys-Gaba-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 22

Ac-Nle-c(D-Cys-Aib-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 23

Ac-Nle-c(D-Cys-Gly-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 24

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-D-Cys)-NH ₂ ;

SEQ ID NO: 25

Ac-Nle-c(Cys-β-Ala-His-D-Phe-Arg-Trp-D-Cys)-NH ₂ ;

SEQ ID NO: 26

Ac-Nle-c(Cys-Gaba-His-D-Phe-Arg-Trp-D-Cys)- NH ₂ ;

SEQ ID NO: 27

Ac-Nle-c(Cys-Aib-His-D-Phe-Arg-Trp-D-Cys)- NH ₂ ;

SEQ ID NO: 28

Ac-Nle-c(Cys-Gly-His-D-Phe-Arg-Trp-D-Cys)-NH ₂ ;

SEQ ID NO: 29

Ac-Nle-c(D-Cys-Ala-His-D-Phe-Arg-Trp-D-Cys)- NH ₂ ;

SEQ ID NO: 30

Ac-Nle-c(D-Cys-D-Ala-His-D-Phe-Arg-Trp-D-Cys)- NH ₂ ;

SEQ ID NO: 31

Ac-Nle-c(D-Cys-β-Ala-His-D-Phe-Arg-Trp-D-Cys)-NH ₂ ;

SEQ ID NO: 32

Ac-Nle-c(D-Cys-Gaba-His-D-Phe-Arg-Trp-D-Cys)- NH ₂ ;

SEQ ID NO: 33

Ac-Nle-c(D-Cys-Aib-His-D-Phe-Arg-Trp-D-Cys)-NH ₂ ;

SEQ ID NO: 34

Ac-Oic-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 35

Ac-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 36

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 37

Ac-D-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 38

Ac-D-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 39

Ac-Nip-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 40

Ac-hPro-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 41

Ac-hLeu-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 42

Ac-Phe-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 43

Ac-D-Phe-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-NH ₂ ;

SEQ ID NO: 44

Ac-D-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 45

n-butanoyl-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 46

n-butyryl-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 47

Ac-hPhe-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 48

Ac-β-hMet-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 49

Ac-Gaba-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 50

Ac-Cha-c(Asp-His-D-Phe-Arg-D-Trp-Ala-Lys)- NH ₂ ;

flSEQ ID NO: 51

Ac-hCha-c(Asp-His-D-Phe-Arg-D-Trp-Ala-Lys)- NH ₂ ;

SEQ ID NO: 52

Ac-Leu-c(Asp-His-D-Phe-Arg-D-Trp-Ala-Lys)-NH ₂ ;

SEQ ID NO: 53

Ac-hLeu-c(Asp-His-D-Phe-Arg-D-Trp-Ala-Lys)- NH ₂ ;

SEQ ID NO: 54

Ac-Phe-c(Asp-His-D-Phe-Arg-D-Trp-Ala-Lys)- NH ₂ ;

SEQ ID NO: 55

Ac-Nle-c(Asp-His-D-Phe-Arg-D-Trp-D-Ala-Lys)-NH ₂ ;

SEQ ID NO: 56

Ac-Nle-c(Asp-His-D-Phe-Arg-D-Trp-β-Ala-Lys)-NH ₂ ;

SEQ ID NO: 57

Ac-Nle-c(Asp-His-D-Phe-Arg-D-Trp-Gaba-Lys)-NH ₂ ;

SEQ ID NO: 58

Ac-Nle-c(Asp-His-D-Phe-Arg-D-Trp-Aha-Lys)- NH ₂ ;

SEQ ID NO: 59

Ac-Nle-c(Asp-His-D-Phe-Arg-D-Trp-Apn-Lys)-NH ₂ ;

SEQ ID NO: 60

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Apn-Cys)- NH ₂ ;

SEQ ID NO: 61

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 62

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Ahx-Cys)- NH ₂ ;

SEQ ID NO: 63

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-β-Ala-Cys)-NH ₂ ;

SEQ ID NO: 64

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-D-Ala-Cys)-NH ₂ ;

SEQ ID NO: 65

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 66

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-2-Nal-Cys)- NH ₂ ;

SEQ ID NO: 67

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-1-Nal-Cys)-NH ₂ ;

SEQ ID NO: 68

n-butanoyl-Nle-c(Cys-D-Ala-His-D-Phe-Arg-2-Nal-Cys)- NH ₂ ;

SEQ ID NO: 69

n-butanoyl-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 70

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-2-Nal-Cys)-NH ₂ ;

SEQ ID NO: 71

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-1-Nal-Cys)-NH ₂ ;

SEQ ID NO: 72

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Bal-Cys)-NH ₂ ;

SEQ ID NO: 73

Ac-Nle-c(Cys-D-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 74

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-D-Ala-Lys)- NH ₂ ;

SEQ ID NO: 75

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-Bal-Cys)-NH ₂ ;

SEQ ID NO: 76

Ac-Nle-c(Pen-D-Ala-His-D-Phe-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 77

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)- NH ₂ ;

SEQ ID NO: 78

Ac-Nle-c(Pen-D-Ala-His-D-Phe-Arg-Trp-Pen)- NH ₂ ;

SEQ ID NO: 79

D-Phe-c(Cys-His-D-Phe-hArg-Trp-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 80

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 81

D-Phe-c(Cys-His-D-Phe-Arg-Bip-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 82

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 83

D-Phe-c(Cys-His-D-Phe-hArg-Bip-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 84

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-NH ₂ ;

SEQ ID NO: 85

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-NH ₂ ;

SEQ ID NO: 86

Ac-Nle-c(Asp-D-Ala-His-D-Phe-Arg-Trp-Lys)-NH ₂ ;

SEQ ID NO: 87

Ac-Nle-c(Asp-D-Ala-His-D-Phe-Arg-Bal-Lys)-NH ₂ ;

SEQ ID NO: 88

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-OH;

SEQ ID NO: 89

Ac-Nle-c(Cys-D-Abu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 90

Ac-Nle-c(Cys-D-Val-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 91

Ac-Nle-c(Cys-D-Ile-His-D-Phe-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 92

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 93

Ac-Nle-c(Cys-D-Tle-His-D-Phe-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 94

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 95

Ac-Nle-c(Pen-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 96

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Pen)- NH ₂ ;

SEQ ID NO: 97

Ac-Nle-c (Pen-His-D-Phe-Arg-Trp-Gaba-Pen) - NH ₂ ;

SEQ ID NO: 98

Ac-Leu-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 99

Ac-Cha-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 100

Ac-Ile-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 101

Ac-Phe-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 102

Ac-Val-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 103

Ac-2-Nal-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 104

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-NH ₂ ;

SEQ ID NO: 105

Phe-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 106

Ac-Nle-c(Cys-3-Pal-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 107

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-OH;

SEQ ID NO: 108

Ac-Nle-c(Cys-His-Phe-Arg-D-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 109

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Ala-Lys)- NH ₂ ;

SEQ ID NO: 110

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-β-Ala-Lys)-NH ₂ ;

SEQ ID NO: 111

Ac-Nle-c(Cys-His-D-2-Nal-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 112

Ac-Nle-c(Cys-His-D-2-Nal-Arg-Trp-Ahx-Cys)- NH ₂ ;

SEQ ID NO: 113

Ac-hPhe-c(Asp-His-D-2-Nal-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 114

Ac-Cha-c(Asp-His-D-2-Nal-Arg-Trp-Gaba-Lys)- NH ₂ ;

SEQ ID NO: 115

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-β-Ala-Lys)-OH;

SEQ ID NO: 116

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Ahx-Cys)-OH;

SEQ ID NO: 117

D-Phe-c(Cys-His-D-Phe-Arg-Trp-Ala-D-Cys)-Thr-OH;

SEQ ID NO: 118

D-Phe-c(Cys-His-D-Phe-Arg-Trp-β-Ala-D-Cys)-Thr-OH;

SEQ ID NO: 119

D-Phe-c(Cys-His-D-Phe-Arg-Trp-Gaba-D-Cys)-Thr-OH;

SEQ ID NO: 120

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-OH;

SEQ ID NO: 121

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Apn-Lys)-OH;

SEQ ID NO: 122

Ac-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 123

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 124

Ac-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 125

Ac-D-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 126

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 127

Ac-D-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 128

Ac-hPhe-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-OH;

SEQ ID NO: 129

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Gaba-Cys)-OH;

SEQ ID NO: 130

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Ahx-Cys)-OH;

SEQ ID NO: 131

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-β-Ala-Cys)-OH;

SEQ ID NO: 132

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-D-Ala-Cys)-OH;

SEQ ID NO: 133

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)-OH;

SEQ ID NO: 134

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-2-Nal-Cys)-OH;

SEQ ID NO: 135

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-1-Nal-Cys)-OH;

SEQ ID NO: 136

Ac-Nle-c(Cys-D-Ala-His-D-2-Nal-Arg-Bal-Cys)-OH;

SEQ ID NO: 137

Ac-Nle-c(Pen-D-Ala-His-D-Phe-Arg-Trp-Cys)-OH;

SEQ ID NO: 138

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Pen)-OH;

SEQ ID NO: 139

Ac-Arg-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 140

Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

SEQ ID NO: 141

Ac-D-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)- NH ₂ ;

SEQ ID NO: 142

Ac-D-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)- NH ₂ ;

SEQ ID NO: 143

Ac-D-Arg-c(Cys-His-D-Phe-Arg-Trp-Gaba-Pen)- NH ₂ ;

SEQ ID NO: 144

Ac-Arg-c(Cys-His-D-Phe-Arg-Trp-Gaba-Pen)- NH ₂ ;

SEQ ID NO: 145

Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)- NH ₂ ;

SEQ ID NO: 146

Ac-D-Arg-c(Asp-His-D-Phe-Arg-Trp-Ala-Lys)- NH ₂ ;

or

SEQ ID NO: 147

Ac-Arg-c(Asp-His-D-Phe-Arg-Trp-Ala-Lys)- NH ₂ ;

or a pharmaceutically acceptable salt of such a compound.

In embodiments, the MC4R agonist is setmelanotide also known as RM-493) having the sequence Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140). Setmelanotide is a peptide that retains the specificity and functionality of the naturally occurring hormone that activates MC4R and has not been shown to adversely affect blood pressure in clinical trials. See, for example, Chen et al. J. Clin. Endocrinol. Metab. 2015;100(4):1639-45. The structure of setmelanotide is shown below.

Setmelanotide is an 8 amino acid cyclic peptide with the ability to activate MC4R. See, for example, US 8,039,435B2, incorporated herein by reference. Setmelanotide is generally well tolerated, with no more than mild signs of high blood pressure and only rare effects on sexual performance.

In one embodiment, an MC4R receptor agonist that can be used to implement the methods described in this application is any compound described by formula (II), or a pharmaceutically acceptable salt, hydrate, solvate, or prodrug of such a compound (see International Patent Publication Application No. WO 2007/008704, which is incorporated herein in its entirety):

(R ² R ³ ) -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -NH ₂ (II)

In formula (II):

A ¹ is Nle or deleted;

A ² is Cys or Asp;

A ³ is Glu or D-Ala;

A ⁴ is His;

A ⁵ is D-Phe;

A ⁶ is Arg;

A ⁷ is Trp, 2-Nal or Bal;

A ⁸ is Gly, Ala, D-Ala, (3-Ala, Gaba or Apn;

A ⁹ is Cys or Lys;

each of R ² and R ³ is independently selected from the group consisting of H or (C ₁ -C ₆ )acyl.

In the examples of the implementation of Formula (II):

(I) if R ² is (C ₁ -C ₆ )acyl then R ³ is H; and

(II) if A ² is Cys, then A ⁹ is Cys.

In alternative embodiments of the present invention, the following compounds can be used to carry out the methods disclosed herein:

SEQ ID NO: 148

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Gly-Cys)- NH ₂ ;

SEQ ID NO: 149

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-D-Ala-Cys)-NH ₂ ;

SEQ ID NO: 150

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-β-Ala-Cys)-NH ₂ ;

SEQ ID NO: 151

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Gaba-Cys)- NH ₂ ;

SEQ ID NO: 152

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Apn-Cys)- NH ₂ ;

SEQ ID NO: 153

Ac-c(Cys-Glu-His-D-Phe-Arg-Trp-Ala-Cys)-NH ₂ ;

SEQ ID NO: 154

Ac-c(Cys-Glu-His-D-Phe-Arg-2-Nal-Ala-Cys)-NH ₂ ;

SEQ ID NO: 155

Ac-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Ala-Cys)-NH ₂ ;

SEQ ID NO: 156

Ac-c(Cys-D-Ala-His-D-Phe-Arg-2-Nal-Ala-Cys)-NH ₂ ;

SEQ ID NO: 157

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Ala-Cys)- NH ₂ ;

or

SEQ ID NO: 158

Ac-Nle-c(Asp-D-Ala-His-D-Phe-Arg-Bal-Ala-Lys)-NH ₂ ;

or its pharmaceutically acceptable salts of such compounds.

In one embodiment, MC4R agonists that can be used to implement the methods described herein are any compound of Formula (III) or a pharmaceutically acceptable salt, hydrate, solvate or prodrug of such a compound (see International Patent Application Publication WO 2007/ 008684, which is hereby incorporated by reference in its entirety):

(R ² R ³ )-B ¹ -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -A ¹⁰ -A ¹¹ -A ¹² -A ¹³ -B ² -B ³ -R ¹ (III).

In formula (III):

B ¹ is a peptide fragment that contains 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 amino acids, with at least 5 amino acids independently selected from the group consisting of L-Arg, D -Arg, L-hArg and D-hArg, or B ¹ is optionally removed;

A ¹ is Acc, HN-(CH ₂ ) _m -C(O), L- or D-amino acid or removed;

A ² is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Asp, or Glu;

A ³ is Gly, Glu, Ala, β-Ala, Gaba, Aib, D-amino acid or removed;

A ⁴ is His, 2-Pal, 3-Pal, 4-Pal, Taz, 2-Thi, 3-Thi, or (X′, X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁵ is D-Phe, D-1-Nal, D-2-Nal, D-Trp, D-Bal, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, D- (Et)Tyr, D-Dip, D-Bip or D-Bpa;

A ⁶ is Arg, hArg, Dab, Dap, Lys, Orn or HN-CH((CH ₂ ) _n -N(R ⁴ R ⁵ ))-C(O);

A ⁷ is Trp, 1-Nal, 2-Nal, Bal, Bip, Dip, Bpa, D-Trp, D-1-Nal, D-2-Nal, D-Bal, D-Bip, D-Dip or D-Bpa;

A ⁸ is Gly, D-Ala, Acc, Ala, β-Ala, Gaba, Apn, Ahx, Aha, HN-(CH ₂ ) _s -C(O) or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen, D-Pen, Dab, Dap, Orn, or Lys;

A ¹⁰ is Acc, HN-(CH ₂ ) _t -C(O), Pro, hPro, 3-Hyp, 4-Hyp, Thr, L- or D-amino acid or removed;

A ¹¹ is Pro, hPro, 3-Hyp, 4-Hyp or deleted;

A ¹² is Lys, Dab, Dap, Arg, hArg or deleted;

A ¹³ is Asp, Glu or deleted;

B ² is a peptide fragment containing 1, 2, 3, 4, or 5 amino acids or deleted,

B ³ is a peptide fragment that contains 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 or 15 amino acids, with at least 5 amino acids independently selected from the group consisting of L-Arg, D -Arg, L-hArg and D-hArg or removed;

R ¹ is OH or NH ₂ ;

each of R ² and R ³ , independently at each occurrence, is selected from the group consisting of H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₁ -C ₃₀ )acyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )alkyl, substituted ( C ₁ -C ₃₀ )heteroalkyl, substituted (C ₁ -C ₃₀ )acyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, substituted aryl(C ₁ -C ₃₀ )alkyl and substituted aryl(C ₁ -C ₃₀ )acyl;

R ⁴ and R ⁵ are each independently H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₁ -C ₄₀ )acyl, (C ₂ - C ₄₀ )alkenyl, (C ₂ -C ₄₀ )alkynyl, aryl(C ₁ -C ₄₀ )alkyl, aryl(C ₁ -C ₄₀ )acyl, substituted (C ₁ -C ₄₀ )alkyl, substituted (C ₁ -C ₄₀ )heteroalkyl, substituted (C ₁ -C ₄₀ )acyl, substituted (C ₂ -C ₄₀ )alkenyl, substituted (C ₂ -C ₄₀ )alkynyl, substituted aryl(C ₁ -C ₄₀ )alkyl, substituted aryl(C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl or C(NH)-NH ₂ ;

n is independently 1, 2, 3, 4, or 5 each time it occurs;

m is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

s is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

t is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

each of X ¹ , X ² , X ³ , X ⁴ and X ⁵ independently each time it occurs is H, F, Cl, Br, I, (C _1-10 )alkyl substituted with (C _1-10 )alkyl, (C _2-10 )alkenyl, substituted (C _2-10 )alkenyl, (C ₂ - ₁₀ )alkynyl, substituted (C _2-10 )alkynyl, aryl, substituted aryl, OH, NH ₂ , NO ₂ or CN.

In one example of the implementation of Formula (III):

(I) if R ⁴ is (C ₁ -C ₄₀ )acyl, aryl(C ₁ -C ₄₀ )acyl, substituted (C ₁ -C ₄₀ )acyl, substituted aryl(C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl or C(NH)-NH _2, then R ⁵ is H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₂ -C ₄₀ )alkenyl, ( C ₂ -C ₄₀ ) alkynyl, aryl (C ₁ -C ₄₀ ) alkyl, substituted (C ₁ -C ₄₀ ) alkyl, substituted (C ₁ -C ₄₀ ) heteroalkyl, substituted (C ₂ -C ₄₀ ) alkenyl, substituted ( C ₂ -C ₄₀ )alkynyl or substituted aryl(C ₁ -C ₄₀ )alkyl;

(II) if R ² is (C ₁ -C ₃₀ )acyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )acyl, or substituted aryl(C ₁ -C ₃₀ )acyl, then R ³ is H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl , substituted (C ₁ -C ₃₀ )alkyl, substituted (C ₁ -C ₃₀ )heteroalkyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, or substituted aryl(C ₁ -C ₃₀ ) alkyl;

(III) neither B ¹ nor B ² contains one or more of the following amino acid sequences: Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ , Tyr-Ala-Arg-Lys-Ala-( Arg) ₂ -Gln-Ala-(Arg) ₂ , Tyr-Ala-Arg-(Ala) ₂ -(Arg) ₂ -(Ala) ₂ -(Arg) ₂ , Tyr-Ala-(Arg) ₉ , Tyr- (Ala) ₃ -(Arg) ₇ , Tyr-Ala-Arg-Ala-Pro-(Arg) ₂ -Ala-(Arg) ₃ or Tyr-Ala-Arg-Ala-Pro-(Arg) ₂ -Pro-( Arg) ₂ ;

(IV) either B ¹ or B ² or both must be present in said compound;

(V) if A ² is Cys, D-Cys, hCys, D-hCys, Pen or D-Pen, then A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen or D-Pen; and

(VI) if A ² is Asp or Glu then A ⁹ is Dab, Dap, Orn or Lys.

In the examples of implementation, in the formula (III):

B ¹ is Arg-Lys-Gln-Lys-(Arg) ₅ , Arg-(Lys) ₂ -Arg-Gln-(Arg) ₄ , Arg-(Lys) ₂ -(Arg) ₃ -Gln-(Arg) ₂ , Arg-(Lys) ₂ -(Arg) ₄ -Gln-Arg, Arg-(Lys) ₂ -(Arg) ₅ -Gln, Arg-(Lys) ₂ -Gln-(Arg) ₅ , Arg-Gln- (Lys) ₂ -(Arg) ₅ , Arg-Gln-(Arg) ₇ , Arg-Gln-(Arg) ₈ , (Arg) ₂ -Gln-(Arg) ₆ , (Arg) ₂ -Gln-(Arg) ₇ , (Arg) ₃ -Gln-(Arg) ₅ , (Arg) ₃ -Gln-(Arg) ₆ , (Arg) ₄ -Gln-(Arg) ₄ , (Arg) ₄ -Gln-(Arg) ₅ , (Arg) ₅ , (Arg) ₅ -Gln-(Arg) ₃ , (Arg) ₅ -Gln-(Arg) ₄ , (Arg) ₆ , (Arg) ₆ -Gln-(Arg) ₃ , (Arg) ₇ , (Arg) ₇ -Gln-(Arg) ₂ , (Arg) ₈ , (Arg)s-Gln-Arg, (Arg) ₉ , (Arg) ₉ -Gln, (D-Arg) ₅ , (D-Arg ) ₆ , (D-Arg) ₇ , (D-Arg) ₈ , (D-Arg) ₉ , Gln-Arg-(Lys) ₂ -(Arg) ₅ , Gln-(Arg) ₈ , Gln-(Arg) ₉ , Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ , Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -Doc or removed;

B ² is β-Ala, β-Ala-Gly, β-Ala-Tyr, β-Ala-Tyr-Gly, (β-Ala) ₂ , (β-Ala) ₂ -Gly, (β-Ala) ₂ -Tyr, (β-Ala) ₂ -Tyr-Gly, Doc, Doc-Gly, Doc-Tyr, Doc-Tyr-Gly, (Doc) ₂ , (Doc) ₂ -Gly, (Doc) ₂ -Tyr, Doc ) ₂ -Tyr-Gly or removed;

B ³ is Arg-Lys-Gln-Lys-(Arg) ₅ , Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ , Arg-(Lys) ₂ -Arg-Gln-(Arg) ₄ , Arg -(Lys) ₂ -Gln-(Arg) ₅ , Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ , Arg-(Lys) ₂ -(Arg) ₃ -Gln-(Arg) ₂ , Arg-(Lys) ₂ -(Arg) ₄ -Gln-Arg, Arg-(Lys) ₂ -(Arg) ₅ -Gln, Arg-Gln-(Lys) ₂ -(Arg) ₅ , Arg-Gln-( Arg) ₇ , Arg-Gln-(Arg) _s , (Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ , (Arg) ₂ -Gln-(Arg) ₆ , (Arg) ₂ -Gln -(Arg) ₇ , (Arg) ₃ -Gln-(Arg) ₅ , (Arg) ₃ -Gln-(Arg) ₆ , (Arg) ₄ -Gln-(Arg) ₄ , (Arg) ₄ -Gln-( Arg) ₅ , (Arg) ₅ , (Arg) _s -Gln-(Arg) ₃ , (Arg) ₅ -Gln-(Arg) ₄ , (Arg) ₆ , (Arg) ₆ -Gln-(Arg) ₃ , (Arg) ₇ , (Arg) ₇ -Gln-(Arg) ₂ , (Arg) ₈ , (Arg) _s -Gln-Arg, (Arg) ₉ , (Arg) ₉ -Gln, (D-Arg) ₅ , (D-Arg) ₆ , (D-Arg) ₇ , (D-Arg) ₈ , (D-Arg) ₉ , Gln-Arg-(Lys) ₂ -(Arg) ₅ , Gln-(Arg) ₈ , Gln -(Arg) ₉ or removed;

A ¹ is A6c, Cha, hCha, Chg, D-Chg, hChg, Gaba, hLeu, Met, β-hMet, D-2-Nal, Nip, Nle, Oic, Phe, D-Phe, hPhe, hPro or removed;

A ² is Cys;

A ³ is D-Abu, Aib, Ala, β-Ala, D-Ala, D-Cha, Gaba, Glu, Gly, D-Ile, D-Leu, D-Met, D-Nle, D-Phe, D-Tle, D-Trp, D-Tyr, D-Val or deleted;

A ⁴ is H;

A ⁵ is D-Bal, D-1-Nal, D-2-Nal, D-Phe, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, D-Trp or D- (Et) Tyr;

A ⁶ is Arg or hArg;

A ⁷ is Bal, Bip, 1-Nal, 2-Nal, Trp or D-Trp;

A ⁸ is A5c, A6c, Aha, Ahx, Ala, β-Ala, Apn, Gaba, Gly, or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Lys, Pen, or D-Pen;

A ¹⁰ is Pro, Thr or deleted;

A ¹¹ is Pro or removed;

A ¹² is arg, Lys or deleted;

A ¹³ is Asp or deleted;

each of R ² and R ³ independently represents H or acyl;

or a pharmaceutically acceptable salt of said.

In exemplary embodiments, MC4R agonists that can be used to implement the methods of the present invention are at least one of the following compounds:

(SEQ ID NO: 159)

Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)- NH ₂ ;

(SEQ ID NO: 160)

Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -Doc-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-NH ₂ ;

(SEQ ID NO: 161)

Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 162)

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 163)

Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-(Doc) ₂ -Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 164)

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-(Pro) ₂ -Lys-Asp-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln- (Arg) ₃ -NH ₂ ;

(SEQ ID NO: 165)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Gly-Cys)-(Pro) ₂ -Lys-Asp-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ - Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 166)

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-(β-Ala) ₂ -Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg ) ₃ -NH ₂ ;

(SEQ ID NO: 167)

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-(Pro) ₂ -Lys-Asp-Doc-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ - Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 168)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Gly-Cys)-(Pro) ₂ -Lys-Asp-Doc-Tyr-Gly-Arg- (Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 169)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -( Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 170)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-Doc-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 171)

Ac-Nle-c(Asp-His-D-2-Nal-Arg-Trp-Lys)-(Doc) ₂ -Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 172)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 173)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 174)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 175)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 176)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -Arg -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 177)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -Gln -(Arg) ₅ -NH ₂ ;

(SEQ ID NO: 178)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-Lys-Gln-Lys- (Arg) ₅ -NH ₂ ;

(SEQ ID NO: 179)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -( Arg) ₄ -Gln-Arg-NH ₂ ;

(SEQ ID NO: 180)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Aib-Arg-(Lys) ₂ -( Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 181)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 182)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 183)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₆ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 184)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 185)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 186)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₆ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 187)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₆ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 188)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 189) Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₆ - Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 190)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -( Arg) ₃ -Gln-(Arg) ₂ -NH ₂ ;

(SEQ ID NO: 191)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-Gln-(Lys) ₂ -(Arg) ₅ -NH ₂ ;

(SEQ ID NO: 192)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -( Arg) ₅ -Gln-NH ₂ ;

(SEQ ID NO: 193)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 194)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -( Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 195)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 196)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Arg-Lys-(Arg) ₃ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 197)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 198)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₂ -Lys -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 199)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-(Arg) ₂ -Lys-( Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 200)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 201)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₂ -Lys -(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 202)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-Lys-(Arg ) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 203)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-(Arg) ₂ -Lys-( Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 204)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 205)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 206)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Arg-Lys-(Arg) ₃ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 207)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-Lys-(Arg ) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 208)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₂ -Lys-(Arg) ₂ - Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 209)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Arg-Lys-(Arg) ₃ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 210)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₂ -Lys-( Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 211)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 212)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 213)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Gly-Arg-Lys-(Arg) ₃ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 214)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 215)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 216)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 217)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 218)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ - _NH2 ;

(SEQ ID NO: 219)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ - _NH2 ;

(SEQ ID NO: 220)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₄ -NH ₂ ;

(SEQ ID NO: 221)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₄ -NH ₂ ;

(SEQ ID NO: 222)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 223)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 224)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₆ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 225)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 226)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 227)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 228)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 229)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₆ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 230)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₆ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 231)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₆ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 232)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 233)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 234)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 235)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 236)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₆ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 237)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₆ -Gln -(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 238)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 239)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln -(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 240)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ - _NH2 ;

(SEQ ID NO: 241)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ - _NH2 ;

(SEQ ID NO: 242)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 243)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₄ -NH ₂ ;

(SEQ ID NO: 244)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-( Arg) ₄ -NH ₂ ;

(SEQ ID NO: 245)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-β-Ala-Tyr-Gly-(Arg) ₆ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 246)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Arg-Asp-β-Ala-Tyr-Gly-(Arg) ₆ -Gln-( Arg) ₃ -NH ₂ ;

(SEQ ID NO: 247)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg ) ₃ -NH ₂ ;

(SEQ ID NO: 248)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-Arg-(Lys) ₂ -Arg-Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 249)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-Arg-(Lys) ₂ -(Arg) ₂ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 250)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 251)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 252)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 253)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 254)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 255)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 256)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Gly-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 257)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Gly-Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 258)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₂ -Lys-(Arg) ₂ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 259)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Arg-Lys-(Arg) ₃ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 260)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 261)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 262)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 263)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 264)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 265)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 266)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 267)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 268)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 269)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 270)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 271)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 272)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 273)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 274)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 275)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 276)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 277)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 278)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 279)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 280)

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-β-Ala-Tyr-Gly- (Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 281)

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 282)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Ala-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 283)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Ala-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 284)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 285)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 286)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 287)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 288)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(β-Ala) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 289)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 290)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 291)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-Doc-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 292)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 293)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 294)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(Doc) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 295)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 296)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 297)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 298)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 299)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 300)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(β-Ala) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 301)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 302)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 303)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-Doc-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 304)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 305)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 306)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(Doc) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 307)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Lys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 308)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-β-Ala-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH _2;

(SEQ ID NO: 309)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-β-Ala-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 310)

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Ahx-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 311)

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Ahx-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 312)

D-Phe-c(Cys-His-D-Phe-Arg-Trp-β-Ala-D-Cys)-Thr-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 313)

D-Phe-c(Cys-His-D-Phe-Arg-Trp-β-Ala-D-Cys)-Thr-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 314)

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 315)

Ac-Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 316)

Ac-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 317)

Ac-Cha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 318)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 319)

Ac-Nle-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 320)

Ac-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 321)

Ac-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 322)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 323)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 324)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 325)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 326)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 327)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 328)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 329)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 330)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 331)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 332)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 333)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 334)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 335)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 336)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 337)

Ac-hCha-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 338)

Ac-D-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 339)

Ac-D-Chg-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 340)

Ac-hPhe-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 341)

Ac-hPhe-c(Asp-His-D-Phe-Arg-Trp-Gaba-Lys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 342)

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Apn-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 343)

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Apn-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 344)

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Ahx-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 345)

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-Ahx-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 346)

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-β-Ala-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 347)

Ac-Nle-c(Cys-His-D-Phe-Arg-D-Trp-β-Ala-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 348)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 349)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 350)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 351)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 352)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-(β-Ala) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 353)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 354)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 355)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-Doc-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 356)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 357)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 358)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-(Doc) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 359)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 360)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 361)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 362)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-β-Ala-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 363)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 364)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg ) ₃ -NH ₂ ;

(SEQ ID NO: 365)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 366)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(β-Ala) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 367)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 368)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 369)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 370)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-Doc-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 371)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 372)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 373)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 374)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(Doc) ₂ -Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 375)

D-Phe-c(Cys-His-D-(Et)Tyr-Arg-Trp-β-Ala-D-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 376)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 377)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 378)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln- (Arg) ₃ -NH ₂ ;

(SEQ ID NO: 379)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 380)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 381)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 382)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg ) ₃ -NH ₂ ;

(SEQ ID NO: 383)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 384)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 385)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln- (Arg) ₄ -NH ₂ ;

(SEQ ID NO: 386)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 387)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ - _NH2 ;

(SEQ ID NO: 388)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 389)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg ) ₄ -NH ₂ ;

(SEQ ID NO: 390)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Trp-β-Ala-D-Cys)-Thr-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 391)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 392)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 393)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 394)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln- (Arg) ₃ -NH ₂ ;

(SEQ ID NO: 395)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 396)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ - _NH2 ;

(SEQ ID NO: 397)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ - _NH2 ;

(SEQ ID NO: 398)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 399)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg ) ₃ -NH ₂ ;

(SEQ ID NO: 400)

D-Phe-c(Cys-His-D-(Et)Tyr-hArg-Bip-β-Ala-D-Cys)-Thr-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 401)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Gly-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 402)

Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Gly-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 403)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 404)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 405)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 406)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 407)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 408)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 409)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 410)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 411)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 412)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 413)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 414)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 415)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 416)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 417)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 418)

Nle-c(Cys-His-D-Phe-Arg-Trp-Apn-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 419)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 420)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 421)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 422)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 423)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 424)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 425)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 426)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 427)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 428)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 429)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 430)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 431)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 432)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 433)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 434)

Ac-Nle-c(Cys-D-Leu-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 435)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 436)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 437)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 438)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 439)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 440)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 441)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 442)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 443)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 444)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 445)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 446)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 447)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 448)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 449)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 450)

Ac-Nle-c(Cys-D-Cha-His-D-Phe-Arg-Trp-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 451)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 452)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 453)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 454)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 455)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-β-Ala-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 456)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-β-Ala-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 457)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(β-Ala) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 458)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(β-Ala) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 459)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 460)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 461)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 462)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₃ -NH ₂ ;

(SEQ ID NO: 463)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-Doc-Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 464)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-Doc-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

(SEQ ID NO: 465)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(Doc) ₂ -Tyr-Gly-(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ;

or

(SEQ ID NO: 466)

Nle-c(Cys-His-D-Phe-Arg-Trp-Gaba-Cys)-(Doc) ₂ -(Arg) ₅ -Gln-(Arg) ₄ -NH ₂ ,

or their pharmaceutically acceptable salts.

In one embodiment, compounds suitable for the methods described herein are compounds of Formula (IV):

Ac- c (Cys-Glu-His-A ¹ -Arg-A ² -A ³ -Cys)-(Pro) ₂ -Lys-Asp-NH ₂ (IV)

or their pharmaceutically acceptable salts.

In formula (IV): A ¹ is the D-isomer of X-Phe or 2-Nal, where X is halogen;

A ² is Bal, 1-Nal, 2-Nal or Trp; and

A ³ is Aib, Ala, β-Ala or Gly,

In some embodiments, at least one of the following compounds is used:

(SEQ ID NO: 467)

Ac-c(Cys-Glu-His-D-4-Br-Phe-Arg-Trp-Gly-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

(SEQ ID NO: 468)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

(SEQ ID NO: 469)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

(SEQ ID NO: 470)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-1-Nal-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

(SEQ ID NO: 471)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-Bal-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

(SEQ ID NO: 472)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-β-Ala-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

or

(SEQ ID NO: 473)

Ac-c(Cys-Glu-His-D-2-Nal-Arg-2-Nal-Aib-Cys)-(Pro) ₂ -Lys-Asp-NH ₂ ;

or their pharmaceutically acceptable salts.

In exemplary embodiments, an MC4R agonist that can be used to implement the methods described herein is at least one compound modified with a hydantoin moiety according to formula (V), (VI), or (VII), or a pharmaceutically acceptable salt , hydrate, solvate or prodrug of such a compound.

Formula (V) is described below: (See WO2008/147556 or International Patent Application No. PCT/US08/06675, which are incorporated herein by reference in their entirety).

(V).

(V).

In formula (V):

X is selected from the group consisting of -CH ₂ -SS-CH ₂ -, -C(CH ₃ ) ₂ -SS-CH ₂ -, -CH ₂ -SSC(CH ₃ ) ₂ -, -C(CH ₃ ) ₂ -SSC(CH ₃ ) ₂ -, -(CH ₂ ) ₂ -SS-CH ₂ -, -CH ₂ -SS-(CH ₂ ) ₂ -, -(CH ₂ ) ₂ -SS-(CH ₂ ) ₂ - , -C(CH ₃ ) ₂ -SS-(CH ₂ ) ₂ -, -(CH ₂ ) ₂ -SSC(CH ₃ ) ₂ -, -(CH ₂ ) _t -C(O)-NR ⁸ -(CH ₂ ) _r - and -(CH ₂ ) _r -NR ⁸ -C(O)-(CH ₂ ) _t -;

each R ² is independently H, (C ₁ -C ₁₀ )alkyl, or substituted (C ₁ -C ₁₀ )alkyl;

R³ represents -OH or -NH₂;

each of R ⁴ and R ⁵ independently represents H, (C ₁ -C ₁₀ )alkyl or substituted (C ₁ -C ₁₀ )alkyl;

X ¹ represents

,

,

A ¹ is His, 2-Pal, 3-Pal, 4-Pal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, Taz, 2-Thi, 3-Thi or deleted;

A ² is D-Bal, D-1-Nal, D-2-Nal, D-Phe or D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ³ is Arg, hArg, Dab, Dap, Lys or Orn;

A ⁴ is Bal, 1-Nal, 2-Nal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe or Trp;

each of R ⁶ and R ⁷ independently, whenever present, is H, (C ₁ -C ₁₀ )heteroalkyl, aryl(C ₁ -C ₅ )alkyl substituted with (C ₁ -C ₁₀ )alkyl substituted with ( C ₁ -C ₁₀ )heteroalkyl or substituted aryl(C ₁ -C ₅ )alkyl, provided that R ⁶ and R ⁷ can be connected to each other to form a ring;

R ⁸ is H, (C ₁ -C ₁₀ )alkyl or substituted (C ₁ -C ₁₀ )alkyl;

r independently, whenever it occurs, is 1, 2, 3, 4, or 5; and

t is independently, in each case it occurs, is 1 or 2.

Compounds corresponding to the above formula may be compounds in which X ¹ is selected from the group consisting of:

,

,

,

,

,

,

и

.

,

,

,

,

,

,

and

.

Representative examples of the class of compounds described above are the following:

(SEQ ID NO: 474

c[hydantoin(C(O)-(Cys-D-Ala))-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 475)

c[hydantoin(C(O)-(hCys-D-Ala))-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 476)

c[hydantoin(C(O)-(Cys-D-Ala))-His-D-2-Nal-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 477)

c[hydantoin(C(O)-(hCys-D-Ala))-His-D-2-Nal-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 478)

c[hydantoin(C(O)-(Asp-D-Ala))-His-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 479)

c[hydantoin(C(O)-(Asp-D-Ala))-His-D-Phe-Arg-Trp-Orn]-NH ₂ ;

(SEQ ID NO: 480)

c[hydantoin(C(O)-(Asp-D-Ala))-His-D-Phe-Arg-Trp-Dab]-NH ₂ ;

(SEQ ID NO: 481)

c[hydantoin(C(O)-(Asp-D-Ala))-His-D-Phe-Arg-Trp-Dap]-NH ₂ ;

(SEQ ID NO: 482)

c[hydantoin(C(O)-(Asp-His))-D-2-Nal-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 483)

c[hydantoin(C(O)-(Asp-His))-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 484)

c[hydantoin(C(O)-(Asp-A3c))-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 485)

c[hydantoin(C(O)-(Asp-A5c))-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 486)

c[hydantoin(C(O)-(Asp-A6c))-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 487)

c[hydantoin(C(O)-(Asp-A3c))-D-2-Nal-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 488)

c[hydantoin(C(O)-(Asp-A5c))-D-2-Nal-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 489)

c[hydantoin(C(O)-(Asp-A6c))-D-2-Nal-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 490)

c[hydantoin(C(O)-(Asp-Aic))-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 491)

c[hydantoin(C(O)-(Asp-Apc))-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 492)

c[hydantoin(C(O)-(Asp-Aic))-D-2-Nal-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 493)

c[hydantoin(C(O)-(Asp-Apc))-D-2-Nal-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 494)

c[hydantoin(C(O)-(Glu-D-Ala))-His-D-Phe-Arg-Trp-Orn]-NH ₂ ;

(SEQ ID NO: 495)

c[hydantoin(C(O)-(Glu-D-Ala))-His-D-Phe-Arg-Trp-Dab]-NH ₂ ;

(SEQ ID NO: 496)

c[hydantoin(C(O)-(Glu-D-Ala))-His-D-Phe-Arg-Trp-Dap]-NH ₂ ;

(SEQ ID NO: 497)

c[hydantoin(C(O)-(Glu-D-Ala))-His-D-Phe-Arg-Trp-Lys]-NH ₂ ;

(SEQ ID NO: 498)

c[hydantoin(C(O)-(Glu-His))-D-Phe-Arg-Trp-Dap]-NH ₂ ;

or

(SEQ ID NO: 499)

c[hydantoin(C(O)-(Glu-His))-D-Phe-Arg-Trp-Lys]-NH ₂ .

In one embodiment, an MC4R agonist that can be used to implement the methods described herein is at least one compound of Formula (VI), a pharmaceutically acceptable salt, hydrate, solvate and/or prodrug of such a compound (see WO2008/ 147556 or international patent application number PCT/US08/06675, which are incorporated herein by reference in their entirety):

(VI).

(VI).

In formula (VI):

;X ¹ represents

;

;X ² represents

;

A ¹ is Asp, Cys, D-Cys, Dab, Dap, Glu, Lys, Orn, Pen or D-Pen;

A ² is an L- or D-amino acid;

A ³ is His, 2-Pal, 3-Pal, 4-Pal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, Taz, 2-Thi or 3-Thi;

A ⁴ is D-Bal, D-1-Nal, D-2-Nal, D-Phe or D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁵ is Arg, hArg, Dab, Dap, Lys or Orn;

A ⁶ is Bal, 1-Nal, 2-Nal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe or Trp;

A ⁷ is Asp, Cys, D-Cys, Dab, Dap, Glu, Lys, Orn, Pen or D-Pen;

R ¹ is H, (C ₁ -C ₁₀ )alkyl or substituted (C ₁ -C ₁₀ )alkyl;

each of R ² and R ³ independently represents H, (C ₁ -C ₁₀ )alkyl, (C ₁ -C ₁₀ )heteroalkyl, aryl(C ₁ -C ₅ )alkyl, substituted (C ₁ -C ₁₀ )alkyl, substituted (C ₁ -C ₁₀ )heteroalkyl or substituted aryl(C ₁ -C ₅ )alkyl, or R ² or R ³ may be linked together to form a cyclic moiety;

R ⁴ is OH, NH ₂ , CO ₂ H or C(O)NH ₂ ;

each of R ⁵ and R ⁶ independently represents, H, (C ₁ -00) alkyl, (C ₁ -C ₁₀ )heteroalkyl, aryl(C ₁ -C ₅ )alkyl, substituted (C ₁ -C ₁₀ )alkyl, substituted (C ₁ -C ₁₀ )heteroalkyl or substituted aryl(C ₁ -C ₅ )alkyl, or R ⁵ and R ⁶ may be joined together to form a cyclic moiety;

each of R ⁷ and R ⁸ independently represents H, (C ₁ -C ₁₀ )alkyl, (C ₁ -C ₁₀ )heteroalkyl, aryl(C ₁ -C ₅ )alkyl, substituted (C ₁ -C ₁₀ )alkyl, substituted (C ₁ -C ₁₀ )heteroalkyl or substituted aryl(C ₁ -C ₅ )alkyl; or R ⁷ and R ⁸ may be joined together to form a cyclic moiety;

R ⁹ is H, (C ₁ -C ₁₀ )alkyl or substituted (C ₁ -C ₁₀ )alkyl; and

n independently, whenever it occurs, is 0, 1, 2, 3, 4, 5, 6, or 7;

or a pharmaceutically acceptable salt of said compound.

Exemplary embodiments of compounds of Formula (VI) are compounds in which:

A ¹ is Cys;

A ² is D-Ala, Asn, Asp, Gln, Glu or D-Phe;

A ³ is His;

A ⁴ is D-2-Nal or D-Phe;

A ⁵ is Arg;

A ⁶ is Trp; and

A ⁷ is Cys or Pen;

each of R ¹ , R ² , R ³ and R ⁹ independently represents H;

R ⁴ is C(O)NH ₂ ;

each of R ⁵ and R ⁶ is independently H, (C ₁ -C ₁₀ )heteroalkyl, substituted (C ₁ -C ₁₀ )alkyl, or substituted (C ₁ -C ₁₀ )heteroalkyl, or R ⁵ and R ⁶ may be combined together with the formation of a cyclic fragment; and each of R ⁷ and R ⁸ is independently H, (C ₁ -C ₁₀ )alkyl, (C ₁ -C ₁₀ )heteroalkyl, substituted (C ₁ -C ₁₀ )alkyl, or substituted (C ₁ -C ₁₀ )heteroalkyl ; or pharmaceutically acceptable salts of such compounds.

Examples of compounds of formula (VI) immediately above include:

(SEQ ID NO: 500)

Hydantoin(C(O)-(Arg-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 501)

Hydantoin(C(O)-(Nle-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 502)

Hydantoin(C(O)-(Gly-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 503)

Hydantoin(C(O)-(Nle-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 504)

Hydantoin(C(O)-(Gly-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 505)

Hydantoin(C(O)-(Nle-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-NH ₂ ;

(SEQ ID NO: 506)

Hydantoin(C(O)-(Gly-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Pen)-NH ₂ ;

(SEQ ID NO: 507)

Hydantoin(C(O)-(Ala-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 508)

Hydantoin(C(O)-(D-Ala-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH _{2 ;}

(SEQ ID NO: 509)

Hydantoin(C(O)-(Aib-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 510)

Hydantoin(C(O)-(Val-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 511)

Hydantoin(C(O)-(Ile-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 512)

Hydantoin(C(O)-(Leu-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 513)

Hydantoin(C(O)-(Gly-Gly))-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 514)

Hydantoin(C(O)-(Nle-Gly))-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 515)

Hydantoin(C(O)-(D-Arg-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 516)

Hydantoin(C(O)-(D-Arg-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 517)

Hydantoin(C(O)-(Arg-Gly))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 518)

Hydantoin(C(O)-(D-Arg-Gly))-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 519)

Hydantoin(C(O)-(Arg-Gly))-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 520)

Hydantoin (C(O)-(Ala-Nle))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 521)

Hydantoin(C(O)-(Val-Nle))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 522)

Hydantoin(C(O)-(Gly-Nle))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 523)

Hydantoin(C(O)-(A6c-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 524)

Hydantoin(C(O)-(Gly-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 525)

Hydantoin(C(O)-(Ala-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 526)

Hydantoin(C(O)-(D-Ala-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 527)

Hydantoin(C(O)-(Val-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 528)

Hydantoin(C(O)-(Leu-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 529)

Hydantoin(C(O)-(Cha-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 530)

Hydantoin(C(O)-(Aib-Nle))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 531)

Hydantoin(C(O)-(Gly-Arg))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 532)

Hydantoin(C(O)-(Gly-Arg))-c(Cys-Glu-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 533)

Hydantoin(C(O)-(Gly-Arg))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 534)

Hydantoin(C(O)-(Gly-Arg))-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 535)

Hydantoin(C(O)-(Gly-D-Arg))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 536)

Hydantoin(C(O)-(Gly-D-Arg))-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 537)

Hydantoin(C(O)-(Gly-D-Arg))-c(Cys-D-Ala-His-D-2-Nal-Arg-Trp-Cys)-NH ₂ ;

or

(SEQ ID NO: 538)

Hydantoin(C(O)-(Nle-Ala))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

or pharmaceutically acceptable salts of said compounds.

In some embodiments, the MC4R agonist comprises/is:

In one embodiment, MC4R agonists that can be used to implement the methods described herein are compounds having a structural formula corresponding to Formula (VII) shown below (see WO2008/147556 or international patent application number PCT/US08/ 06675, which are incorporated herein by reference in their entirety):

(VII),

(VII)

where:

X is selected from the group consisting of -CH ₂ -SS-CH ₂ -, -C(CH ₃ ) ₂ SSCH ₂ -,-CH ₂ -SSC(CH ₃ ) ₂ -, -C(CH ₃ ) ₂ -SSC( CH ₃ ) _z -, -(CH ₂ ) ₂ -SS-CH ₂ -, -CH ₂ -SS-(CH ₂ ) ₂ , (CH ₂ ) ₂ -SS-(CH ₂ ) ₂ -, -C(CH ₃ ) ₂ -SS-(CH ₂ ) ₂ -, -(CH ₂ ) ₂ -SSC(CH ₃ ) ₂ -, -(CH ₂ ) _t -C(O)-NR ⁸ -(CH ₂ ) _r - and -(CH ₂ ) _r -NR ⁸ -C(O)-(CH ₂ ) _t -;

each of R ¹ and R ⁵ independently represents H, (C ₁ -C ₁₀ )alkyl or substituted (C ₁ -C ₁₀ )alkyl;

each of R ² and R ³ independently represents H, (C ₁ -C ₁₀ )alkyl, (C ₁ -00)heteroalkyl, aryl(C ₁ -C ₅ )alkyl, substituted (C ₁ -C ₁₀ )alkyl, substituted (C ₁ -C ₁₀ )heteroalkyl or substituted aryl(C ₁ -C ₅ )alkyl, or R ² and R ³ may be joined together to form a ring;

R ⁴ is OH or NH ₂ ;

each of R ⁶ and R ⁷ independently represents H, (C ₁ -C ₁₀ )alkyl or substituted (C ₁ -C ₁₀ )alkyl;

A ¹ is an L- or D-amino acid or removed;

A ² is His, 2-Pal, 3-Pal, 4-Pal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, Taz, 2-Thi or 3-Thi;

A ³ is D-Bal, D-1-Nal, D-2-Nal, D-Phe or D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe;

A ⁴ is Arg, hArg, Dab, Dap, Lys or Orn;

A ⁵ is Bal, 1-Nal, 2-Nal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe or Trp;

r independently, whenever it occurs, is 1, 2, 3, 4, or 5; and

t is independently, whenever it occurs, is 1 or 2;

or pharmaceutically acceptable salts of such compounds.

In one embodiment of the compounds of Formula (VII),

A ¹ is Ala, D-Ala, Asn, Asp, Gln, Glu, or Gly.

Examples of compounds according to formula (VII) include the following compounds:

(SEQ ID NO: 539)

c[hydantoin(C(O)-(Nle-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 540)

c[hydantoin(C(O)-(Ala-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 541)

c[hydantoin(C(O)-(D-Ala-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 542)

c[hydantoin(C(O)-(Aib-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 543)

c[hydantoin(C(O)-(Val-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 544)

c[hydantoin(C(O)-(Abu-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 545)

c[hydantoin(C(O)-(Leu-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 546)

c[hydantoin(C(O)-(Ile-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 547)

c[hydantoin(C(O)-(Cha-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 548)

c[hydantoin(C(O)-(A6c-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 549)

c[hydantoin(C(O)-(Phe-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

(SEQ ID NO: 550)

c[hydantoin(C(O)-(Gly-Cys))-D-Ala-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

or

(SEQ ID NO: 551)

c[hydantoin(C(O)-(Gly-Cys))-Glu-His-D-Phe-Arg-Trp-Cys]-NH ₂ ;

or pharmaceutically acceptable salts of such compounds.

In one embodiment, an MC4R agonist that can be used to implement the methods described herein is at least one compound according to formula (VIII) (see international patent application number PCT/US08/07411, incorporated herein in its entirety via link):

(R ² R ³ )-A ⁰ -A ¹ - c (A ² -A ³ -A ⁴ -A ⁵ -A ⁶ -A ⁷ -A ⁸ -A ⁹ ) -A ¹⁰ -R ¹ (VIII)

In formula (VIII):

A ⁰ is an aromatic amino acid

A ¹ is Acc, HN-(CH ₂ ) _m -C(O), L- or D-amino acid;

A ² is Asp, Cys, D-Cys, hCys, D-hCys, Glu, Pen, or D-Pen;

A ³ is Aib, Ala, β-Ala, Gaba, Gly or D-amino acid;

A ⁴ is His, 2-Pal, 3-Pal, 4-Pal, (X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, Taz, 2-Thi, or 3-Thi;

A ⁵ is D-Bal, D-1-Nal, D-2-Nal, D-Phe, L-Phe, D-(X ¹ , X ² , X ³ , X ⁴ , X ⁵ )Phe, L- Phe, D-Trp or D-(Et)Tyr;

A ⁶ is Arg, hArg, Dab, Dap, Lys, Orn or HN-CH((CH ₂ ) _n -N(R ⁴ R ⁵ ))-C(O);

A ⁷ is Bal, D-Bal, Bip, D-Bip, 1-Nal, D-1-Nal, 2-Nal, D-2-Nal, or D-Trp;

A ⁸ is Acc, Aha, Ahx, Ala, D-Ala, β-Ala, Apn, Gaba, Gly, HN-(CH ₂ ) _s -C(O) or deleted;

A ⁹ is Cys, D-Cys, hCys, D-hCys, Dab, Dap, Lys, Orn, Pen, or D-Pen;

A ¹⁰ is Acc, HN-(CH ₂ ) _t -C(O), L- or D-amino acid or removed;

R ¹ is OH or NH ₂ ;

each of R ² and R ³ in each occurrence is selected from the group consisting of H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₁ -C ₃₀ )acyl, ( C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )alkyl, substituted by (C ₁ -C ₃₀ )heteroalkyl, substituted (C ₁ -C ₃₀ )acyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, substituted aryl(C ₁ -C ₃₀ )alkyl and substituted aryl (C ₁ -C ₃₀ )acyl;

R ⁴ and R ⁵ are each independently H, (C ₁ -C ₄₀ )alkyl, (C ₁ -C ₄₀ )heteroalkyl, (C ₁ -C ₄₀ )acyl, (C ₂ - C ₄₀ ) alkenyl, (C ₂ -C ₄₀ ) alkynyl, aryl (C ₁ -C ₄₀ ) alkyl, aryl (C ₁ -C ₄₀ ) acyl, substituted (C ₁ -C ₄₀ ) alkyl, substituted by (C ₁ -C ₄₀ ) heteroalkyl, substituted (C ₁ -C ₄₀ ) acyl, substituted (C ₂ -C ₄₀ ) alkenyl, substituted (C ₂ -C ₄₀ ) alkynyl, substituted aryl (C ₁ -C ₄₀ ) allyl, substituted aryl (C ₁ -C ₄₀ )acyl, (C ₁ -C ₄₀ )alkylsulfonyl, or -C(NH)-NH ₂ ;

m is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

n is independently 1, 2, 3, 4, or 5 each time it occurs;

s is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

t is independently 1, 2, 3, 4, 5, 6, or 7 each time it occurs;

each of X ¹ , X ² , X ³ , X ⁴ and X ⁵ independently each time it occurs is H, F, Cl, Br, I, (C _1-10 )alkyl substituted with (C _1-10 )alkyl, (C _2-10 )alkenyl, substituted (C _2-10 )alkenyl, (C _2-10 )alkynyl, substituted (C _2-10 )alkynyl, aryl, substituted aryl, OH, NH ₂ , NO ₂ or CN.

In the implementation examples of Formula (VIII),

(I) if R⁴ represents (C_one-C₄₀)acyl, aryl(C_one-C₄₀)acyl substituted with (C_one-C₄₀)acyl, substituted aryl(C_one-C₄₀)acyl, (C_one-C₄₀)alkylsulfonyl or -C(NH)-NH₂, then R^five represents H or (C_one-C₄₀)alkyl, (C_one-C₄₀)heteroalkyl, (C₂-C₄₀)alkenyl, (C₂-C₄₀)alkynyl, aryl(C_one-C₄₀)alkyl substituted with (C_one-C₄₀)alkyl substituted with (C_one-C₄₀)heteroalkyl substituted (C₂-C₄₀)alkenyl, substituted (C₂-C₄₀)alkynyl or substituted aryl(C_one-C₄₀)alkyl;

(II) if R ² is (C ₁ -C ₃₀ )acyl, aryl(C ₁ -C ₃₀ )acyl, substituted (C ₁ -C ₃₀ )acyl, or substituted aryl(C ₁ -C ₃₀ )acyl, then R ³ is H, (C ₁ -C ₃₀ )alkyl, (C ₁ -C ₃₀ )heteroalkyl, (C ₂ -C ₃₀ )alkenyl, (C ₂ -C ₃₀ )alkynyl, aryl(C ₁ -C ₃₀ )alkyl , substituted (C ₁ -C ₃₀ )alkyl, substituted (C ₁ -C ₃₀ )heteroalkyl, substituted (C ₂ -C ₃₀ )alkenyl, substituted (C ₂ -C ₃₀ )alkynyl, or substituted aryl(C ₁ -C ₃₀ ) alkyl;

(III) if A ² is Cys, D-Cys, hCys, D-hCys, Pen, or D-Pen, then A ⁹ is Cys, D-Cys, hCys, D-hCys, Pen, or D-Pen;

(IV) if A ² is Asp or Glu, then A ⁹ is Dab, Dap, Orn or Lys;

(V) if A^eight is Ala or Gly, then A^one is not Nle; or the compound is a pharmaceutically acceptable salt of the same.

In the examples of the compounds of Formula (VIII):

A ⁰ is 1-Nal, 2-Nal, H is Pff, Phe, Trp or Tyr;

A ¹ is Arg;

A ² is Cys;

A ³ is D-Ala;

A ⁴ is His;

A ⁵ is D-Phe

A ⁶ is Arg;

A ⁷ is Trp

A ⁸ deleted;

A ⁹ is Cys; and

A ¹⁰ removed;

or the compound is a pharmaceutically acceptable salt of the same.

Specific compounds of the immediately above group of compounds have the formulas:

(SEQ ID NO: 552)

Ac-Tyr-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 553)

Ac-2-Nal-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 554)

Ac-1-Nal-Arg-c(Cys-D-Ala-His-DPhe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 555)

Ac-Phe-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 556)

Ac-Trp-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 557)

Ac-Pff-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

(SEQ ID NO: 558)

H-His-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

or

(SEQ ID NO: 559)

Ac-His-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ ;

or are their pharmaceutically acceptable salts.

In one embodiment, the MC4R agonist is Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140) or a pharmaceutically acceptable salt thereof. In another embodiment, the MC4R agonist is hydantoin(C(O)-(Arg-Gly))-c(Cys-Glu-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 500) or a pharmaceutically acceptable salt thereof.

In some embodiments, the MC4R agonist is the agonist described in WO2014/144260 A1, which is incorporated herein by reference. The administration of a compound, or a pharmaceutically acceptable salt thereof, or a composition containing a compound or a pharmaceutical salt of a compound of the present invention, suitable for carrying out the methods described herein, may be continuous, carried out every hour, four times a day, three times a day, twice a day, once a day, every other day, twice a week, once a week, once every two weeks, once a month, or once every two months or longer, or using some other regimen with breaks.

Examples of administration of a compound or composition containing a compound or pharmaceutical salt of a compound of the present invention include peripheral administration. Examples of peripheral administration include oral, subcutaneous, intraperitoneal, intravenous, rectal, transdermal or intranasal forms of administration.

As used herein, peripheral administration may include all forms of administration of a compound or composition containing a compound or pharmaceutical salt of a compound of the present invention that exclude intracranial administration. Examples of peripheral administration include, but are not limited to, oral, parenteral (eg, intramuscular, intraperitoneal, intravenous or subcutaneous injection, sustained release, slow release implants, depot, etc.), nasal, vaginal, rectal, sublingual or topical routes of administration, including the use of transdermal patches and the like.

To describe peptides, the nomenclature commonly used in the art is used, according to which the amino group at the N-terminus is on the left, and the carboxyl group at the C-terminus is on the right. Where an amino acid has both D and L isomeric forms, the L form of the amino acid is given unless otherwise indicated.

Compounds of the present invention that can be used to implement the methods described herein may have one or more chiral centers and, accordingly, exist in several stereoisomeric forms. All stereoisomers and mixtures thereof are included within the scope of the present invention. Racemic compounds can either be separated using preparative HPLC and a chiral stationary phase column, or separated to give individual stereoisomers by methods known to those skilled in the art. Additionally, chiral intermediates can be separated and used to prepare chiral compounds according to the present invention.

The compounds described herein may exist in one or more tautomeric forms. All tautomers and mixtures thereof are included within the scope of the present invention. For example, reference to 2-hydroxypyridinyl also encompasses its tautomeric form, α-pyridonyl.

Unless otherwise indicated, all technical and scientific terms used in this document have the same meaning that is usually put into them by specialists in the field to which this invention belongs. In addition, all publications, patent applications, patent applications and other references mentioned in this document are incorporated herein by reference in their entirety.

Symbol Meaning Abu α-aminobutyric acid AC acyl group Acc 1-amino-1-cyclo(C ₃ -C ₉ )alkyl carboxylic acid A3c 1-amino-1-cyclopropanecarboxylic acid A4c 1-amino-1-cyclobutanecarboxylic acid A5c 1-amino-1-cyclopentanecarboxylic acid A6c 1-amino-1-cyclohexanecarboxylic acid Aha 7-aminoheptanoic acid Ahx 6-aminocaproic acid Aib α-aminoisobutyric acid Aic 2-aminoindan-2-carboxylic acid Ala or A alanine β-Ala β-alanine Apc

stands for structure:

Apn 5-aminovaleric acid (HN-(CH2) ₄ -C(O) Arg or R arginine hArg homoarginine Asn or N asparagine Asp or D aspartic acid Bal 3-benzothienylalanine Bip 4,4'-biphenylalanine represented by the structure

bpa 4-benzoylphenylalanine 4-Br-Phe 4-bromo-phenylalanine Cha β-cyclohexylalanine hCha homocyclohexylalanine Chg cyclohexylglycine Cys or C cysteine hCys homocysteine Dab 2,4-diaminobutyric acid Dap 2,3-diaminopropionic acid dip β,β-diphenylalanine Doc 8-amino-3,6-dioxaoctanoic acid having the structure:

2-fua β-(2-furyl)-alanine Gaba 4-aminobutyric acid Gln or Q glutamine Glu or E glutamic acid Gly or G glycine His or H histidine 3 Hyp trans-3-hydroxy-L-proline, i.e., (2S,3S)-3-hydroxy-pyrrolidine-2-carboxylic acid 4-Hyp 4-hydroxyproline, i.e., (2S,4R)-4-hydroxypyrrolidine-2-carboxylic acid ile or 1 isoleucine Leu or L leucine hLeu homoleucine Lys or K lysine Met or M methionine β-hMet β-homomethionine 1-Nal β-(1-naphthyl)alanine 2-Nal β-(2-naphthyl)alanine Nip Nipecotic acid Nle norleucine Ole octahydroindole-2-carboxylic acid Orn ornithine 2-Pal β-(2-pyridiyl)alanine 3-Pal β-(3-pyridiyl)alanine 4-Pal β-(4-pyridiyl)alanine pen penicillamine pff (S)-pentafluorophenylalanine Phe or F phenylalanine hPhe homophenylalanine Pro or P proline hProP homoproline Ser or S serine Tle tert-leucine Taz β-(4-thiazolyl)alanine 2-thi β-(2-thienyl)alanine 3-thi β-(3-thienyl)alanine Thr or T threonine TRP or W tryptophan Tyr or Y tyrosine D-(Et) Tyr Has a structure

Val or V valine certain other abbreviations used in this document are defined as follows: boc: tert-butyloxycarbonyl bzl: benzyl DXM: dichloromethane DIC: N,N-diisopropylcarbodiimide DIEA: diisopropylethylamine Dmab: 4-{N-(1-(4,4-dimethyl-2,6-dioxocyclohexylidene)-3-methylbutyl)-amino}benzyl DMAP: 4-(dimethylamino)pyridine DMF: dimethylformamide DNP: 2,4-dinitrophenyl FM: fluorenylmethyl fmoc: fluorenylmethyloxycarbonyl For: formyl HBTU: 2-(1H-benzotriazol-1-yl)-1,1,3,3-tetramethyluronium hexafluorophosphate cHex cyclohexyl HOAT: O-(7-azabenzotriazol-1-yl)-1,1,3,3-tetramethyluronium hexafluorophosphate HOBt: 1-hydroxy-benzotriazole MBNA 4-methylbenzhydrylamine mmt: 4-methoxytrityl NMP: N-methylpyrrolidone O-tBu hydroxy-tert-butyl pbf: 2,2,4,6,7-pentamethyldihydrobenzofuran-5-sulfonyl PyBroP bromine-tris-pyrrolidino-phosphonium hexafluorophosphate tBu: tert-butyl TIS: triisopropylsilane T.O.S.: tozil Trt trityl TFA: trifluoroacetic acid TFFH: Tretramethylfluoroformamidinium hexafluorophosphate Z: benzyloxycarbonyl

Unless otherwise noted, except for the N-terminal amino acid, all amino acid abbreviations (e.g., Ala) in this disclosure denote the structure -NH-C(R)(R')-CO-, where R and R' are each independently hydrogen or an amino acid side chain (eg R═CH ₃ and R′═H for Ala), or R and R′ can be connected to form a ring system.

For an N-terminal amino acid, the abbreviation represents the structure:

The designation "NH ₂ " in, for example, Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 13), indicates that C the end of the peptide is amidated. Ac-Nle-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys) (SEQ ID NO: 107), or alternatively Ac-Nle-c(Cys-D-Ala- His-D-Phe-Arg-Trp-Cys)-OH (SEQ ID NO: 107) indicates that the C-terminus is free acid.

"-c(Cys-Cys)-" or "-cyclo(Cys-Cys)-" denotes the structure:

"-c(Cys-Pen)-" or "-cyclo(Cys-Pen)-" denotes the structure:

"-c(Asp-Lys)-" or "-cyclo(Asp-Lys)-" denotes the structure:

Applicants have developed the following conventions for naming particular embodiments and/or molecules:

"hydantoin-(C(O)-(A ^a -A ^b ))" refers to the structure:

,

,

where the amino acid "A ^a " has the structure:

,

,

and the amino acid "A ^b " has the structure:

.

.

For example, "hydantoin-(C(O)-Arg-A ^b ))" would have the following structure:

.

.

For example, "hydantoin-(C(O)-(Arg-Gly))" would have the following structure:

.

.

For example, a compound represented as "c[hydantoin(C(O)-(Cys-A ^b ))-A ¹ -A ² -A ³ -A ⁴ -Cys]-" would have the following structure:

,

,

and the compound represented as "c[hydantoin(C(O)-(A ^b -Cys))-A ¹ -A ² -A ³ -A ⁴ -Cys]-" will have the structure:

.

.

For further reference: "c[hydantoin(C(O)-(Asp-A ^b ))-A ¹ -A ² -A ³ -A ⁴ -Lys]-" represents the following compound:

,

,

and "c[hydantoin(C(O)-(Dap-A ^b ))-A ¹ -A ² -A ³ -A ⁴ -Asp]-" has the following formula:

.

.

"Acyl" refers to R″-C(O)-, where R″ is H, alkyl, substituted alkyl, heteroalkyl, substituted heteroalkyl, alkenyl, substituted alkenyl, aryl, alkylaryl, or substituted alkylaryl, and is indicated in the general formula of a particular embodiment implementations as "Ac".

"Alkyl" refers to a hydrocarbon group containing one or more carbon atoms, where several carbon atoms, when present, are connected by single bonds. The alkyl hydrocarbon group may be linear or contain one or more branches or cyclic groups.

"Hydroxyalkyl" refers to an alkyl group in which one or more hydrogen atoms of the hydrocarbon group are replaced by one or more hydroxyl radicals such as hydroxymethyl, hydroxyethyl, hydroxypropyl, hydroxybutyl, hydroxypentyl, hydroxyhexyl, and the like.

"Substituted alkyl" refers to alkyl in which one or more hydrogen atoms of the hydrocarbon group have been replaced by one or more substituents selected from the group consisting of halogen (i.e., fluorine, chlorine, bromine and iodine), -OH, - CN, -SH, amine (e.g. -NH ₂ , -NHCH ₃ ), -NO ₂ , guanidine, urea, amidine and -C _1-20 alkyl, said -C _1-20 alkyl optionally being substituted by one or more substituents selected, independently for each occurrence, from the group consisting of halogens, -CF ₃ , -OCH ₃ , -OCF ₃ and -(CH ₂ ) _0-20 -COOH. In other embodiments, 1, 2, 3, or 4 substituents are present. The presence of -(CH ₂ ) _0-20 -COOH leads to the formation of an alkyl acid. Non-limiting examples of alkyl acids containing or consisting of -(CH ₂ ) _0-20 -COOH include 2-nonbornanoacetic acid, t-butyric acid, 3-cyclopentylpropionic acid, and the like.

The term "halo" ("halogen") includes fluorine, chlorine, bromine and iodine.

Guanidines are a group of organic compounds that share a functional group with the general structure (R ¹ R ² N)(R ³ R ⁴ N)C=NR ⁵ . The central bond in this group is an imine bond, and the group is structurally similar to amidines and ureas.

"Heteroalkyl" refers to alkyl in which one or more carbon atoms in the hydrocarbon group is replaced by one or more of the following groups: amino, amido, -O-, -S- or carbonyl. In other embodiments, 1 or 2 heteroatoms are present.

"Substituted heteroalkyl" refers to a heteroalkyl in which one or more hydrogen atoms of the hydrocarbon group are replaced by one or more substituents selected from the group consisting of halogen (i.e., fluorine, chlorine, bromine and iodine), -OH, -CN, -SH, -NH ₂ , -NHCH ₃ , -NO ₂ and -C _1-20 alkyl, said -C _1-20 alkyl optionally being substituted with one or more substituents selected, independently for each occurrence, from a group consisting of halogens, -CF ₃ , -OCH ₃ , -OCF ₃ and -(CH ₂ ) _0-20 -COOH. In other embodiments, 1, 2, 3, or 4 substituents are present.

"Alkenyl" refers to a hydrocarbon group of two or more carbon atoms in which one or more carbon-carbon double bonds are present. The alkenyl hydrocarbon group may be linear or contain one or more branches or cyclic groups.

"Substituted alkenyl" refers to alkenyl in which one or more hydrogens have been replaced by one or more substituents selected from the group consisting of halogen (i.e., fluorine, chlorine, bromine and iodine), -OH, -CN, - SH, -NH ₂ , -NHCH ₃ , -NO ₂ , and -C _1-20 alkyl, said -C _1-20 alkyl optionally being substituted with one or more substituents selected, independently for each occurrence, from the group consisting of from halogens, -CF ₃ , -OCH ₃ , -OCF ₃ and -(CH ₂ ) _0-20 -COOH. In other embodiments, 1, 2, 3, or 4 substituents are present.

"Aryl" refers to an optionally substituted aromatic group with at least one ring atom with a conjugated pi electron system containing up to three conjugated or connected ring systems. Aryl includes carbocyclic aryl, heterocyclic aryl, and biaryl groups. In a preferred embodiment, aryl is a 5- or 6-membered ring. Preferred atoms for heterocyclic aryl are one or more sulfur, oxygen and/or nitrogen atoms. Non-limiting examples of aryl include phenyl, 1-naphthyl, 2-naphthyl, indole, quinolinyl, 2-imidazole, 9-anthracene, and the like. Aryl substituents are selected from the group consisting of -C _1-20 alkyl, -C _1-20 alkoxy, halogen (i.e., fluorine, chlorine, bromine and iodine), -OH, -CN, -SH, -NH ₂ , -NO ₂ , -C _1-20 alkyl substituted with halogens, -CF ₃ , -OCF ₃ and -(CH ₂ ) _0-20 -COOH. In other embodiments, the aryl contains 0, 1, 2, 3, or 4 substituents.

"Alkylaryl" refers to "alkyl" coupled to "aryl".

The term "(C _1-12 )hydrocarbon group" embraces alkyl, alkenyl and alkynyl, and in the case of alkenyl and alkynyl, is C ₂ -C ₁₂ .

For the avoidance of doubt, unless otherwise indicated, the term "substituted" means substituted by one or more of the specified groups. Where the groups may be selected from a number of alternative groups, the selected groups may be the same or different. For the avoidance of doubt, the term "independently" means that if more than one substituent is selected from a number of possible substituents, these substituents may be the same or different.

Pharmaceutically acceptable salts of the compounds of the present invention which contain a basic basic center are, for example, non-toxic acid addition salts formed with inorganic acids such as hydrochloric, hydrobromic, hydroiodic, sulfuric and phosphoric acids, with carboxylic acids or with organo-sulfonic acids. acids. Examples include HCl, HBr, HI salts, sulfate or bisulfate, nitrate, phosphate or hydrogen phosphate, acetate, benzoate, succinate, saccharate, fumarate, maleate, lactate, citrate, tartrate, gluconate, camsylate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate and pamoat. The compounds of the present invention may also give pharmaceutically acceptable metal salts, in particular non-toxic alkali and alkaline earth metal salts, with bases. Examples include sodium, potassium, alucinium, calcium, magnesium, zinc, and diethanolamine salts (Berge, SM et al., J. Pharm. Sci., 66:1-19 (1977); Gould, PL, Int'l J. Pharmaceutics , 33:201-17 (1986), and Bighley, LD et al., Encyclo Pharma Tech, Marcel Dekker Inc, New York, 13:453-97 (1996).

Pharmaceutically acceptable solvates of the compounds of the present invention include their hydrates. Also included within the scope of the present invention are the various salts of the present invention and their polymorphs. Further, the compounds, their pharmaceutically acceptable salts, solvates or polymorphs thereof, as defined in any aspect of the invention (excluding chemical process intermediates) are referred to as "compounds of the present invention".

The designation "(amino acid) _n " denotes that the amino acid is repeated n times. For example, the designation "(Pro) ₂ " or "(Arg) ₃ " means that the proline or arginine residues are repeated two or three times, respectively.

The MC4R agonists and their pharmaceutically acceptable salts described herein can also be used to treat individuals, including human subjects, with impaired melanocoritin receptor signaling due to mutations/defects upstream of MC4R. The MC4R agonists and their pharmaceutically acceptable salts described herein are useful in the treatment of individuals, including human subjects, who carry mutations in the genes encoding pro-opiomelanocortin (POMC) and leptin, in cases where these mutations result in haplo POMC deficiency or haplo deficiency and/or leptin haplo deficiency or haplo deficiency.

In one embodiment, the MC4R agonist is a compound represented by the structural formula (X):

(X)

(X)

or a pharmaceutically acceptable salt thereof. In structural formula (X), chemical substituents are defined as follows:

R ₁ is -NH-C(O)- or -C(O)-NH-;

R ₂ is -H, -CH ₂ -, or R ₂ together with R ₃ forms a pyrrolidine ring optionally substituted with -OH;

R ₃ is -(CH ₂ ) ₂ - if R ₂ is -CH ₂ - and in other cases R ₃ is selected from

;

;

each of R _4a , R _4b and R _4c is independently selected from hydrogen, halo, (C ₁ -C ₁₀ )alkyl halo, (C ₁ -C ₁₀ )alkyl dihalo, (C ₁ -C ₁₀ )alkyl trihalo, (C ₁ -C ₁₀ )alkyl, (C ₁ -C ₁₀ )alkoxy, (C ₁ -C ₁₀ )alkylthio, aryl, aryloxy, nitro, nitrile, sulfonamide, amino, hydroxyl, carboxy, and aoxycarbonyl. In one embodiment, R _4a , R _4b and R _4c are not hydrogen.

R ₅ is -OH or -N(R _6a )(R _6b );

Each of R _6a and R _6b independently represents H or C ₁ - C ₄ linear, branched or cyclic alkyl chain;

R ₇ is -H or -C(O)-NH ₂ ;

w in each case is independently from 0 to 5;

x is from 1 to 5;

y is from 1 to 5;

z is in each case independently from 1 to 5.

An example of a compound of structural formula (X) is a cyclic peptide defined by structural formula (XI):

(XI),

(XI),

or a pharmaceutically acceptable salt thereof.

Pharmaceutical Compositions/Introduction

In accordance with any method or composition described herein, embodiments provide a dosage unit of an MC4R agonist described herein, for example, setmelanotide. In embodiments, said dosage unit contains 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, or 2 mg of the agonist. In embodiments, said dosage unit is suitable for injection, eg subcutaneous injection. In embodiments, said dosage unit is in a delivery device suitable for injection, eg subcutaneous injection. In embodiments, said dosage unit is in a syringe suitable for injection, such as subcutaneous injection, or a pen-type injection device. Examples of pen-type injection devices are described, for example, in US 8512297B2, US5688251A, US5820602A, US2014/0163526A1 and US5226895A, incorporated herein by reference.

Embodiments also provide a pharmaceutical composition comprising an MC4R agonist described herein, eg, setmelanotide. In embodiments, the pharmaceutical composition comprises a therapeutically effective amount of an MC4R agonist described herein, for example, setmelanotide. The therapeutically effective amount of an agonist may vary depending on factors such as the disease state, age, sex, and weight of the individual, and the ability of the agonist to elicit the desired response in the individual , e.g. at least one symptom of the disorder, e.g., obesity, hyperphagia, Prader-Willi syndrome (PWS), or other obesity-associated genetic disorders (e.g., obesity associated with POMC genotype null or PCSK1 genotype null, among others). In embodiments, a therapeutically effective amount is also one such that any toxic or undesirable effects from the composition are outweighed by the therapeutically beneficial effects.

In some embodiments, the agonist may be combined with a carrier that protects it from rapid release, such as a controlled release formulation, including implants and microencapsulated delivery systems. Biodegradable, biocompatible polymers such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthesters and polylactic acid. Many processes for the preparation of such preparations are well known or patented. See, for example, Sustained and Controlled Release Drug Delivery Systems, J. R. Robinson, ed., Marcel Dekker, Inc., New York, 1978, USA.

In other embodiments, the agonist may be manufactured as described in WO2014/144842, incorporated herein by reference. In embodiments, the agonist is included in a formulation containing an anionic excipient, eg, a PEG carboxylic acid, a fatty acid having 10 or more carbon atoms, and/or an anionic phospholipid. In embodiments, the anionic phospholipid is the phospholipid described in WO2014/144842 (eg, pages 7-9). In some embodiments, the anionic phospholipid is 1,2-distearyl-sn-glycero-3-phosphoethanolamine (DSPE), optionally polyethylene glycol (PEG) conjugated, which has the following structure:

,

,

where the value of "n" varies depending on the molecular weight. In embodiments, the fatty acid is a fatty acid as described in WO2014/144842 (eg, on page 9). In embodiments, the PEG carboxylic acid is the PEG carboxylic acid described in WO2014/144842 (eg, pages 9-11). In embodiments, the molar ratio of agonist to anionic excipient ranges from about 1:1 to about 1:10.

In embodiments, the agonist forms an ionic complex with another drug moiety and, for example, provides the desired pharmacokinetic profile for the agonist (eg, increases duration of drug action and/or minimizes side effects). In embodiments, the drug is a sustained release drug. In embodiments, the drug provides a reduction in fluctuations in the concentration of the agonist after administration.

The MC4R agonist described herein, eg, setmelanotide, can be administered to a subject, eg, a human subject, in a variety of ways. In embodiments, the route of administration is one of: intravenous injection or infusion, subcutaneous injection, or intramuscular injection. In embodiments, the route of administration is subcutaneous injection.

In embodiments, pharmaceutical compositions, for example, containing the MC4R agonist described herein, can be administered using medical devices. For example, compositions containing an agonist can be administered using a needle-free hypodermal injection device, such as the device described in US Pat. Examples of implants and modules include; U.S. Patent No. 4,447,224, which discloses an implantable infusion device with a variable flow rate for continuous drug delivery, U.S. Patent No. 4,439,196, which discloses a system for osmotic drug delivery containing multi-chamber compartments, and US Pat. No. 4,475,196, which discloses a system for osmotic drug delivery. Other such implants, delivery systems, and modules may also be used.

In embodiments, continuous administration may be indicated, for example, using a subcutaneous pump. In embodiments, the agonist is administered via a syringe (eg, a pre-filled syringe), an implantable device, a needleless hypodermic injection device, an infusion pump (eg, an implantable infusion pump), or an osmotic delivery system.

In embodiments, the agonist is administered in a unit dosage, e.g., containing 0.1-10 mg, e.g. , 1.7, 1.8, 1.9, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, or 10 mg agonist, eg subcutaneously.

In embodiments, the agonist is administered in boluses at a dose in the range of 0.1-10 mg, e.g. 1.7, 1.8, 1.9, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5 or 10 mg agonist, e.g. subcutaneously.

In embodiments, the agonist is administered continuously, for example by means of a pump, such as a subcutaneous pump.

In embodiments, the agonist, e.g., the agonist dosage unit, is in a delivery device, e.g., a syringe (e.g., a pre-filled syringe), an implantable device, a needleless hypodermic injection device, an infusion pump (e.g., an implantable infusion pump), or an osmotic delivery system.

In embodiments, the subject is administered a daily dosage of the agonist, eg, subcutaneously. In embodiments, the daily dosage of the agonist is about 0.1 mg to about 10 mg, e.g. -2.5, 2.5-3, 3-3.5, 3.5-4, 4-4.5, 4.5-5, 5-5.5, 5.5-6, 6-6.5, 6.5-7, 7-7.5, 7.5-8, 8-8.5 , 8.5-9, 9-9.5, 9.5-10 mg, for example, injected subcutaneously.

In embodiments, the agonist, e.g., setmelanotide, is administered, e.g., one or more times, for at least 3 weeks, e.g., at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 , 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 , 38, 39, or 40 weeks or more, or at least 1, 2, 3, 4, 5, 6, 7, 8, 8, 9, 10, 11, or 12 months or more, or at least 1, 2 , 3, 4 years or more. In embodiments where multiple administrations of the agonist are contemplated, the time interval between any two administrations is at least 6 hours, e.g., 6 hours, 12 hours, 24 hours, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 1 week, 2 weeks, 3 weeks, 4 weeks or more. In embodiments, the interval between any two of the administrations is 1 day.

Sets

The MC4R agonist described herein, for example, setmelanotide, may be provided in a kit. The kit includes the MC4R agonist described herein and optionally a container, pharmaceutically acceptable carrier and/or information material. The informational material may be descriptive material, instructional material, marketing material, or other material relating to the methods described herein and/or the use of an agonist for the methods described herein.

The information material in the set has no restrictions on the form. In one embodiment, the information material may contain information about the manufacture of the agonist, physical properties of the agonist, concentration, expiration date, batch and place of manufacture, and so on. In one embodiment, the information material relates to methods of administering the agonist, for example, using the route of administration described herein and/or the dose and/or schedule of administration described herein.

In one embodiment, the communication material may contain instructions for administering the agonist described herein in a manner suitable for carrying out the methods described herein, e.g., at an appropriate dose, dosage form, or using an appropriate mode of administration ( e.g., dose dosage form or mode of administration described herein). In another embodiment, the information material may contain instructions for administering the agonist to a suitable subject, e.g., a human, e.g., an obese person, e.g., a severely obese person, e.g., having PWS or a genetic defect in one or more POMC-MC4R pathway genes.

The information material in the kits has no restrictions on the form. In many cases, the information material, such as instructions, may be in printed form, such as printed text, an image, and/or a photograph, such as a label or printed sheet. However, informational material may also be presented in other formats such as Braille, computer-readable material, videotape, or audiotape. In another embodiment, the information material in the kit is contact information, such as a physical address, email address, website, or telephone number, enabling the user to obtain meaningful information regarding the agonist described herein and/or its use in the methods described in this document. Information material can be presented in any combination of formats.

In addition to the agonist, the kit composition may contain other ingredients such as a surfactant, a lyoprotectant or stabilizer, an antioxidant, an antibacterial agent, a bulking agent, a chelating agent, an inert gas, tonicity regulators/or a viscosity adjusting agent, a solvent or a buffer, a stabilizer, a preservative, a pharmaceutically acceptable carrier, and/or a second agent for treating the condition or disorder described herein. Alternatively, other ingredients may be included in the kit, but in different compositions or containers than those containing the agonist described herein.

In some embodiments, the kit component is stored in a stoppered bottle, eg, with a rubber or silicone lid ( eg, a polybutadiene or polystyrene lid). In some embodiments, the kit component is stored under inert conditions ( eg, under nitrogen or another inert gas such as argon). In some embodiments, the kit component is stored under anhydrous conditions ( eg, with a desiccant). In some embodiments, the kit component is stored in a light-protective container, such as an amber bottle.

The agonist described herein may be in any form, such as liquid, frozen, dried, or lyophilized form. In a preferred embodiment, the composition comprising the agonist described herein is essentially pure and/or sterile. Where the agonist described herein, such as setmelanotide, is provided in a liquid solution, the liquid solution is preferably an aqueous solution, with a sterile aqueous solution being preferred. In one embodiment, the agonist is supplied with a diluent or dilution instructions. The diluent may contain, for example, saline or saline, such as sodium chloride solution pH 6 to 9, Ringer's lactate injection, D5W, or PLASMA-LYTE A Injection pH ^7.4® (Baxter, Deerfield, IL, USA). ).

The kit may contain one or more containers for a composition containing an agonist described herein. In some embodiments, the Kit contains separate containers, dividers or compartments for composition and informational material. For example, the composition may be contained in a vial, vial, IV bag, IV infusion set, piggyback kit, or syringe (eg, pre-filled syringe), and the information material may be contained in a plastic file or bag. In other implementations, the separate elements of a set are in a single, non-separated container. For example, the composition is contained in a vial, vial or syringe, to which information material is attached in the form of a label. In embodiments, the composition is contained in an injection device, such as a pen-type injection device. The containers included in the kit may be airtight, watertight ( e.g. impervious to moisture changes or evaporation), and/or lightproof.

EXAMPLES

Hereinafter, the present invention is described in detail with reference to the following experimental examples. These examples are for illustrative purposes only and are not intended to be limiting unless otherwise noted. Accordingly, the present invention should in no way be construed as being limited to the examples below, but, on the contrary, it should be understood to include any and all variations that will become apparent from the foregoing description.

Without further ado, it is assumed that the average specialist, based on the following illustrative examples, will be able to receive and use the compounds according to the present invention, as well as to implement the claimed methods. The following working examples describe various specific aspects of the present invention and should in no way be construed as limiting the rest of the disclosure.

Example 1 Melanocortin 4 Receptor (MC4R) Agonist Treatment of a POMC Deficient Patient Suffering from Severe Obesity and Hyperphagia

Patients with defects in the POMC gene, such as POMC mutations leading to loss of function, suffer from severe early-onset obesity, hyperphagia, red hair, adrenal insufficiency, and ACTH deficiency. Early-onset obesity and hyperphagia are thought to be caused by a deficiency of POMC-derived peptides such as MSH and ACTH, which are melanocortin receptor ligands. MSH, a cleavage product of POMC, is a hypothalamic MC4R ligand that plays an important role in the regulation of feeding behavior and energy homeostasis. There is a need for targeted replacement therapy for patients with genetic defects in the leptin-melanocortin pathway, such as those with POMC mutations leading to loss of function.

The present example describes a study in which an MC4R agonist, setmelanotide (also referred to as RM-493), having the sequence Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp- Cys)-NH ₂ (SEQ ID NO: 140). See, for example, Chen et al. J.Clin. Endocrinol. Metab. 2015;100:1639-45. The present study was an Investigator-initiated, Phase 2, open-label, non-randomized, proof-of-concept study (EudraCT No. 2014-002392-28; Clinical Trials Identifier No. NCT02507492) consisting of three parts: a pre-study, a pivotal study (approximately 13 weeks), and a short period without taking the drug long extended phase.

During the pre-study period, a baseline examination was performed, including analysis of metabolic parameters, including oral glucose tolerance test (OGTT), GnRH, fasting blood glucose, leptin measurement, and bioelectrical resistance (BIA) analysis, according to standard protocols; input data, Nutriguard-MS), indirect calorimetry (CareFusion, VMAX® Encore system), heart rate and blood pressure monitoring (after the first injection and after each dose increase, blood pressure was measured regularly for more than 12 hours; additional pressure was measured at home 3 times a day), as well as a dermatological and psychological examination. All parameters were within the normal range, except for increased fasting insulin, which was indicative of insulin resistance. These measurements were repeated 13 and 26 weeks after the start of treatment. The initial examination also included a physical examination, such as measuring height and weight. Treatment with setmelanotide was initiated at a dose of 0.25 mg subcutaneously (s.c.) once a day. The dose was increased every 1-2 weeks after careful evaluation of safety and weight loss. After the first injection and after each dose increase, blood pressure was measured regularly for more than 12 hours. Additionally, the pressure was measured 3 times a day. Setmelanotide injections were given once a day.

After approximately 90 days of treatment (main study), the examination was repeated, including assessment of metabolic parameters, such as blood tests, skin examination and assessment of psychological status. Treatment with setmelanotide was discontinued and, without treatment, a rapid and significant weight gain was observed. Therefore, treatment with setmelanotide was continued for another 3 months (extended phase) along with continuous evaluation (of metabolic parameters). Hunger scores were assessed using the Lakert hunger scale from 0 to 10 points (0=no hunger; 10=very hungry). See, for example, Sibilia. Psychologicol Topics 19 (2010), 2, 341-354.

Bioelectrical impedance analysis (BIA) and indirect calorimetric analysis were performed according to standard protocols, for example, as described by Barak et al. See comment in PubMed Commons belowJPEN J. Parenter. enteral nutr. 27.1(2003):43-6; and Compher et al. J. Am. Diet Assoc. 106.6(2006):881-903.

Statistical Analysis: Systolic and diastolic blood pressure and heart rate values were analyzed using a non-parametric Student's t-test.

The MAINTAIN: Maintain-Z-Project control group is a randomized controlled trial (ClinicalTrials.gov: NCT00850629) that examines the impact of a multimodal lifestyle on weight maintenance after weight loss in children and adolescents. The preliminary result was to describe the dynamics of hormonal and metabolic mechanisms compensating for sustained weight loss during adolescence and adolescence. 147 participants achieved an initial weight loss of -0.2 BMI standard deviation (SDS) (the weight loss phase lasted an average of 15.7 ± 5.2 standard deviation (SD) weeks). From this study cohort, 12 girls with extreme but not monogenic obesity (age 16.5 ± 0.6 SD years; BMI 38.8 ± 2.5 SD kg/m²) were selected as the control group for weight loss using the addition the same study protocol (with the exception of the definition of GnRH).

results

Clinical signs of POMC deficiency in a patient

The patient was a 21-year-old woman with a complex heterozygous mutation of the POMC gene leading to loss of function (p.Lys51Term g.A6851>T, p.Arg145ProfsX12 g.7134delG). See, for example, Krude et al. Nat. Genet. 1998;19:155-7. Her older brother, who was previously found to also be a carrier of compound heterozygous mutations, died at 7 months of age due to adrenocorticotropic hormone (ACTH)-deficient adrenal insufficiency. Since the patient was diagnosed with adrenal insufficiency immediately after birth, she was treated with hydrocortisone from the age of three weeks. After three months of age, the patient developed obesity and severe hyperphagia. At the age of four, the patient was diagnosed with a defect in the POMC gene by genetic analysis of the POMC gene. This was the first description of a POMC mutation in humans leading to loss of function.

Despite significant efforts in which the patient received medical treatment for adrenal insufficiency and intensive counseling on nutrition, exercise, and behavioral appetite control, the patient was unable to stabilize her body weight, except for short periods of weight stabilization, during which she still could not lose significant amount of mass. In all cases of short-term weight loss, the patient experienced immediate rapid weight loss. Severe obesity led to moderate metabolic disorders and progressive deformity of the lower limb, which required major surgical orthopedic interventions. Similar to patients with leptin deficiency1 (see, e.g., Farooqi et al. N. Engl. J. Med. 1999;341:879-84), her progression at puberty stopped at Tanner stage 2, and menarche was still absent at age 21. She was treated with L-Thyroxine (175 µg/day) for elevated serum TSH levels (range: 6-15 mU/l) and hydrocortisone replacement (at 12.7 mg/m ² BSA)).

Body weight, body composition and hunger

At baseline (before treatment with setmelanotide), the patient weighed 155 kg and was 176.5 cm tall (BMI 49.8 kg/m2; body mass index (SD) + 4.52). At the beginning of the study, the patient suffered from severe hyperphagia: her degree of hunger on the Lakert scale was 9 out of 10 points (extreme hunger). Psychological assessment consistently revealed marked discomfort with her quality of life due to severe obesity.

Weight Loss and Changes in Hunger Scores

Setmelanotide was administered subcutaneously once a day with dose escalation starting at a low dose of 0.25 mg with weekly increases of 0.5 mg, 1.0 mg, and finally 1.5 mg. Initially, at the low dose, weight loss was moderate with little change in hunger. However, with an increase in the dose to 1 mg of setmelanotide, the patient noticed a clear decrease in the degree of hunger (5 out of 10 points), and at a dose of 1.5 mg her appetite almost completely disappeared (0-1 out of 10 points; no hunger). With this change in satiety, she achieved a consistent rate of weight loss of 2-3 kg per week using a dose of 1.5 mg, resulting in a total weight loss of 25.8 kg after the first 13 weeks of treatment (16.7% of her initial body weight; final body weight was 129.2 kg; BMI 41.5 kg/m ² ; BMI SDS+3.86).

Due to regulatory obligations, clinical trials of treatment with setmelanotide were stopped after 13 weeks. Shortly thereafter, the patient experienced a significant increase in hunger (the degree of hunger on the Likert scale was 7 points) and a return of weight (4.8 kg). As a result of the reversibility of the course of the disease, the patient developed acute situational depression and for this reason the treatment was resumed (after three weeks of not taking the drug). Immediately after the resumption of setmelanotide (1 mg for 4 weeks and 1.5 mg after), hunger again decreased and weight loss was restored. During the second phase of treatment, the patient lost approximately 1-2 kg per week and her total weight loss was 35.9 kg of body weight after 26 weeks of treatment (23.2% of her initial body weight). Thereafter, the patient continued to lose weight and lost 60.5 kg of body weight during 86 weeks of treatment. The patient remained responsive to treatment with setmelanotide.

Metabolism

Metabolic parameters and blood pressure were monitored. Before the start of the study, after 13 weeks and during the extended phase of the study, an oral glucose tolerance test was performed. During the study, the patient's blood glucose levels always remained within the normal range (fasting and post-glucose loading). Elevated insulin levels measured during preliminary studies, demonstrating marked insulin resistance, improved significantly with treatment with setmelanotide.

Despite severe weight loss, resting energy expenditure (REE)/kg lean body mass remained relatively stable. In contrast to the significant decrease in REE after weight loss in patients with ordinary obesity (see, for example, Leibel et al. N Engl J Med 1995;332:621-8; Johannsen et al. J Clin Endocrinol Metab 2012; 97:2489- 96; Ebbeling et al. JAMA 2012;307:2627-34; and de Jonge et al. Obesity (Silver Spring) 2012;20:2384-9), which is considered to be one of the contributors to weight gain in conventionally obese patients. In addition, in a POMC deficient subject, no significant difference in lean body mass was found and the decrease in body weight was mainly due to loss of body fat, which was accompanied by a significant decrease in serum leptin concentration. Blood sugar levels were relatively stable across all analyses; insulin sensitivity improved significantly with continued treatment with setmelanotide.

HDL cholesterol, LDL cholesterol and triglycerides were also measured at 13 weeks and compared with baseline values. HDL cholesterol and triglyceride levels did not change, while LDL cholesterol and total cholesterol levels decreased after 13 weeks of treatment with setmelanotide. Triglycerides, LDL and total cholesterol levels further decreased after 26 weeks of treatment.

Blood pressure

During the study, blood pressure (KP) and heart rate (HR) were determined. In this study, blood pressure (BP) and heart rate (HR) were measured three times a day and for 12 hours after the start of treatment and after each dose increase.

During all dose escalation steps, no increase in blood pressure was observed (analyzed using a non-parametric Student's t-test). A significant decrease in systolic and diastolic blood pressure, as well as heart rate, was observed.

Safety and tolerability of treatment with setmelanotide

In general, treatment with setmelanotide is well tolerated. The patient reported occasional dry mouth. In general, there were no changes in laboratory safety parameters that could cause concern from a clinical point of view.

Conclusions

As shown in this application, setmelanotide resulted in significant weight loss and reduced hunger without side effects. The present study represents the first successful attempt to treat a patient with POMC deficiency with targeted replacement therapy (MSH replacement therapy) using setmelanotide. Setmelanotide therapy resulted in complete reversal of hyperphagia and normalization of insulin resistance caused by disruption of the hypothalamic leptin-melanocortin pathway in a patient with POMC deficiency. Treatment with setmelanotide resulted in significant and sustained weight loss and the cessation of lifelong hyperphagia. Significant and continuous weight loss during therapy, indicating complete reversibility of severe obesity, was comparable to or greater than the changes observed after leptin administration in leptin-deficient individuals. Treatment with setmelanotide can provide a normal long-term outcome and improve the quality of life of a patient who was at risk of serious comorbidities and reduced life expectancy before treatment.

In the present study, the significant treatment outcome was largely confirmed by prolonged weight gain and severe hyperphagia prior to treatment. Additionally, a significant dose-dependent effect was found for both hunger and weight loss during the dose escalation phase. Stopping treatment between the main study (first 13 weeks) and the extended phase allowed the patient to be a "control" for herself. After short-term withdrawal, an immediate and rapid increase in hunger and weight was observed, as well as a rapid response to restarted therapy, thus demonstrating a strong effect of setmelanotide. The quality of life after the start of treatment with setmelanotide improved significantly. Surprisingly, steady weight loss was observed under the action of setmelanotide. Diet-induced weight loss in conventionally obese patients is usually accompanied by significant counter-regulatory effects, including reduced resting energy expenditure (REE) and increased hunger, leading to weight gain in most patients. See, for example, Johannsen et al. J. Clin. Endocrinol. Metab. 2012;97:2489-96. The weight loss observed in this patient on treatment with the MC4R agonist, setmelanotide, did not result in counterregulatory responses even after more than 26 weeks of treatment and a dramatic weight loss. These data showed that treatment with setmelanotide (RM-493) also helps obese individuals avoid weight gain after a period of significant weight loss. This is consistent with reports that the leptin-melanocortin signaling cascade plays an important role in regulating weight gain and energy expenditure after a period of significant weight loss, such as that induced by dieting (Rosenbaum et al. JCI, 2005; Kissileff et al. Am J Clin Nutra 2012).

Compared to obese wild type patients administered with setmelanotide, the weight loss observed in the POMC deficient patient was significantly greater. For example, as described in Example 3, obese wild-type patients treated with setmelanotide exhibited a weight loss of about 0.6 to about 0.9 kg per week. In this example, a POMC deficient patient treated with setmelanotide exhibited a weight loss of approximately 2-2.5 kg per week. The findings show that POMC deficient subjects (e.g. POMC genotype null) are hypersensitive to MC4R agonists such as setmelanotide compared to obese wild-type patients e.g. who are not POMC deficient (e.g. POMC genotype null) . Because POMC acts upstream of MC4R, deficiencies of other genes in the POMC-MC4R pathway upstream of MC4R would also likely result in hypersensitivity to MC4R agonists such as setmelanotide compared to obese patients with the wild-type genotype.

POMC deficiency is a "very rare disease" that occurs in early childhood and has been found in only approximately 15-20 children, of which only three have reached adulthood. To date, no adult patients have been reported with this diagnosis. The efficacy and safety shown in the present study in an adult with POMC deficiency is likely to apply to pediatric patients and/or subjects with other deficiencies in the hypothalamic leptin-melanocortin pathway, for example, that result in decreased or impaired POMC function or signaling, altered POMC processing , reduced hypothalamic expression of POMC (eg, which may be caused by genetic and epigenetic variations in the POMC gene, such as heterozygous carriers of the POMC variant); in subjects with a mutation in the leptin receptor gene; in subjects with functional hypothalamic syndromes such as Prader-Willi syndrome or PCSK1 deficiency; or in a subject with MC4R mutations or other defects that affect the functioning of the POMC-MC4R pathway.

Example 2 Melanocortin 4 receptor (MC4R) agonist is effective in a mouse model (null gene Magel2 ) Prader-Willi Syndrome (PSW)

PWS is a gene sequence disorder associated with the loss of expression of several paternally inherited genes in a ~2 Mb region of chromosome 15 (15q11.2-13), known as the PWS region. Maternal genes at this locus are usually inactive. See, for example, Elena et al. J of Obesity (2012). The SPV region includes several protein-coding genes, as well as DNA regions that form long non-coding RNAs, many small nucleolar RNAs (snoRNAs), and antisense transcripts. Inactivation of this 2 Mb region, which normally expresses several gene products, results in symptoms of PWS. The symptoms associated with PWS are described in this application.

Deficiency in function of the MAGEL2 gene, located at the 2 Mb PWS locus, is likely responsible for the development of a number of signs and symptoms in patients with PWS. Magel2 null mice reproduce many aspects of the PWS phenotype (Bischof et. al., Hum Mol Gen, 2007, Vol 16, no 22, 2713-2719). Magel2 null mice initially fail to develop phenotypic traits (including stunted growth and reduced food intake) in the neonatal phase, and then show excess weight gain post-ablactation with a modest increase in food intake. These progressive changes in energy metabolism mimic the condition seen in people with PWS, leading to a significant increase in obesity in adulthood. Mice with the Magel2 gene null also show delayed gonadal development, altered behavior with increased anxiety, and defects in the hypothalamic-pituitary axis—features reminiscent of defects in PWS. Mechanically, developmental delay in Magel2 null mice coincides with a period when pro-opiomelanocortin neurons still respond normally to the appetite-reducing hormone leptin. However, pro-opiomelanocortin neurons in Magel2 null mice lose their ability to respond to leptin at approximately 8 weeks of age, potentially leading to significant changes in body composition and a significant increase in body fat mass (Pravdivyi et. al., Hum Mol Gen, 2015, May 14 , 1-8). Accordingly, loss of function of pro-opiomelanocortin neurons in Magel2 null mice may reproduce important aspects of the clinical features of PWS, mimicking the progression from failure to develop phenotypic features early in life to subsequent metabolic disorders and obesity. Magel2 null mice are a suitable rodent model for PWS.

Methods

Experiments were performed to determine the effect of the MC4R agonist, setmelanotide, on Magel2 gene null mice. The amount of setmelanotide was determined for wild-type and Magel2 gene null mice. Adult mice (N=6 per group) were adapted to life in metabolic chambers and food intake and energy expenditure (kcal/h) were measured over time. The mice were 8 weeks old. At this age, Magel2 gene null mice did not yet show the mild hyperphagia that was seen later in life in this animal model. Vehicle and drug (setmelanotide) were administered intraperinatally (ip) (n=6 for each application). A dose of 0.1 mg/kg setmelanotide was injected into mice ip before the start of the night cycle.

The total food intake (total amount in grams (g)) was assessed within three hours after dosing and during the night. Energy expenditure was also measured after dosing. The data obtained after the administration of setmelanotide were compared with the data obtained in the same group of mice after the administration of the vehicle. Statistical analysis was performed using two-way ANOVA with Bonferroni correction.

results

Administration of a dose of 0.1 mg/kg of setmelanotide significantly suppressed spontaneous food intake in Magel2 gene null mice (~75% reduction during the first 3 h; P<0.05) (Figure 1A). This suppression of food intake was maintained during the entire nocturnal cycle (Figure 1B). Setmelanotide also increased energy expenditure by 11% 3 hours post-dose in Magel2 null mice compared to vehicle- treated Magel2 null mice. Accordingly, setmelanotide resulted in reduced food intake and increased energy expenditure in Magel2 gene null mice.

In addition, Magel2 null mice showed significantly greater sensitivity to setmelanotide than wild-type mice, as wild-type mice treated with a dose of 0.1 mg/kg maintained normal food intake levels and did not respond to the indicated dose of setmelanotide (Figures 1A-B ). These data indicate that Magel2 null mice, a human model of PWS, showed unexpected sensitivity to MSH "replacement therapy" with setmelanotide. This is likely due in part to the lack of expression of the appetite-reducing hormone MSH in PWS patients due to dysfunction of the hypothalamic pro-opiomelanocortin neurons (Pravdivyi et. al., Hum Mol Gen, 2015, May 14, 1-8). The significant effect on food intake suppression observed in Magel2 null mice compared to wild-type mice indicated that treatment with setmelanotide as a replacement for lost MSH signaling may influence key performance outcome measures in patients with PWS, for example, by restoring downstream signaling of defective proopiomelanocortin neurons.

Conclusions

Magel2 null mice are a suitable rodent model for PWS. Treatment of Magel2 null mice with 0.1 mg/kg setmelanotide demonstrated a statistically significant reduction in total food intake (P < 0.05). These data demonstrate that the MC4R agonist setmelanotide is effective in a mouse model of PWS and suggest that setmelanotide may be effective in the treatment of PWS, for example, by reducing appetite and behavioral hyperphagia in addition to regulating body weight in patients with PWS. In addition, Magel2 null mice showed significantly greater sensitivity to setmelanotide (eg, reduced food intake) than obese wild-type mice.

Example 3 Effect of an MC4R Agonist on Obese Wild Type Patients

The effect of the MC4R agonist setmelanotide on obese wild-type human patients was evaluated. Patients were treated with either placebo or setmelanotide twice daily (BID) at a dosage of 0.01 mg/kg or 0.015 mg/kg. There were 9 patients in each treatment group (6 received setmelanotide and 3 received placebo).

Weight loss was determined after 2 weeks or after 4 weeks of treatment. Figure 2 shows placebo-adjusted weight differences in obese wild-type genotype patients following administration of various doses of setmelanotide at 2 or 4 weeks. Weight loss among obese wild-type patients ranged from about 0.6 to about 0.9 kg per week.

Example 4 Treatment of PWS

PWS is a rare genetic disorder that causes life-threatening obesity. Defects in the MC4 pathway are thought to be the cause of weight and appetite disturbances in PWS.

A phase II clinical trial was conducted to evaluate the safety and efficacy of setmelanotide on weight and eating behavior (weight loss and eating behavior) in obese patients with Prader-Willi syndrome (PWS). The present study is a double-blind, placebo-controlled, parallel-group study with a randomized, placebo-controlled withdrawal phase and an open-label extended active treatment phase. The study evaluated the effectiveness of setmelanotide as a replacement therapy for the treatment of severe obesity and hyperphagia in PWS, using a personalized medical approach to restore lost function, which is presumably caused by a defect in the MC4 signaling pathway.

Approximately 36 obese adolescent and adult patients with PWS participated in the study. Setmelanotide was administered once daily by subcutaneous injection for up to 10 weeks of treatment. After a two-week placebo-controlled baseline period, patients were randomly assigned to one of the following three treatment groups: 1) setmelanotide 0.5 mg daily, 2) setmelanotide 1.5 mg daily, and 3) placebo daily. After 4 weeks of treatment, patients' weight, degree of hyperphagia, and body composition were assessed at the primary point of efficacy. After 4 weeks, patients underwent a 2-week randomized withdrawal period where 50% of patients participated in double-blind withdrawal (50% of patients received setmelanotide and 50% of patients received placebo). After a two-week withdrawal period, patients underwent a two-week extended active dose treatment period.

Obese PWS patients may respond (eg, greater response, eg, greater efficacy) to treatment with setmelanotide than obese patients who do not have PWS.

Example 5 Treatment of Obesity with POMC Gene Null (POMC Deficiency)

POMC gene null obesity is a very rare, life-threatening genetic disorder for which no effective treatment has been known. Patients with POMC null gene lack POMC gene function and are characterized by pre-existing severe obesity and extreme hunger. These symptoms are thought to be related to a genetic defect in the MC4 pathway.

To assess the safety and efficacy of the effect of setmelanotide on weight and appetite in patients with a null POMC gene, phase 2 open-label clinical trials were conducted.

It was assumed that the study would involve about 6 obese adolescent and adult patients with genetic defects associated with the null POMC gene. Setmelanotide was administered once daily by subcutaneous injection for up to 13 weeks.

Patients' body weight, hunger, waist circumference, daily food intake, blood pressure (systolic and diastolic), and heart rate were monitored before, during, and after treatment. Side effects were also monitored during and after treatment to assess safety.

Obese POMC null patients may respond, eg, greater response, eg maximum efficacy, to treatment with setmelanotide than obese patients who are not POMC null patients.

Example 6 Effect of Different Concentrations of Setmelanotide on Food Consumption in WT and Genotype Mice db/db (receptor deficient mice)

Mice carrying the db/db mutation lack the leptin receptor gene. It has been suggested that these mice should be particularly sensitive to the MC4R agonist setmelanotide.

To establish this, wild-type and db/db mice were exposed to neutral media or various concentrations of setmelanotide (0.0554 mpk; 0.137 mpk, 0.344 mpk, or 1.37 mpk) and their food intake was measured for four hours.

The results are shown in FIGURES 3A-F. For example, at a dose of 0.0544 mpk, wild-type mice and mice treated with neutral media show similar food intake at the 4 hour time point, and food intake in mice with the db/db genotype by the end of the 4 hour period was significantly reduced, by approximately 80% (Figure 3A). A decrease in food intake in wild-type mice was observed at this dose of drug at 1 and 2 hours, although food intake approached wild-type values at 3 hours and did not differ from wild-type mice treated with neutral medium at 4 hours. with the DB/DV genotype.

The suppression of food intake was even more pronounced at higher doses of setmelanotide (FIGS. 3B-3D). Higher doses of setmelanotide (0.137 mpk, 0/344 mpk and 1.37 mpk) resulted in a significant reduction in food intake in wild-type mice, as well as in mice with the genotypedb/db, compared with neutral-treated wild-type mice and mice with the genotypedb/db. Dose-response relationships for wild-type mice and mice with genotypedb/dbat the investigated concentrations of setmelanotide are shown in FIGURES 3E and 3F, respectively. At all concentrations, mice with genotypesdb/db always show greater suppression of food intake than wild-type mice treated with setmelanotide.

These results demonstrate that wild-type mice consumed less food when they were exposed to increasing concentrations of setmelanotide. Additionally, these results show that db/db mice exhibit hyperreactivity (hypersensitivity) to this MC4R agonist.

EQUIVALENTS

The disclosures of each and every patent, patent application, and publication cited herein are incorporated herein by reference in their entirety. While the present invention has been disclosed in terms of specific aspects, it is understood that other aspects and variations may also be developed by a person skilled in the art without departing from the spirit and scope of the present invention. The appended claims are intended to include all such aspects and equivalents.

Claims (53)

1. A method for treating a disorder in a subject in need thereof, comprising: administration of a melanocortin 4 receptor agonist (MC4R) at a daily dosage of 0.1 mg to 10 mg, wherein the disorder is characterized by hypermethylation of the POMC gene; wherein said agonist is an MC4R agonist having the formula Ac-Arg-c(Cys-D-Ala-His-D-Phe-Arg-Trp-Cys)-NH ₂ (SEQ ID NO: 140). 2. The method of claim 1 wherein the disorder is characterized by a hypermethylated POMC intron. 3. The method of claim 1, wherein the POMC gene is hypermethylated at the CpG island. 4. The method according to any one of paragraphs. 1-3, where the daily dosage is from 1 mg to 7.5 mg. 5. The method according to any one of paragraphs. 1-3, where the daily dosage is from 0.1 mg to 5 mg. 6. The method according to any one of paragraphs. 1-3, where the daily dosage is from 1 mg to 5 mg. 7. The method according to any one of paragraphs. 1-3, where the daily dosage is from 5 mg to 10 mg. 8. The method according to any one of paragraphs. 1-3 comprising administering the agonist in a dosage unit suitable for injection into a subject. 9. The method of claim 8, wherein said dosage unit contains 0.1 mg to 10 mg of the agonist. 10. The method of claim 8, wherein said dosage unit is in a delivery device, implantable device, needleless hypodermal injection device, infusion pump, or osmotic delivery system. 11. The method according to any one of paragraphs. 1-3, wherein said agonist is administered subcutaneously. 12. The method according to any one of paragraphs. 1-3, said agonist being administered daily for at least 3 weeks. 13. The method according to any one of paragraphs. 1-3, said agonist being administered daily for at least 1 month. 14. The method according to any one of paragraphs. 1-3, said agonist being administered daily for at least 1 year. 15. The method according to any one of paragraphs. 1-3, where the subject is obese. 16. The method according to any one of paragraphs. 1-3, where the subject is obese with early onset. 17. The method according to any one of paragraphs. 1-3, where the subject suffers from hyperphagia. 18. The method according to any one of paragraphs. 1-3, wherein the subject has a body mass index (BMI) greater than 25 kg/m ² prior to administration of the agonist. 19. The method according to any one of paragraphs. 1-3, wherein the subject has a body mass index (BMI) greater than 35 kg/m ² prior to administration of the agonist. 20. The method according to any one of paragraphs. 1-3, wherein the subject has a body mass index (BMI) greater than 40 kg/m ² prior to administration of the agonist. 21. The method according to any one of paragraphs. 1-3, wherein the subject has a body mass index (BMI) greater than 45 kg/m ² prior to administration of the agonist. 22. The method according to any one of paragraphs. 1-3, where the subject has already had one or more failed therapies prior to administration of the agonist. 23. The method according to any one of paragraphs. 1-3, where the body weight of the subject after administration of the agonist is lower than before administration of the agonist. 24. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a weight loss of the subject compared to the subject's pre-treatment weight of 1 kg to 3 kg after 1 week of treatment. 25. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a weight loss of the subject compared to the subject's pre-treatment weight of 1 kg to 6 kg after 2 weeks of treatment. 26. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a weight loss of the subject compared to the subject's pre-treatment weight of 2 kg to 12 kg after 4 weeks of treatment. 27. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a weight loss of the subject compared to the subject's pre-treatment weight of between 4 kg and 24 kg after 8 weeks of treatment. 28. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a weight loss of the subject compared to the subject's pre-treatment weight of 8 kg to 48 kg after 16 weeks of treatment. 29. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in weight loss in the subject at a rate of 1-2 kg/week over 1-2 weeks of treatment or more. 30. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in weight loss in the subject at a rate of 1-2 kg/week for 2-4 weeks of treatment or more. 31. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in weight loss in the subject at a rate of 1-2 kg/week for 4-8 weeks of treatment or more. 32. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in weight loss in the subject at a rate of 1-2 kg/week for 8-16 weeks of treatment or more. 33. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in weight loss in the subject at a rate of 1-2 kg/week for 16-32 weeks of treatment or more. 34. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in weight loss in the subject at a rate of 1-2 kg/week for 32-64 weeks or more. 35. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a decrease in the subject's hunger level compared to the subject's pre-treatment hunger level after 1-2 weeks of treatment or more. 36. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a decrease in the subject's hunger level compared to the subject's pre-treatment hunger level after 2-4 weeks of treatment or more. 37. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a decrease in the subject's hunger level compared to the subject's pre-treatment hunger level after 4-8 weeks of treatment or more. 38. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a decrease in the subject's hunger level compared to the subject's pre-treatment hunger level after 8-16 weeks of treatment or more. 39. The method according to any one of paragraphs. 1-3, where administration of the agonist does not result in a detectable/significant reduction in basal metabolic energy (REE) in the subject compared to a control REE value. 40. The method of claim 39, wherein administration of the agonist results in an increase in basal metabolic energy (REE) in the subject compared to a control REE value. 41. The method according to any one of paragraphs. 1-3, where the administration of the agonist results in a reduction in the food intake of the subject compared to the control. 42. The method of claim 41, wherein administration of the agonist results in a reduction in food intake of at least 100 kilocalories. 43. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a reduction in the subject's waist circumference compared to controls as measured at least 1 week after the start of treatment. 44. The method of claim 43, wherein administration of the agonist results in a reduction in waist circumference of at least 2 cm in the subject compared to a control as measured at least 1 week or more after the start of treatment. 45. The method according to any one of paragraphs. 1-3, wherein administration of the agonist does not result in a detectable increase in the subject's blood pressure relative to the subject's pre-treatment blood pressure as measured at least 1 week after the start of treatment. 46. The method according to any one of paragraphs. 1-3, wherein administration of the agonist results in a decrease in the subject's blood pressure compared to the subject's pre-treatment blood pressure as measured at least 1 week after the start of treatment. 47. The method according to p. 46, where the introduction of the agonist leads to a decrease in systolic blood pressure in the subject by at least 3 mm Hg. Art. compared to the subject's pre-treatment blood pressure as measured at least 1 week after the start of treatment. 48. The method according to p. 46, where the introduction of the agonist leads to a decrease in diastolic blood pressure of the subject by at least 4 mm Hg. Art. compared to the subject's pre-treatment blood pressure as measured at least 1 week after the start of treatment. 49. The method according to any one of paragraphs. 1-3, where the subject is a mammal. 50. The method according to any one of paragraphs. 1-3, where the subject is a human.

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