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CN111909204B - A tenofovir diphenylpropionate-based phosphoramidate compound and its pharmaceutical composition and application - Google Patents

A tenofovir diphenylpropionate-based phosphoramidate compound and its pharmaceutical composition and application Download PDF

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CN111909204B
CN111909204B CN202010635351.5A CN202010635351A CN111909204B CN 111909204 B CN111909204 B CN 111909204B CN 202010635351 A CN202010635351 A CN 202010635351A CN 111909204 B CN111909204 B CN 111909204B
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刘洪海
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Abstract

本发明公开了一种替诺福韦双苯丙酸酯基氨基磷酸酯化合物及其盐,还公开了制备方法以及含有该组化合物的药物组合物。试验证明本发明化合物具有抑制HBV病毒复制的活性,同时所述化合物具有比目前治疗艾滋病药物替诺福韦酯富马酸盐(TAF)活性高、开发系数大等优点。实验还证明本发明化合物还具有抑制HIV‑1病毒复制的活性,可用于治疗艾滋病药物或乙型肝炎药物的开发。The invention discloses a tenofovir bisphenylpropionate-based phosphoramidate compound and a salt thereof, a preparation method and a pharmaceutical composition containing the compound. Tests have proved that the compound of the invention has the activity of inhibiting HBV virus replication, and at the same time, the compound has the advantages of higher activity and larger development coefficient than the current AIDS drug tenofovir disoproxil fumarate (TAF). Experiments also prove that the compound of the present invention also has the activity of inhibiting HIV-1 virus replication, and can be used for the development of AIDS medicine or hepatitis B medicine.

Description

一种替诺福韦双苯丙酸酯基氨基磷酸酯化合物及其药物组合 物和用途A tenofovir diphenylpropionate-based phosphoramidate compound and its drug combination substance and use

技术领域technical field

本发明涉及医药技术领域,特别涉及一种替诺福韦双苯丙酸酯基氨基磷酸酯化合物,以及含有该化合物的药物组合物和用途。The invention relates to the technical field of medicine, in particular to a tenofovir bisphenylpropionate-based phosphoramidate compound, a pharmaceutical composition containing the compound and use thereof.

背景技术Background technique

乙型肝炎,特别是慢性乙肝,已成为全球性的公共健康问题,据统计目前全球每年有100万以上的人死于HBV感染及其相关疾病。但迄今为止对慢性乙肝尚缺乏理想的治疗方法和药物。因此,如何有效地防治乙肝是21世纪将面临和需要解决的重大问题。Hepatitis B, especially chronic hepatitis B, has become a global public health problem. According to statistics, more than 1 million people worldwide die from HBV infection and related diseases every year. But so far there is still a lack of ideal treatment methods and drugs for chronic hepatitis B. Therefore, how to effectively prevent and treat hepatitis B is a major problem that will be faced and needs to be solved in the 21st century.

目前中国市场治疗乙肝的一类用药TAF(韦立得)、ETV(恩替卡韦)自上市以来,逐渐显示出了各自的缺点。At present, TAF (Valide) and ETV (Entecavir), the first-class drugs for the treatment of hepatitis B in the Chinese market, have gradually shown their respective shortcomings since they were launched.

《2018年美国肝病学会慢性乙型肝炎预防诊断及治疗》中,推荐恩替卡韦(ETV)、富马酸替诺福韦二吡呋酯(TDF)、富马酸丙酚替诺福韦(TAF)为治疗乙肝的佳选药物,三者各有优缺点:In the 2018 American Society of Liver Diseases Prevention, Diagnosis and Treatment of Chronic Hepatitis B, entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide fumarate (TAF) were recommended For the best choice of drugs for the treatment of hepatitis B, each of the three has its own advantages and disadvantages:

ETV的优点:副作用小;缺点:有一定的耐药,孕妇禁用;Advantages of ETV: small side effects; Disadvantages: certain drug resistance, contraindicated for pregnant women;

TDF优点:抗病毒效果好,极少耐药;缺点:有一定的肾毒性,长期应用会对骨骼和肾脏有一定的副作用;Advantages of TDF: good antiviral effect, little drug resistance; Disadvantages: certain nephrotoxicity, long-term application will have certain side effects on bones and kidneys;

TAF优点:与TDF抗病毒效果相当,提高了肾脏和骨骼实验室安全参数,极少耐药,使用剂量仅为一代替诺福韦的十二分之一。Advantages of TAF: It has the same antiviral effect as TDF, improves the safety parameters of kidney and bone laboratory, has very little drug resistance, and the dosage is only one-twelfth of that of Nofovir.

韦立得(TAF)是治疗乙肝的新型口服方案,虽不能完全治愈乙肝,但是其功效有了大大的提升,能够很好的控制乙肝病毒量。在临床效果上,TAF和TDF在治疗乙肝有相同的临床效果,但是TAF的用量更小,毒性更低,在耐药性和联合治疗中会发挥更大的作用。但由于TAF进入人体后要脱落一分子的苯酚,所以TAF复方制剂上市以来逐渐表现出来了不容忽视的毒副作用:乳酸中毒及严重肝脏肿大合并脂肪肝。Vilide (TAF) is a new oral regimen for the treatment of hepatitis B. Although it cannot completely cure hepatitis B, its efficacy has been greatly improved, and it can well control the amount of hepatitis B virus. In terms of clinical effect, TAF and TDF have the same clinical effect in the treatment of hepatitis B, but the dosage of TAF is smaller, the toxicity is lower, and it will play a greater role in drug resistance and combination therapy. However, since TAF will shed a molecule of phenol after entering the human body, the TAF compound preparation has gradually shown toxic and side effects that cannot be ignored: lactic acidosis, severe hepatomegaly and fatty liver.

因此开发新的TAF的类似物,保持结构的微小变化,维持TAF优秀的抗病毒活性,同时具有在血浆中更好的稳定性和口服生物利用度意义重大。Therefore, it is of great significance to develop new analogues of TAF, maintain small changes in structure, maintain the excellent antiviral activity of TAF, and have better stability in plasma and oral bioavailability.

综上,虽然目前全球的艾滋病/乙肝治疗药物,吉利德公司的TDF、TAF复方制剂仍然独霸市场,但是我们的基于TNF的治疗艾滋病/乙肝药物研究仍然意义巨大。进一步改善其人体的生物利用度、提高活性、降低毒副作用而充分发挥治疗乙肝和艾滋病的药效仍然具有重要的价值。To sum up, although Gilead’s TDF and TAF compound preparations still dominate the global market for AIDS/Hepatitis B drugs, our research on TNF-based AIDS/Hepatitis B drugs is still of great significance. It is still of great value to further improve its bioavailability in the human body, increase its activity, reduce its toxic and side effects and give full play to its efficacy in the treatment of hepatitis B and AIDS.

发明内容Contents of the invention

在对TAF类似物的前药研究过程中,意外地发现把TAF的苯环链替换成氨基NHR链后,活性有所升高,生物活性选择系数SI也有所升高,这样使得研究样品的使用剂量比较TAF可以进一步降低,即可以进一步降低TAF的毒性,同时保持TAF的活性,在组织细胞特别是肝细胞中药物浓度与TAF相比有显著的增加。所以本发明的替诺福韦双苯丙酸酯基氨基磷酸酯化合物由于可以显著提高对乙肝和艾滋病的治疗效果,并极大的降低TDF或TAF引起的肾毒性和骨毒性。由此提出了下述发明。In the process of prodrug research on TAF analogs, it was unexpectedly found that after the benzene ring chain of TAF was replaced by an amino NHR chain, the activity increased, and the biological activity selection coefficient SI also increased, which made the use of research samples Compared with the dose, TAF can be further reduced, that is, the toxicity of TAF can be further reduced, while maintaining the activity of TAF, and the drug concentration in tissue cells, especially liver cells, is significantly increased compared with TAF. Therefore, the tenofovir bisphenylpropionate-based phosphoramidate compound of the present invention can significantly improve the therapeutic effect on hepatitis B and AIDS, and greatly reduce the nephrotoxicity and bone toxicity caused by TDF or TAF. Accordingly, the following inventions have been proposed.

一种替诺福韦双苯丙酸酯基氨基磷酸酯化合物,包括:A tenofovir bisphenylpropionate-based phosphoramidate compound, comprising:

a)化合物(Ia),其结构如下所示,a) Compound (Ia), the structure of which is shown below,

Figure BDA0002568793850000031
Figure BDA0002568793850000031

其中,R1=R2=C1-C12烷基;或Wherein, R 1 =R 2 =C 1 -C 12 alkyl; or

b)由如a)所述化合物(Ia)与酸制得的药学上可接受的盐。b) A pharmaceutically acceptable salt prepared from the compound (Ia) as described in a) and an acid.

进一步,当所述R1、R2基团选自异丙基、乙基、异丁基、新戊基、正丁基、环己基、甲基或叔丁基时,化合物的结构式分别为下列结构式:Further, when the R 1 and R 2 groups are selected from isopropyl, ethyl, isobutyl, neopentyl, n-butyl, cyclohexyl, methyl or tert-butyl, the structural formulas of the compounds are as follows Structural formula:

Figure BDA0002568793850000032
Figure BDA0002568793850000032

进一步,所述药学上可接受的盐为草酸盐、丙二酸盐、琥珀酸盐、富马酸盐、天冬氨酸盐、柠檬酸盐、水杨酸盐、盐酸盐、硫酸盐、磷酸盐,酸和化合物(Ia)摩尔比的范围为(0.5~1):1。Further, the pharmaceutically acceptable salt is oxalate, malonate, succinate, fumarate, aspartate, citrate, salicylate, hydrochloride, sulfate , phosphate, the range of molar ratio of acid and compound (Ia) is (0.5~1):1.

进一步,当所述R1、R2基团选自异丙基、乙基、异丁基、新戊基、正丁基、环己基、甲基或叔丁基时,所述富马酸盐的结构式分别为下列结构式:Further, when the R 1 and R 2 groups are selected from isopropyl, ethyl, isobutyl, neopentyl, n-butyl, cyclohexyl, methyl or tert-butyl, the fumarate The structural formula is the following structural formula respectively:

Figure BDA0002568793850000041
Figure BDA0002568793850000041

进一步,所述富马酸盐是由富马酸与化合物按照0.5:1的摩尔比制得。Further, the fumarate is prepared from fumaric acid and the compound at a molar ratio of 0.5:1.

另一方面,本发明还提供了一种药物组合物,包含治疗有效量的替诺福韦双苯丙酸酯基氨基磷酸酯化合物,以及至少一种药学上可接受的载体或赋形剂。On the other hand, the present invention also provides a pharmaceutical composition, comprising a therapeutically effective dose of tenofovir bisphenylpropionate phosphoramidate compound, and at least one pharmaceutically acceptable carrier or excipient.

进一步,所述药物组合物还包含治疗有效量的额外治疗剂,所述额外治疗剂选自抑制HIV蛋白酶的化合物、逆转录酶的HIV非核苷抑制剂、逆转录酶的HIV核苷抑制剂、逆转录酶的HIV核苷酸抑制剂、HIV整合酶抑制剂、gp41抑制剂、CXCR4抑制剂、gp120抑制剂、CCR5抑制剂、病毒壳体聚合抑制剂、非催化部位HIV整合酶部位抑制剂的至少一种。Further, the pharmaceutical composition also comprises a therapeutically effective amount of an additional therapeutic agent selected from compounds that inhibit HIV protease, HIV non-nucleoside inhibitors of reverse transcriptase, HIV nucleoside inhibitors of reverse transcriptase, HIV nucleotide inhibitors of reverse transcriptase, HIV integrase inhibitors, gp41 inhibitors, CXCR4 inhibitors, gp120 inhibitors, CCR5 inhibitors, capsid polymerization inhibitors, non-catalytic site HIV integrase site inhibitors at least one.

进一步,所述药物组合物的剂型为片剂或胶囊。Further, the dosage form of the pharmaceutical composition is tablet or capsule.

本发明所述的替诺福韦双苯丙酸酯基氨基磷酸酯化合物可应用于制备用于预防或治疗病毒疾病的药物。具体的病毒疾病为HIV-1感染或HBV感染或HIV-1与HBV同时感染。The tenofovir bisphenylpropionate-based phosphoramidate compound of the present invention can be applied to the preparation of medicines for preventing or treating viral diseases. A particular viral disease is HIV-1 infection or HBV infection or HIV-1 and HBV co-infection.

经测定,本发明化合物具有成为治疗艾滋病/乙肝的药物所需的优良属性,具体如下:It has been determined that the compound of the present invention has the excellent properties required to become a drug for the treatment of AIDS/hepatitis B, specifically as follows:

在一体外抗乙肝病毒活性筛选中,化合物C0P371371的IC50是TAF(阳性对照)的6倍,生物活性选择系数SI是TAF(阳性对照)的4.0倍;化合物C0P374374的IC50是TAF(阳性对照)的6倍,生物活性选择系数SI是TAF(阳性对照)的1.5倍。其表明本发明所述化合物比一类抗乙肝药物TAF抑制病毒复制的活性高,开发生物活性选择系数大,有望成为治疗HBV感染的药物。本发明化合物集高活性、低毒性、高生物利用度等各种良好属性于一体,有着成为新一代治疗艾滋病或治疗乙型肝炎的药物的前景。In an in vitro anti-hepatitis B virus activity screening, the IC of compound COP371371 is 6 times that of TAF (positive control), and the selection coefficient SI of biological activity is 4.0 times of TAF (positive control); the IC of compound COP374374 is TAF (positive control). ) of 6 times, the biological activity selection coefficient SI is 1.5 times of TAF (positive control). It shows that the compound of the present invention has higher activity of inhibiting virus replication than a class of anti-hepatitis B drug TAF, has a large selection coefficient of biological activity, and is expected to become a drug for treating HBV infection. The compound of the invention integrates various good properties such as high activity, low toxicity and high bioavailability, and has the prospect of becoming a new generation of medicine for treating AIDS or hepatitis B.

具体实施方式Detailed ways

以下实施例可以使本专业技术人员更全面地理解本发明,但不以任何方式限制本发明。所有化合物的结构均经1H NMR或MS确定。The following examples can enable those skilled in the art to understand the present invention more fully, but do not limit the present invention in any way. The structures of all compounds were determined by 1 H NMR or MS.

本发明所用原料:替诺福韦、L-丙氨酸酯盐酸盐、富马酸都由市场购买得到。The raw materials used in the present invention: tenofovir, L-alanine ester hydrochloride and fumaric acid are all purchased from the market.

实施例1Example 1

9-[(R)-2-[[二[[(S)-(1-正丁氧基羰基-2-苯基)乙基]氨基]氧膦基]甲氧基]丙基]腺嘌呤(C0P374374)的制备。9-[(R)-2-[[Di[[(S)-(1-n-butoxycarbonyl-2-phenyl)ethyl]amino]phosphinyl]methoxy]propyl]adenine Preparation of (COP374374).

称取市售的替诺福韦(C0P00)7.2g(25mmol),加入250ml烧瓶中,再加入氯化亚砜50g,升温至55℃,10分钟后,再继续升温至70℃后搅拌1小时,减压蒸馏氯化亚砜,蒸馏结束后再加入100ml干燥乙腈并在85℃下回流10min后,减压蒸干乙腈,降温至室温,然后加入50ml干燥二氯甲烷,再继续搅拌0.5h后加入19.4g(75mmol,3eq)L-苯丙氨酸正丁酯盐酸盐(AH374),再搅拌10min后滴加大约20ml三乙胺,滴加完毕,继续搅拌0.5h。Take commercially available tenofovir (COP00) 7.2g (25mmol), add in the 250ml flask, then add thionyl chloride 50g, heat up to 55°C, after 10 minutes, continue to heat up to 70°C and stir for 1 hour , distilled thionyl chloride under reduced pressure, added 100ml of dry acetonitrile after the distillation was completed and refluxed at 85°C for 10min, evaporated the acetonitrile to dryness under reduced pressure, cooled down to room temperature, then added 50ml of dry dichloromethane, and continued to stir for 0.5h Add 19.4g (75mmol, 3eq) of L-phenylalanine n-butyl hydrochloride (AH374), stir for another 10min, then add about 20ml of triethylamine dropwise, after the dropwise addition is complete, continue stirring for 0.5h.

抽滤,滤液蒸干后再加入100ml乙酸乙酯。并分别用100g 5%碳酸氢钾水溶液洗涤两次、100g 20%氯化钠水溶液洗涤两次,无水硫酸钠干燥,干燥后抽滤,滤液蒸干。乙酸乙酯柱层析得C0P374374约8g(纯度98.2%)。After suction filtration, the filtrate was evaporated to dryness, and then 100ml of ethyl acetate was added. It was washed twice with 100 g of 5% potassium bicarbonate aqueous solution and twice with 100 g of 20% sodium chloride aqueous solution, dried over anhydrous sodium sulfate, suction filtered after drying, and the filtrate was evaporated to dryness. Ethyl acetate column chromatography yielded about 8 g of COP374374 (purity 98.2%).

1H NMR(400MHz,CDCl3)δ,(ppm):0.85-0.98(6H,dt,2×CH3),1.02-1.15(3H,d,CH3),1.25-1.41(4H,m,2×CH2),1.45-1.67(4H,m,2×CH2),2.73-2.98(5H,m,OCH and 2×CH2),3.01-3.54(4H,m,2×NH and OCH2P),3.70-4.12(6H,m,2×NCH and 2×COOCH2),4.13-4.36(2H,m,NCH2),6.27(2H,s,NH2),7.00-7.38(10H,m,两个苯环上的氢),7.88(1H,s,嘌呤环上的H),8.32(1H,s,嘌呤环上的H)。 1 H NMR (400MHz, CDCl 3 ) δ, (ppm): 0.85-0.98 (6H, dt, 2×CH 3 ), 1.02-1.15 (3H, d, CH 3 ), 1.25-1.41 (4H, m, 2 ×CH 2 ), 1.45-1.67(4H,m,2×CH 2 ),2.73-2.98(5H,m,OCH and 2×CH 2 ),3.01-3.54(4H,m,2×NH and OCH 2 P ),3.70-4.12(6H,m,2×NCH and 2×COOCH 2 ),4.13-4.36(2H,m,NCH 2 ),6.27(2H,s,NH 2 ),7.00-7.38(10H,m, hydrogen on two benzene rings), 7.88 (1H, s, H on the purine ring), 8.32 (1H, s, H on the purine ring).

ESI-MS:[M+H]+694.7ESI-MS: [M+H]+694.7

实施例2Example 2

9-[(R)-2-[[二[[(S)-(1-正丁氧基羰基-2-苯基)乙基]氨基]氧膦基]甲氧基]丙基]腺嘌呤富马酸盐(FC0P374374)的制备。9-[(R)-2-[[Di[[(S)-(1-n-butoxycarbonyl-2-phenyl)ethyl]amino]phosphinyl]methoxy]propyl]adenine Preparation of Fumarate (FCOP374374).

Figure BDA0002568793850000061
Figure BDA0002568793850000061

将等量9-[(R)-2-[[二[[(S)-(1-正丁氧基羰基-2-苯基)乙基]氨基]An equivalent amount of 9-[(R)-2-[[two[[(S)-(1-n-butoxycarbonyl-2-phenyl)ethyl]amino]

氧膦基]甲氧基]丙基]腺嘌呤(C0P374374)和富马酸溶于热的乙腈中,回流搅拌2小时,室温下冷却析晶,滤出析出的固体并用乙腈洗涤得白色固体:9-[(R)-2-[[二[[(S)-(1-正丁氧基羰基-2-苯基)乙基]氨基]氧膦基]甲氧基]丙基]腺嘌呤富马酸盐(FC0P374374)。Phosphinyl] methoxyl group] propyl group] adenine (COP374374) and fumaric acid were dissolved in hot acetonitrile, stirred at reflux for 2 hours, cooled and crystallized at room temperature, filtered out the precipitated solid and washed with acetonitrile to obtain a white solid: 9-[(R)-2-[[Di[[(S)-(1-n-butoxycarbonyl-2-phenyl)ethyl]amino]phosphinyl]methoxy]propyl]adenine Fumarate (FCOP374374).

实施例3Example 3

本发明化合物抗HBV病毒活性的体外测定In Vitro Determination of Anti-HBV Viral Activity of Compounds of the Present Invention

1.体外细胞模型:HepG 2.2.15细胞1. In vitro cell model: HepG 2.2.15 cells

2.Dot blot法测定化合物抗乙肝病毒活性2. Dot blot method to determine the anti-hepatitis B virus activity of the compound

2.1种HepG 2.2.15细胞(4×104细胞/孔)到96孔板,在37℃,5%培养过夜。2. Put 1 HepG 2.2.15 cells (4×10 4 cells/well) into a 96-well plate and culture overnight at 37°C with 5%.

2.2第二天,稀释化合物,加不同浓度化合物到培养孔中。培养液中DMSO的终浓度为1%。1μM恩替卡韦(ETV)作为100%Inhibition对照;1%的DMSO作为0%Inhibition对照。2.2 On the second day, dilute the compound and add different concentrations of the compound to the culture wells. The final concentration of DMSO in the culture medium was 1%. 1 μM entecavir (ETV) was used as 100% Inhibition control; 1% DMSO was used as 0% Inhibition control.

2.3第五天,更换含有化合物的新鲜培养液。2.3 On the fifth day, replace with fresh culture medium containing the compound.

2.4第八天和第九天,去除培养孔中的培养液,收取细胞进行点杂交。2.4 On the eighth day and the ninth day, the culture medium in the culture well was removed, and the cells were harvested for dot hybridization.

3.结果:见表一。3. Results: See Table 1.

表一:化合物的细胞毒性,胞外抗HBV活性(HepG2.2.15)Table 1: Cytotoxicity of compounds, extracellular anti-HBV activity (HepG2.2.15)

Figure BDA0002568793850000071
Figure BDA0002568793850000071

4.实验结论:4. Experimental conclusion:

4.1阳性化合物TAF在HepG 2.2.15细胞中对乙肝病毒复制符合预期的抑制效果,证明实验有效可信。4.1 The positive compound TAF has the expected inhibitory effect on the replication of hepatitis B virus in HepG 2.2.15 cells, which proves that the experiment is effective and credible.

4.2抗乙肝病毒活性。在点杂交实验中,上表2个待测化合物在抗乙肝病毒的活性都是TAF(阳性对照)的6倍。且开发系数SI都比阳性对照TAF抑制率高。4.2 Anti-hepatitis B virus activity. In the dot hybridization experiment, the anti-hepatitis B virus activity of the two tested compounds in the above table was 6 times that of TAF (positive control). And the development coefficient SI is higher than the positive control TAF inhibition rate.

4.3这充分表明:本发明化合物比目前抗乙肝药物TAF抑制病毒复制的活性高,有望成为治疗HBV感染的新一代药物。4.3 This fully shows that the compound of the present invention has higher activity in inhibiting virus replication than the current anti-hepatitis B drug TAF, and is expected to become a new generation of drugs for the treatment of HBV infection.

实施例4Example 4

制剂配方与工艺Preparation formula and process

本发明的药物组合物可按通用的口服药物制剂制备方法制成片剂或胶囊,5mg剂量的本发明化合物片剂或胶囊单位含量如下:The pharmaceutical composition of the present invention can be made into tablet or capsule according to the preparation method of general oral pharmaceutical preparation, and the tablet or capsule unit content of the compound of the present invention of 5mg dosage is as follows:

表二Table II

名称name 配比/mgProportion/mg 本发明化合物Compounds of the invention 2.502.50 乳糖lactose 1.651.65 淀粉starch 0.660.66 微晶纤维素microcrystalline cellulose 0.080.08 羧甲淀粉钠Carboxymethyl Starch Sodium 0.080.08 硬脂酸鎂Magnesium stearate 0.030.03

.

Claims (4)

1. A tenofovir disoproxil phosphoramidate compound or a pharmaceutically acceptable salt thereof, wherein the structural formula of the tenofovir disoproxil phosphoramidate compound is selected from one of the following structural formulas:
Figure QLYQS_1
the pharmaceutically acceptable salt is fumarate, and the structural formula of the fumarate is selected from one of the following structural formulas:
Figure QLYQS_2
2. the tenofovir disoproxil phosphoramidate compound or a pharmaceutically acceptable salt thereof according to claim 1, wherein the molar ratio of fumaric acid of the fumarate to the tenofovir disoproxil phosphoramidate compound is in the range of (0.5-1): 1.
3. a pharmaceutical composition comprising a therapeutically effective amount of a tenofovir disoproxil phosphoramidate compound or a pharmaceutically acceptable salt thereof according to any one of claims 1 to 2, and at least one pharmaceutically acceptable carrier or excipient.
4. Use of a tenofovir dipivoxil phenylpropionate compound or a pharmaceutically acceptable salt thereof according to any one of claims 1 to 2 in the manufacture of a medicament for the prevention or treatment of HBV infection viral diseases.
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