Dapagliflozin: a sodium glucose cotransporter 2 inhibitor in development for type 2 diabetes

Perturbations of Telmisartan Alone and in Combination with Ranolazineor Dapagliflozin on the Amplitude and Gating of Voltage-gated Na + Current in Neuroblastoma Neuronal Cells

A recent study investigated the correlation between telmisartan (TEL) exposure and Alzheimer's disease (AD) risk among African Americans (AAs) and European Americans. Their findings indicated that moderate-to-high TEL exposure was linked to a decreased incidence of AD among AAs. These results suggest a potential association between TEL and a reduced risk of AD specifically within the AA population. Here, we investigated the effects of TEL, either alone or in combination with ranolazine (Ran) or dapagliflozin (Dapa), on voltage-gated Na + currents ( INa ) in Neuro-2a cells. TEL, primarily used for treating hypertension and cardiovascular disorders, showed a stimulatory effect on INa , while Ran and Dapa reversed this stimulation. In Neuro-2a cells, we demonstrated that with exposure to TEL, the transient ( INa(T) ) and late ( INa(L) ) components of INa were differentially stimulated with effective EC 50 's of 16.9 and 3.1 μM, respectively. The research implies that TEL's impact on INa might be associated with enhanced neuronal excitability. This study highlights the complex interplay between TEL, Ran, and Dapa on INa and their potential implications for AD, emphasizing the need for further investigation to understand the mechanisms involved.

Canagliflozin: metabolic, cardiovascular and renal protection

Patients with Type 2 Diabetes (T2D) are at risk of developing macrovascular (cardiac, cerebrovascular, peripheral arterial disease) and microvascular (nephropathy, neuropathy, retinopathy) complications. Glycemic control improves only microvascular outcomes. However, some SGLT-2 inhibitors and GLP1-R agonists have proven beneficial in macrovascular conditions. Canagliflozin is an SGLT2 inhibitor that provides sustained reductions in HbA1c, blood pressure and weight. Remarkably, as CANVAS program and CREDENCE trial demonstrated, canagliflozin promotes significant reductions in the frequency of atherosclerotic cardiovascular events, hospitalizations for heart failure and renal outcomes. In addition, real-world studies have confirmed the results of clinical trials in clinical practice. Therefore, canagliflozin should be considered a first-line therapy in the management of T2D patients in order to reduce both micro- and macrovascular complications.

Dapagliflozin improves cardiovascular risk factors in Emirati patients with T2DM

BACKGROUND

Dapagliflozin is a sodium-glucose co transporter-2 inhibitor that proved efficacy in reduction of blood glucose level through extrusion of glucose in urine. It is used in treatment of type 2 diabetes mellitus (T2DM). It also has reported cardiovascular and renal benefits in patients with T2DM. Data are very limited about its effects in Emirati patients with diabetes. Our aim was to evaluate dapagliflozin treatment in Emirati patients with T2DM.

PATIENTS AND METHODS

This is a retrospective study involving 89 diabetes patients who were using dapagliflozin 10 mg once daily as add-on therapy for 12 months. All patients had T2DM, aged over 18 years and had an estimated glomerular filtration rate (eGFR) over 60 ml/min/1.73 m². Body weight, height, body mass index, sitting blood pressure and heart rate were collected. Fasting plasma glucose, glycosylated hemoglobin (HbA1c), lipid profile and other available biochemical parameters, for example, creatinine, blood urea nitrogen, and urine albumin/creatinine ratio were traced from medical records and eGFR was calculated.

RESULTS

Patients were aged 62.3 ± 9.4 years with a median duration of diabetes of 15 (10-20) years. Data were analyzed before, at 6 months and 12 months of treatment. Fasting plasma glucose, HbA1c, body mass index, systolic and diastolic blood pressure significantly decreased (p = 0.002, p < 0.0005, p < 0.002, p < 0.0005, p < 0.0005, respectively). The median reduction of HbA1c was 0.7% (0.2-1.2) and 0.9% (0.5-1.8) at 6 and 12 months, respectively. Systolic blood pressure decreased by a median of 7 mmHg (4-20 mmHg) and 9 mmHg (1-10 mmHg) on the 6th and 12th month of treatment, respectively, while the diastolic decreased by a median of 3 mmHg (4 to 10 mmHg) and 6 mmHg (1-10 mmHg); without increase in heart rate (p = 0.188). A significant reduction of body mass index, C-reactive protein and rate pressure product was noticed (p = 0.002, p = 0.001, p < 0.0005, respectively). No decline in eGFR or microalbuminuria was noticed. Stage I chronic kidney disease with eGFR < 90 ml/min/1.73 m² showed continuous progressive reduction of HbA1c without a significant change in other variables.

CONCLUSION

Our data indicate improved cardiovascular risk profile in dapagliflozin-treated Emirati patients with T2DM.

Effectiveness in the inhibition of dapagliflozin and canagliflozin on M-type K+ current and α-methylglucoside-induced current in pituitary tumor (GH3) and pheochromocytoma PC12 cells

Dapagliflozin (DAPA) or canagliflozin (CANA), Na⁺-dependent glucose co-transporter type 2 (SGLT2) inhibitors, were used for treatment of type II diabetes mellitus. Addition of DAPA or CANA suppressed M-type K⁺ current (I_K(M)) in pituitary tumor (GH₃) and pheochromocytoma PC12 cells. The IC₅₀ value for DAPA- or CANA-mediated inhibition of I_K(M) in GH₃ cells was 0.11 or 0.42 μM, respectively. The presence of DAPA (0.1 μM) shifted the steady-state activation of I_K(M) to less depolarized potential without changing the gating charge of the current. During high-frequency depolarizing pulses, I_K(M) magnitude was reduced by DAPA; however, DAPA-induced block of I_K(M) remained effective. The amplitude of neither erg-mediated K⁺ current nor hyperpolarization-activated cation current in GH₃ cells was modified in the presence of 1 μM DAPA. Alternatively, addition of DAPA, CANA, phlorizin or chlorotoxin effectively suppressed α-methylglucoside-(αMG-) induced current (I_αMG) in GH₃ cells, albeit inability of tefluthrin (activator of I_Na) to suppress this current. DAPA shifted the charge-voltage relation of presteady-state I_αMG in a rightward and downward direction with no change in the gating charge of the I_αMG. Under current-clamp recordings, subsequent additions of DAPA, but still in the continued presence of αMG, increased the firing rate of spontaneous action potentials stimulated by αMG. Our results suggested that activity of SGLT was expressed functionally in GH₃ and PC12 cells. Therefore, inhibitory actions of DAPA or CANA on the amplitude and gating of I_K(M) might provide a yet unidentified mechanism through which the SGLT1 or SGLT2 activity were attenuated in unclamped cells occurring in vivo.

What does sodium-glucose co-transporter 1 inhibition add: Prospects for dual inhibition

Epithelial glucose transport is accomplished by Na+ -glucose co-transporters, SGLT1 and SGLT2. In the intestine, uptake of dietary glucose is for its majority mediated by SGLT1, and humans with mutations in the SGLT1 gene show glucose/galactose malabsorption. In the kidney, both transporters, SGLT1 and SGLT2, are expressed and recent studies identified that SGLT2 mediates up to 97% of glucose reabsorption. Humans with mutations in the SGLT2 gene show familial renal glucosuria. In the last three decades, significant progress was made in understanding the physiology of these transporters and their potential as therapeutic targets. Based on the structure of phlorizin, a natural compound acting as a SGLT1/2 inhibitor, initially several SGLT2, and later SGLT1 and dual SGLT1/2 inhibitors have been developed. Interestingly, SGLT2 knockout or treatment with SGLT2 selective inhibitors only causes a fractional glucose excretion in the magnitude of ∼60%, an effect mediated by up-regulation of renal SGLT1. Based on these findings the hypothesis was brought forward that dual SGLT1/2 inhibition might further improve glycaemic control via targeting two distinct organs that express SGLT1: the intestine and the kidney. Of note, SGLT1/2 double knockout mice completely lack renal glucose reabsorption. This review will address the rationale for the development of SGLT1 and dual SGLT1/2 inhibitors and potential benefits compared to sole SGLT2 inhibition.

Sodium Glucose Co-transporter-2 Inhibitor: Benefits beyond Glycemic Control

Type 2 diabetes mellitus (T2DM) is a family of metabolic disorders characterized by hyperglycemia as a consequence of abnormalities in insulin secretion and insulin sensitivity. It affects hundreds of millions of people worldwide and leads to increased morbidity, compromised quality of life, higher mortality sodium glucose co-transporter 2 (SGLT2) inhibitors, a new class of oral antidiabetic drugs, have garnered considerable attention in the recent past and are considered potential first-line candidates for the management of T2DM. This review outlines the evidence-based therapeutic efficacy, safety, limitations, and advantages of SGLT2 inhibitors in the management of T2DM. SGLT2 inhibitors work by preventing the kidneys from reabsorbing glucose back into the blood, leading to increase in excretion of glucose through urine, thereby lowering hyperglycemia. Treatment with SGLT2 inhibitors improves A1C levels, reduces blood pressure and body weight, and is overall well tolerated by patients with T2DM. However, additional data on long-term cardiovascular safety are still needed. Characteristic adverse events include mild genital - urinary tract infection more commonly seen in women than in men, but serious infection is uncommon. Their use should be exercised with extra caution in patients suffering from renal impairment. Further, advancing to dual/triple combinational therapies with SGLT2 inhibitors and existing oral antidiabetic options may prove to be a breakthrough in the management of T2DM.

Rosemary (Rosmarinus officinalis) essential oil components exhibit anti-hyperglycemic, anti-hyperlipidemic and antioxidant effects in experimental diabetes

INTRODUCTION

The present study aims to investigate the protective effects of Rosemary (Rosmarinus officinalis L.) essential oils (ROEO) against alloxan-induced diabetes and oxidative stress in rats.

METHODS

The animals were divided into four groups: Healthy Control (HC); Diabetic Control (DC); Healthy+ROEO (H+ROEO) and Diabetic+ROEO (D+ROEO).

RESULTS

The use of GC/MS technique has allowed us to identify fifteen compounds in ROEO. We have found that alloxan administration induced hyperglycaemia, lipid metabolic parameters deregulation as well as liver and kidney dysfunctions. Alloxan administration has also induced an oxidative stress status as assessed by malondialdehyde (MDA) content increase, thiol groups (-SH) level decrease and antioxidant enzyme activities depletion such as catalase (CAT), total superoxide dismutase (SOD), Cu/Zn-SOD, Mn-SOD and Fe-SOD in both liver and kidney tissues. More importantly subacute (15days) ROEO administration has significantly corrected all biochemical alterations induced by alloxan intoxication.

CONCLUSIONS

We propose that Rosmarinus officinalis essential oils exhibit protective effects in alloxan-induced hyperglycaemia as well as protecting against liver and kidney oxidative stress in rats, reflecting its antioxidant properties.

Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitors: Comparing Trial and Real World Use (Study Protocol)

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors (gliflozins) are the newest class of medication available to treat type 2 diabetes (T2DM). Recent findings from the first complete cardiovascular safety trial in SGLT2 inhibitors, the Empagliflozin, Cardiovascular Outcomes, and Mortality in type 2 diabetes (EMPA-REG OUTCOMES) trial, demonstrated reduced cardiovascular outcomes in people with high cardiovascular risk. How to apply these findings to clinical practice remains unclear, with questions remaining on who will reap this cardiovascular benefit.

AIM

To describe the proportion of people in the real world currently treated with SGLT2 inhibitors who meet the inclusion criteria of the EMPA-REG trial and therefore could expect the cardiovascular benefit identified by the trial. Similarly, to describe the proportion of people from the whole T2DM population who could also expect this same benefit.

DESIGN AND SETTING

Routinely collected data from UK primary care in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database will be used. The study population will include all people with T2DM within this database (approximately 60,000). We will perform a cross-sectional investigation to describe the characteristics of people currently using SGTL2 inhibitors compared with the population of the EMPA-REG trail. We will similarly compare the characteristics of the RCGP RSC T2DM cohort with the inclusion criteria of the EMPA-REG trial.

METHOD

People with T2DM using a pre-existing verified clinical ontological process will be identified, as will people with prescriptions for SGLT2 inhibitors and other medications using Read coded and other proprietary coding systems. Descriptive statistics will be used to characterise the key clinical characteristics of people with T2DM using SGLT2 inhibitors and to compare these characteristics to people included in EMPA-REG trial; the proportion of people who match the trial criteria will be reported.

PLANNED OUTPUTS

Peer review publication reporting the real world lessons for clinical practice.

FUNDING

AstraZeneca.

Dapagliflozin in patients with type 2 diabetes mellitus

Dapagliflozin is a selective and reversible inhibitor of sodium-glucose linked transporter type 2 (SGLT2), which mediates approximately 90% of active renal glucose reabsorption in the early proximal tubule of the kidney. Dapagliflozin significantly reduces glucose reabsorption and decreases serum glucose concentration in an insulin-independent manner. The decrease of glucose reabsorption by dapagliflozin has also been associated with a reduction in body weight. Furthermore, the drug modestly reduces blood pressure levels through weight loss and its action as osmotic diuretic. Dapagliflozin has been approved as monotherapy in patients with type 2 diabetes mellitus (T2DM) who cannot tolerate metformin or in combination with other antidiabetic drugs, with the exception of pioglitazone due to the theoretical increased risk of bladder cancer. The drug should not be prescribed in patients with moderate or severe renal impairment or in patients at risk for developing volume depletion. Dapagliflozin is associated with increased incidence of genital and lower urinary tract infections, but these infections are usually mild to moderate and respond to standard antimicrobial treatment. Based on current evidence, dapagliflozin is a useful drug for patients with T2DM with a favorable safety profile. However, further research regarding the effects of dapagliflozin on cardiovascular outcomes is needed.

Renal effects of dapagliflozin in patients with type 2 diabetes

Diabetes mellitus was originally conceived as a renal disorder. In the last decade, however, there has been renewed interest in role of the kidney in the development and maintenance of high glucose levels. This has led to the development of novel agents to inhibit sodium glucose transporter-2 (SGLT2) as a means to better control glucose levels and at the same time augment calorie wasting and lower insulin, blood pressure and uric acid levels. Such actions, indirectly, may also have benefits for the prevention of diabetic complications including renal disease. However, there are also data to support the potential for direct renoprotective actions arising from inhibition of SGLT2, including actions to attenuate diabetes-associated hyperfiltration and tubular hypertrophy, as well as reduce the tubular toxicity of glucose. Some studies have demonstrated significant reductions in albumin excretion in various experimental models, independent of its effects on blood pressure or glucose control. Although promising, such actions remain to be established by comprehensive clinical trials with a renal focus, many of which are currently in progress. This article reviews the clinical and experimental data pertaining to the renal effects of SGLT2 inhibition with a particular focus on dapaglifozin.

The efficacy of dapagliflozin combined with hypoglycaemic drugs in treating type 2 diabetes mellitus: meta-analysis of randomised controlled trials

OBJECTIVES

This meta-analysis aimed to evaluate whether dapagliflozin is synergistic with other antidiabetic drugs without body weight gain.

SETTING

Randomised controlled trial (RCT) reports were retrieved from PubMed, Cochrane Library, EMBASE, ClinicalTrials.gov, Google Scholar and Google. Eligible RCTs were selected according to the criteria (including types of participants, intervention, outcomes) and assessed by the Cochrane risk of bias tool and GRADEpro software for evidential quality. Meta-analysis on the eligible RCTs was performed with the random effects model. The RCTs of low-quality and interim stages were excluded for further sensitivity analysis. Meta-regression was conducted on the follow-up durations. Publication bias was evaluated with funnel plots and the Egger's regression test and adjusted using the trim-and-fill procedure. Heterogeneity was assessed with the I(2) statistics.

PARTICIPANTS

Adult patients with type 2 diabetes mellitus (T2DM).

INTERVENTIONS

Dapagliflozin combined with conventional antidiabetic drugs.

PRIMARY AND SECONDARY OUTCOME MEASURES

Glycaemic level (measured by glycosylated haemoglobin (HbA1c) and fasting plasma glucose (FPG)) and body weight.

RESULTS

12 RCTs were eligible for quantitative synthesis and meta-analysis. The overall effect size of HbA1c calculated from mean difference was -0.52% (Z=-13.56, p<0.001) with 95% CI (-0.60 to -0.45). The effect size of FPG was -1.13 mmol/L (Z=-11.12, p<0.001) with 95% CI (-1.33 to -0.93). The effect size of body weight was -2.10 kg (Z=-18.77, p<0.001) with 95% CI (-2.32 to -1.88). Exclusions of low quality and interim RCTs changed the overall mean differences respectively to -0.56%, -1.11 mmol/L, 2.23 kg and -0.50%, -1.08 mmol/L, -2.08 kg. The sensitivity analysis indicated good robustness of the meta-analysis on HbA1c, FPG and body weight.

CONCLUSIONS

The meta-analysis showed that dapagliflozin as an add-on drug to conventional antidiabetic drugs improved the glycaemic control in T2DM participants without significant body weight gain.

TRIAL REGISTRATION NUMBER

CRD42013005034.

The efficacy of dapagliflozin combined with hypoglycemic drugs in treating type 2 diabetes: protocol for meta-analysis of randomized controlled trials

BACKGROUND

Dapagliflozin is a first-in-class oral sodium glucose co-transporter 2 (SGLT2) inhibitor. It is often used in combination with conventional anti-diabetic drugs such as metformin, glimepiride, and insulin in treating type 2 diabetes (T2D). It not only reduces glucose reabsorption in the kidney but also increases renal glucose excretion. Some studies found the actions of dapagliflozin independent of insulin and free from risk of weight gain. This meta-analysis aims to evaluate whether dapagliflozin is synergistic with other anti-diabetic drugs without risk of weight gain.

METHODS/DESIGN

This meta-analysis will include the randomized controlled trials (RCT) evaluating the efficacy of dapagliflozin as an add-on drug in treating T2D for >8 weeks with the outcome measures glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG) and body weight. Information of relevant RCTs will be retrieved from major databases including PubMed, Cochrane Library, Embase, ClinicalTrials.gov, and Google Scholar according to a pre-specified search strategy. Google and manual search will find other unpublished reports and supplementary data. Eligible RCTs will be selected according to pre-specified inclusion and exclusion criteria. Data will be extracted and input into a pre-formatted spreadsheet. The Cochrane risk of bias tool will be used to assess the quality of the eligible RCTs. Meta-analysis based on the random-effects model will be conducted to compare the changes of HbA1c (%), FPG (mmol/L), and body weight (kg) between dapagliflozin arm and placebo arm. Publication bias will be evaluated with a funnel plot and the Egger's test. Heterogeneity will be assessed with the I2 statistics. Sensitivity analysis will be conducted on follow-up periods. The evidential quality of the findings will be assessed with the GRADE profiler.

DISCUSSION

The findings of this meta-analysis will be important to clinicians, patients, and health policy-makers regarding the use of dapagliflozin in T2D treatment.

STUDY REGISTRATION

PROSPERO registration number: CRD42013005034.

Inhibition of the sodium glucose co-transporter-2: its beneficial action and potential combination therapy for type 2 diabetes mellitus

Sodium glucose co-transporter-2 (SGLT2) inhibitors are an emerging class of glucose-lowering drugs in the management of type 2 diabetes mellitus (T2DM). In this context, SGLT2 is a low-affinity, high-capacity transporter that is expressed predominantly in the proximal renal tubules. The rationale for using SGLT2 inhibition as a drug for T2DM is derived from early evidence obtained from individuals with familial renal glycosuria, due to a SGLT2 mutation, which exhibits decreased renal tubular reabsorption of glucose in the absence of hyperglycaemia or any other signs of dysfunction. Thus, reduction of glucose reabsorption by SGLT2 inhibition represents a novel T2DM treatment approach. In light of the emerging role of SGLT2 inhibition in controlling glucose homeostasis, the current review provides a critical appraisal of the rationale, overviews of structural differences between SGLT2 inhibitors and summarizes recent preclinical and clinical studies. The physiological actions of SGLT2 inhibition in relation to insulin sensitivity, islet morphology, inflammation, body weight and blood pressure are reviewed. Finally, the safety and tolerability of SGLT2 inhibitors are also discussed in relation to their potential to provide insulin independence and enhance β-cell function, as well as their potential for synergistic/additive effects if used in combination with other antidiabetic drugs.

Improved glycemic control in mice lacking Sglt1 and Sglt2

Sodium-glucose cotransporter 2 (SGLT2) is the major, and SGLT1 the minor, transporter responsible for renal glucose reabsorption. Increasing urinary glucose excretion (UGE) by selectively inhibiting SGLT2 improves glycemic control in diabetic patients. We generated Sglt1 and Sglt2 knockout (KO) mice, Sglt1/Sglt2 double-KO (DKO) mice, and wild-type (WT) littermates to study their relative glycemic control and to determine contributions of SGLT1 and SGLT2 to UGE. Relative to WTs, Sglt2 KOs had improved oral glucose tolerance and were resistant to streptozotocin-induced diabetes. Sglt1 KOs fed glucose-free high-fat diet (G-free HFD) had improved oral glucose tolerance accompanied by delayed intestinal glucose absorption and increased circulating glucagon-like peptide-1 (GLP-1), but had normal intraperitoneal glucose tolerance. On G-free HFD, Sglt2 KOs had 30%, Sglt1 KOs 2%, and WTs <1% of the UGE of DKOs. Consistent with their increased UGE, DKOs had lower fasting blood glucose and improved intraperitoneal glucose tolerance than Sglt2 KOs. In conclusion, 1) Sglt2 is the major renal glucose transporter, but Sglt1 reabsorbs 70% of filtered glucose if Sglt2 is absent; 2) mice lacking Sglt2 display improved glucose tolerance despite UGE that is 30% of maximum; 3) Sglt1 KO mice respond to oral glucose with increased circulating GLP-1; and 4) DKO mice have improved glycemic control over mice lacking Sglt2 alone. These data suggest that, in patients with type 2 diabetes, combining pharmacological SGLT2 inhibition with complete renal and/or partial intestinal SGLT1 inhibition may improve glycemic control over that achieved by SGLT2 inhibition alone.