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Salmen T, Bobirca FT, Bica IC, Mihai DA, Pop C, Stoian AP. The Safety Profile of Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide 1 Receptor Agonists in the Standard of Care Treatment of Type 2 Diabetes Mellitus. Life (Basel) 2023; 13:life13030839. [PMID: 36983994 PMCID: PMC10051290 DOI: 10.3390/life13030839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/30/2023] Open
Abstract
AIM We evaluated the safety of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for their use with other glucose-lowering drugs and drugs for the treatment of type 2 diabetes mellitus (T2DM), in a standard-of-care regimen with maximum tolerated doses, and, respectively, when compared with metformin. METHODS We conducted a retrospective, observational study on 405 patients that were seen in the outpatient clinic of the N Paulescu National Institute for Diabetes Mellitus, Bucharest, Romania, in 2019. Their demographics, metabolic parameters, and medication safety were evaluated at three follow-up visits, from baseline, six months, and twelve months. RESULTS Both SGLT-2is and GLP-1 RAs are safe regarding creatinine, eGFR, urea, GOT, and GPT upon the comparison of the data from the six- and twelve-month visits with the initial visit, and also the twelve-month visit with the six-month visit. Moreover, when comparing SGLT-2is and GLP-1 RAs with metformin, there are safety data only for urea. CONCLUSIONS In this retrospective analysis, both SGLT-2is and GLP-1 RAs, when used in conjunction with other glucose-lowering, blood-pressure-lowering, and lipid-lowering medications, appeared to be safe for the management of T2DM.
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Affiliation(s)
- Teodor Salmen
- Doctoral School of Carol Davila, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Florin-Teodor Bobirca
- Department of General Surgery, Carol Davila, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ioana-Cristina Bica
- Doctoral School of Carol Davila, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Doina-Andrada Mihai
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Corina Pop
- Department of Gastroenterology and Internal Medicine, Carol Davila, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Lamprecht DG, Saseen JJ, Shaw PB. Clinical conundrums involving statin drug-drug interactions. Prog Cardiovasc Dis 2022; 75:83-89. [PMID: 36400235 DOI: 10.1016/j.pcad.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/06/2022] [Indexed: 11/17/2022]
Abstract
Statins are the cornerstone of pharmacologic therapy for the prevention and treatment of atherosclerotic cardiovascular disease. While they are generally considered safe, statins can be affected by drug-drug interactions (DDIs) that increase their systemic exposure increasing the risk for statin-associated muscle symptoms. These interactions are primarily mediated through metabolizing enzymes such as cytochrome P450 isoenzymes and membrane-bound drug transporting proteins including P-glycoprotein and organic ion transporting polypeptide. Recognition and avoidance of clinically significant statin DDIs is important to ensure their safe use. Conversely, concern over statin DDIs that are not clinically significant may lead to inappropriate underutilization or avoidance of statins in patients who would benefit from them. While many statin DDIs are well-characterized, we present several others that are less-well-established which may warrant clinical attention.
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Affiliation(s)
- Donald G Lamprecht
- Kaiser Permanente, Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy, Aurora, CO, USA.
| | - Joseph J Saseen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy, Aurora, CO, USA; Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine; Aurora, CO, USA
| | - Paul B Shaw
- Kaiser Permanente, Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO, USA; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy, Aurora, CO, USA
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Development of UPLC-MS/MS Method to Study the Pharmacokinetic Interaction between Sorafenib and Dapagliflozin in Rats. Molecules 2022; 27:molecules27196190. [PMID: 36234746 PMCID: PMC9571628 DOI: 10.3390/molecules27196190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/18/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
Sorafenib (SOR), an inhibitor of multiple kinases, is a classic targeted drug for advanced hepatocellular carcinoma (HCC) which often coexists with type 2 diabetes mellitus (T2DM). Dapagliflozin (DAPA), a sodium–glucose cotransporter-2 inhibitor (SGLT2i), is widely used in patients with T2DM. Notably, co-administration of SOR with DAPA is common in clinical settings. Uridine diphosphate-glucuronosyltransferase family 1 member A9 (UGT1A9) is involved in the metabolism of SOR and dapagliflozin (DAPA), and SOR is the inhibitor of UGT1A1 and UGT1A9 (in vitro). Therefore, changes in UGT1A9 activity caused by SOR may lead to pharmacokinetic interactions between the two drugs. The objective of the current study was to develop an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for the simultaneous determination of SOR and DAPA in plasma and to evaluate the effect of the co-administration of SOR and DAPA on their individual pharmacokinetic properties and the mechanism involved. The rats were divided into four groups: SOR (100 mg/kg) alone and co-administered with DAPA (1 mg/kg) for seven days, and DAPA (1 mg/kg) alone and co-administered with SOR (100 mg/kg) for seven days. Liquid–liquid extraction (LLE) was performed for plasma sample preparation, and the chromatographic separation was conducted on Waters XSelect HSS T3 column with a gradient elution of 0.1% formic acid and 5 mM ammonium acetate (Phase A) and acetonitrile (Phase B). The levels of Ugt1a7 messenger RNA (mRNA) were determined in rat liver and intestine using quantitative real-time polymerase chain reaction (qRT-PCR). The method was successfully applied to the study of pharmacokinetic interactions. DAPA caused a significant decrease in the maximum plasma concentrations (Cmax) and the area under the plasma concentration–time curves (AUC0–t) of SOR by 41.6% and 50.5%, respectively, while the apparent volume of distribution (Vz/F) and apparent clearance (CLz/F) significantly increased 2.85- and 1.98-fold, respectively. When co-administering DAPA with SOR, the AUC0–t and the elimination half-life (t1/2Z) of DAPA significantly increased 1.66- and 1.80-fold, respectively, whereas the CLz/F significantly decreased by 40%. Results from qRT-PCR showed that, compared with control, seven days of SOR pretreatment decreased Ugt1a7 expression in both liver and intestine tissue. In contrast, seven days of DAPA pretreatment decreased Ugt1a7 expression only in liver tissue. Therefore, pharmacokinetic interactions exist between long-term use of SOR with DAPA, and UGT1A9 may be the targets mediating the interaction. Active surveillance for the treatment outcomes and adverse reactions are required.
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Scheen AJ. Counteracting heart failure with diabetes drugs: a review into the pharmacokinetic and pharmacodynamic properties. Expert Opin Drug Metab Toxicol 2022; 18:381-393. [PMID: 35876091 DOI: 10.1080/17425255.2022.2105693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION : Heart failure (HF) is becoming a huge public health burden. New diabetes drugs for type 2 diabetes (T2D), sodium-glucose cotransporter type 2 inhibitors (SGLT2is), reduce the rate of hospitalization for HF in placebo-controlled trials. AREAS COVERED : Pharmacokinetics of dapagliflozin and empagliflozin (in presence of renal impairment and hepatic dysfunction, two comorbidities frequently associated with HF) and pharmacodynamic studies in patients with HF. Main HF outcomes in T2D patients with cardiovascular risk and in patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction, with or without T2D, from DAPA-HF, EMPEROR-Reduced and EMPEROR-Preserved original findings and post hoc analyses. EXPERT OPINION : No clinically relevant changes are expected concerning SGLT2i pharmacokinetics in patients with HF while pharmacodynamic studies reported improvements in myocardium/vascular parameters, biomarkers and functional status. All SGLT2is showed a remarkable reduction in hospitalization for HF in patients with T2D and high cardiovascular risk. Furthermore, both dapagliflozin and empagliflozin improved the prognosis of patients with HFrEF, independently of the presence of T2D. Similar results were reported with empagliflozin in patients with HFpEF, to be confirmed with dapagliflozin in an ongoing trial (DELIVER). Thus, SGLT2is offer a new opportunity for the prevention and management of HF in patients with or without T2D.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.,Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
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Glycaemic Control in Patients Undergoing Percutaneous Coronary Intervention: What Is the Role for the Novel Antidiabetic Agents? A Comprehensive Review of Basic Science and Clinical Data. Int J Mol Sci 2022; 23:ijms23137261. [PMID: 35806265 PMCID: PMC9266811 DOI: 10.3390/ijms23137261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and revascularization through percutaneous coronary interventions (PCI) significantly improves survival. In this setting, poor glycaemic control, regardless of diabetes, has been associated with increased incidence of peri-procedural and long-term complications and worse prognosis. Novel antidiabetic agents have represented a paradigm shift in managing patients with diabetes and cardiovascular diseases. However, limited data are reported so far in patients undergoing coronary stenting. This review intends to provide an overview of the biological mechanisms underlying hyperglycaemia-induced vascular damage and the contrasting actions of new antidiabetic drugs. We summarize existing evidence on the effects of these drugs in the setting of PCI, addressing pre-clinical and clinical studies and drug-drug interactions with antiplatelet agents, thus highlighting new opportunities for optimal long-term management of these patients.
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Peng P, Zhao C, Yang J, Liu X, Yu J, Zhang F. Synthesis, Isolation, Characterization and Suppression of Impurities during Optimization of Empagliflozin (Jardiance). ORG PREP PROCED INT 2022. [DOI: 10.1080/00304948.2021.2022922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Peng Peng
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Xiacheng, Hangzhou, China
| | - Chuanmeng Zhao
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong, Shanghai, China
| | - Jiangtao Yang
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong, Shanghai, China
| | - Xiao Liu
- College of Chemistry and Chemical Engineering, Shanghai University of Engineering Science, Shanghai, China
| | - Jun Yu
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong, Shanghai, China
| | - Fuli Zhang
- Shanghai Institute of Pharmaceutical Industry, China State Institute of Pharmaceutical Industry, Pudong, Shanghai, China
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Tuladhar LR, Shrestha SL, Regmi D, Bimali S, Bhusal S, Khadka P. Drug-drug Interactions between Hypoglycemic and Non-hypoglycemic Medication in Diabetic Patients with Comorbidities in a Tertiary Care Center: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc 2021; 59:1125-1130. [PMID: 35199748 PMCID: PMC9124339 DOI: 10.31729/jnma.7080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/17/2021] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Drug-drug interaction is one of the causes of adverse drug reactions. Generally, drug-drug interaction is common in multidrug therapy. Diabetic patients, particularly due to associated comorbidities tend to have various drug-drug interactions due to the effect of multiple drugs. The objective of this study was to find out the prevalence of drug-drug interactions in diabetic patients. METHODS It was a descriptive cross-sectional study that was conducted among previously diagnosed diabetic patients visiting the outpatient department of medicine at a tertiary care hospital between March 2021 and August 2021. Ethical approval was taken from the institutional review committee (Ref no: 030-076/077). Data was collected from diabetic patients presenting to the outpatient department of medicine using a preformed self-constructed questionnaire. Convenient sampling was done. Statistical Package for Social Sciences version 21 and Microsoft Excel were used for data analysis. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. RESULTS The prevalence of drug-drug interaction between hypoglycemic and non-hypoglycemic medication was 56 (44.1%) (35.5-52.7 at 95% Confidence Interval) of the patients out of which at least one drug-drug interaction was seen in 48 (37.8%) of the patients. CONCLUSIONS Our study showed the prevalence of drug-drug interactions in diabetic patients to be higher than other studies done in similar settings. Based on the severity, we observed two types of drug-drug interactions; close monitoring drug-drug interactions and minor drug-drug interactions.
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Affiliation(s)
- Lujaw Ratna Tuladhar
- Department of Pharmacology, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Shirish Lall Shrestha
- Department of Internal Medicine, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Deepak Regmi
- Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Sneha Bimali
- Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Srijana Bhusal
- Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Pingala Khadka
- Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
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Lu J, Tian X, Tang D, Zhou X, Xu Z, Ding J, Wang T, Yu Q, Ding J. In vitro study of the drug-drug interaction potential of cetagliptin and clinical study of pharmacokinetic interaction of cetagliptin and metformin in healthy volunteers. Xenobiotica 2021; 51:1122-1131. [PMID: 34329567 DOI: 10.1080/00498254.2021.1963010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/20/2022]
Abstract
Cetagliptin is an oral, potent, and newly developed selective inhibitor of dipeptidyl peptidase-4 (DPP-4). We evaluated the in vitro drug-drug interaction (DDI) potential of cetagliptin, as well as the pharmacokinetics of cetagliptin and metformin and the interaction between cetagliptin and metformin.Cetagliptin did not inhibit CYP1A2, CYP2C8, CYP2B6, CYP2C9, CYP2C19, and CYP3A4, only has a moderate inhibitory effect on CYP2D6, and did not induce CYP1A2, CYP2B6, and CYP3A4. Plasma protein binding of cetagliptin didn't have species differences or concentration dependence. Cetagliptin was a substrate for P-glycoprotein (P-gp).The 34 healthy subjects enrolled were randomly divided into two sequences (A and B) with 17 subjects in each sequence. Coadministration with metformin had no effect on cetagliptin AUC0-120 (GMR, 99.25%; 90% CI, 95.96%-102.65%). There was a slightly increase in cetagliptin Cmax (GMR, 117.33%; 90% CI, 102.54%-134.25%). Coadministration with cetagliptin did not affect the metformin's AUC0-24 (GMR, 108.54%; 90% CI, 101.41%-116.17%) or Cmax (GMR, 97.67%; 90% CI, 90.96%-104.89%).Based on in vitro study results, cetagliptin is unlikely to cause CYP-mediated, clinically relevant DDI. Although the possibility of transporter-mediated, clinically relevant DDI cannot be ruled out, there is little or no risk of side effects. Coadministration of cetagliptin and metformin had no clinically meaningful effect on the pharmacokinetics of each drug. There was no drug-drug interaction between cetagliptin and metformin. Both monotherapies and combination therapy were well tolerated. No serious AEs and hypoglycaemia was reported.
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Affiliation(s)
- Jinmiao Lu
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, China
| | - Xusheng Tian
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Dong Tang
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Xinyi Zhou
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Zengyan Xu
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Juping Ding
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Tong Wang
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Qiang Yu
- CGeneTech (Suzhou, China) Co., Ltd, Suzhou, Jiangsu, China
| | - Jinsong Ding
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, China
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Fediuk DJ, Nucci G, Dawra VK, Cutler DL, Amin NB, Terra SG, Boyd RA, Krishna R, Sahasrabudhe V. Overview of the Clinical Pharmacology of Ertugliflozin, a Novel Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor. Clin Pharmacokinet 2021; 59:949-965. [PMID: 32337660 PMCID: PMC7403171 DOI: 10.1007/s40262-020-00875-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ertugliflozin, a selective inhibitor of sodium-glucose cotransporter 2 (SGLT2), is approved in the US, EU, and other regions for the treatment of adults with type 2 diabetes mellitus (T2DM). This review summarizes the ertugliflozin pharmacokinetic (PK) and pharmacodynamic data obtained during phase I clinical development, which supported the registration and labeling of this drug. The PK of ertugliflozin was similar in healthy subjects and patients with T2DM. Oral absorption was rapid, with time to peak plasma concentrations (Tmax) occurring at 1 h (fasted) and 2 h (fed) postdose. The terminal phase half-life ranged from 11 to 18 h and steady-state concentrations were achieved by 6 days after initiating once-daily dosing. Ertugliflozin exposure increased in a dose-proportional manner over the tested dose range of 0.5–300 mg. Ertugliflozin is categorized as a Biopharmaceutical Classification System Class I drug with an absolute bioavailability of ~ 100% under fasted conditions. Administration of the ertugliflozin 15 mg commercial tablet with food resulted in no meaningful effect on ertugliflozin area under the plasma concentration–time curve (AUC), but decreased peak concentrations (Cmax) by 29%. The effect on Cmax is not clinically relevant and ertugliflozin can be administered without regard to food. Mild, moderate, and severe renal impairment were associated with a ≤ 70% increase in ertugliflozin exposure relative to subjects with normal renal function, and no dose adjustment in renal impairment patients is needed based on PK results. Consistent with the mechanism of action of SGLT2 inhibitors, 24-h urinary glucose excretion decreased with worsening renal function. In subjects with moderate hepatic impairment, a decrease in AUC (13%) relative to subjects with normal hepatic function was observed and not considered clinically relevant. Concomitant administration of metformin, sitagliptin, glimepiride, or simvastatin with ertugliflozin did not have clinically meaningful effects on the PK of ertugliflozin or the coadministered medications. Coadministration of rifampin decreased ertugliflozin AUC and Cmax by 39% and 15%, respectively, and is not expected to affect efficacy in a clinically meaningful manner. This comprehensive evaluation supports administration to patients with T2DM without regard to prandial status and with no dose adjustments for coadministration with commonly prescribed drugs, or in patients with renal impairment or mild-to-moderate hepatic impairment based on ertugliflozin PK.
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Affiliation(s)
- Daryl J Fediuk
- Pfizer Inc., 445 Eastern Point Road, Groton, CT, 06340, USA
| | | | | | - David L Cutler
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
| | - Neeta B Amin
- Pfizer Inc., 1 Portland St, Cambridge, MA, 02139, USA
| | | | - Rebecca A Boyd
- Pfizer Inc., 445 Eastern Point Road, Groton, CT, 06340, USA
| | - Rajesh Krishna
- Merck & Co., Inc., 2000 Galloping Hill Rd, Kenilworth, NJ, 07033, USA
- Certara USA Inc., Parsippany, NJ, 07054, USA
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Lalagkas PN, Poulentzas G, Kontogiorgis C, Douros A. Potential drug-drug interaction between sodium-glucose co-transporter 2 inhibitors and statins: pharmacological and clinical evidence. Expert Opin Drug Metab Toxicol 2021; 17:697-705. [PMID: 33888031 DOI: 10.1080/17425255.2021.1921735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Recent case reports suggested that concomitant use of sodium-glucose co-transporter 2 (SGLT2) inhibitors with statins could lead to increased statin toxicity. We provide a comprehensive overview of the available pharmacological and clinical evidence on this potential drug-drug interaction (DDI). AREAS COVERED We searched MEDLINE PubMed until November 2020 for (i) pharmacokinetic studies on SGLT2 inhibitors, statins, and their potential interaction, and (ii) case reports and clinical studies assessing the safety of concomitant use of SGLT2 inhibitors and statins. We also searched regulatory documents submitted to the United States Food and Drug Administration for unpublished data on this potential DDI. EXPERT OPINION SGLT2 inhibitors are increasingly used for type 2 diabetes, chronic heart failure, and chronic kidney disease, and concomitant use with statins is common given the comorbidity of indications. While pharmacokinetic studies in healthy subjects showed no clinically relevant changes in statin levels during SGLT2 inhibitor co-administration, the published case reports and pharmacologic reasoning support the possibility of an interaction. Underlying mechanisms could be pharmacokinetic or pharmacodynamic, and canagliflozin appears to be the SGLT2 inhibitor with the highest interaction potential. Further research including 'real-world' pharmacoepidemiologic studies is needed to better understand the clinical significance of this DDI.
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Affiliation(s)
- Panagiotis-Nikolaos Lalagkas
- Laboratory of Hygiene and Environmental Protection, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Georgios Poulentzas
- Laboratory of Hygiene and Environmental Protection, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christos Kontogiorgis
- Laboratory of Hygiene and Environmental Protection, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece.,Institute of Agri-Food and Life Sciences, Hellenic Mediterranean University Research Centre, Heraklion, Greece
| | - Antonios Douros
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Departments of Medicine and Epidemiology, McGill University, Montreal, QC, Canada.,Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Terasaka S, Hachiuma K, Mano Y, Onishi K, Kitajima I, Nishino I, Endo H. Drug-drug interaction potential and clinical pharmacokinetics of enerisant, a novel potent and selective histamine H 3 receptor antagonist. Xenobiotica 2021; 51:786-795. [PMID: 33910470 DOI: 10.1080/00498254.2021.1918361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We evaluated the in vitro drug-drug interaction (DDI) potential of enerisant (TS-091), a histamine H3 receptor antagonist/inverse agonist, mediated by cytochrome P450 (CYP) and transporters, as well as the pharmacokinetics of enerisant in healthy male subjects.Enerisant did not inhibit CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, or CYP3A4 and did not induce CYP1A2, CYP2B6, or CYP3A4. Enerisant inhibited organic cation transporter 2, multidrug and toxin extrusion protein (MATE) 1, and MATE2-K, but not P-glycoprotein (P-gp), breast cancer resistance protein, organic anion transporting polypeptide (OATP) 1B1, OATP1B3, organic anion transporter (OAT) 1, or OAT3. Enerisant was a substrate for P-gp, but not for eight other transporters.In healthy male subjects, enerisant was rapidly absorbed after oral administration, and the plasma concentration increased dose-dependently. The urinary excretion of enerisant within 48 h after administration was 64.5% to 89.9% of the dose, indicating that most of the absorbed enerisant was excreted in the urine without being metabolized.Based on the plasma concentrations at the estimated clinical dose, enerisant is unlikely to cause CYP-mediated, clinically relevant DDI. Although the possibility of transporter-mediated, clinically relevant DDI cannot be ruled out, there is little or no risk of side effects.
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Affiliation(s)
- Shuichi Terasaka
- Drug Metabolism and Pharmacokinetics, Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd., Saitama, Japan
| | - Kenji Hachiuma
- Drug Metabolism and Pharmacokinetics, Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd., Saitama, Japan
| | - Yoko Mano
- Development Headquarters, Taisho Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Koichi Onishi
- Development Headquarters, Taisho Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Iwao Kitajima
- Development Headquarters, Taisho Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Izumi Nishino
- Development Headquarters, Taisho Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Hiromi Endo
- Drug Metabolism and Pharmacokinetics, Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd., Saitama, Japan
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Ninčević V, Omanović Kolarić T, Roguljić H, Kizivat T, Smolić M, Bilić Ćurčić I. Renal Benefits of SGLT 2 Inhibitors and GLP-1 Receptor Agonists: Evidence Supporting a Paradigm Shift in the Medical Management of Type 2 Diabetes. Int J Mol Sci 2019; 20:ijms20235831. [PMID: 31757028 PMCID: PMC6928920 DOI: 10.3390/ijms20235831] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 01/09/2023] Open
Abstract
Diabetic nephropathy (DN) is one of the most perilous side effects of diabetes mellitus type 1 and type 2 (T1DM and T2DM).). It is known that sodium/glucose cotransporter 2 inhibitors (SGLT 2i) and glucagone like peptide-1 receptor agonists (GLP-1 RAs) have renoprotective effects, but the molecular mechanisms are still unknown. In clinical trials GLP-1 analogs exerted important impact on renal composite outcomes, primarily on macroalbuminuria, possibly through suppression of inflammation-related pathways, however enhancement of natriuresis and diuresis is also one of possible mechanisms of nephroprotection. Dapagliflozin, canagliflozin, and empagliflozin are SGLT2i drugs, useful in reducing hyperglycemia and in their potential renoprotective mechanisms, which include blood pressure control, body weight loss, intraglomerular pressure reduction, and a decrease in urinary proximal tubular injury biomarkers. In this review we have discussed the potential synergistic and/or additive effects of GLP 1 RA and SGLT2 inhibitors on the primary onset and progression of kidney disease, and the potential implications on current guidelines of diabetes type 2 management.
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Affiliation(s)
- Vjera Ninčević
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia
| | - Tea Omanović Kolarić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia
| | - Hrvoje Roguljić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department for Cardiovascular Disease, University Hospital Osijek, 4, 31000 Osijek, Croatia
| | - Tomislav Kizivat
- Clinical Institute of Nuclear Medicine and Radiation Protection, University Hospital Osijek, 31000 Osijek, Croatia;
- Department for Nuclear Medicine and Oncology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek; J. Huttlera 4, 31000 Osijek, Croatia
| | - Martina Smolić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia
| | - Ines Bilić Ćurčić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Diabetes, Endocrinology and Metabolism Disorders, University Hospital Osijek, 31000 Osijek, Croatia
- Correspondence:
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13
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New antihyperglycemic medications with cardiovascular protection for patients with diabetes: What do surgeons need to know? J Thorac Cardiovasc Surg 2019; 158:1113-1117. [DOI: 10.1016/j.jtcvs.2019.03.140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/12/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022]
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14
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Elgawish MS, Nasser S, Salama I, Abbas AM, Mostafa SM. Liquid chromatography tandem mass spectrometry for the simultaneous determination of metformin and pioglitazone in rat plasma: Application to pharmacokinetic and drug-drug interaction studies. J Chromatogr B Analyt Technol Biomed Life Sci 2019; 1124:47-57. [PMID: 31177048 DOI: 10.1016/j.jchromb.2019.05.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/27/2019] [Accepted: 05/30/2019] [Indexed: 01/13/2023]
Abstract
Failure to attain and sustain long term glycemic control is an ongoing challenge in diabetes therapy. The trend to use a combined therapy and the risk of drug-drug interaction (DDI) are elevated and thus the need for sensitive analytical methods is of great significance. Herein, a simple, robust, and sensitive reverse phase high performance liquid chromatography-electrospray ionization-tandem mass spectrometry (ESI-MS/MS) method for simultaneous determination of metformin (MET) and pioglitazone (PGT) in rat plasma using canagliflozin (CAN) as internal standards (IS) was developed and fully validated. Prior Chromatographic separation on an Agilent Eclipse Plus C18 (4.6 × 100 mm, 3.5 μm) using gradient mobile phase system consisting of ammonium formate pH 4.5 and acetonitrile at a flow rate of 0.5 mL min-1, within a run time of 14 min, the antidiabetic drugs were extracted from rat plasma using acetonitrile-induced protein precipitation technique. Multiple reaction monitoring in positive ion mode was used for quantitation of precursor to production at m/z 130.1 → 71.0 & 60 for MET, 357.2 → 134.2 for PGT, and 462.16 → 191.1 for CAN. Method linearity was obeyed in the range of 1 to 5000 and 1 to 2500 ng mL-1 for MET and PGT, respectively. The developed method was validated in terms of accuracy, precision, selectivity, recovery, matrix effects, and stability as per US-FDA bioanalytical guidelines and successfully applied to clinical pharmacokinetic and DDI studies with a single oral administration of target compounds. The peak plasma concentrations (Cmax) and area under the concentration-time curve (AUC) of MET was significantly influenced by the concomitant administration of PGT at equal concentration and vice versa. PGT affected the absorption and elimination rate of MET via inhibition of organic cationic transporter (OCT). Molecular modeling study revealed the significant interaction of PGT with OCT. A potential DDI in type 2 diabetic patient receiving chronic treatment with MET and PGT deserves further attention and study to improve drug therapy and prevent adverse effects.
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Affiliation(s)
- Mohamed Saleh Elgawish
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt.
| | - Sally Nasser
- Pharmaceutical Chemistry Department, Faculty of Pharmacy and Pharmaceutical Industries, Sinai University, Arish, Egypt
| | - Ismail Salama
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt
| | - Abbas Mamdoh Abbas
- Chemistry Department, Faculty of Science, Suez Canal University, Ismailia 41522, Egypt
| | - Samia M Mostafa
- Medicinal Chemistry Department, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt
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15
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Abstract
INTRODUCTION Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are recommended after metformin for a large spectrum of patients with type 2 diabetes, because of a favorable benefit/risk profile despite a variety of adverse events. AREAS COVERED This narrative review discusses the safety profile of SGLT2is: initial concerns (cardiovascular safety, acute renal failure, hypoglycemia, urinary and genital infections, volume depletion, bladder cancer), further concerns (euglycemic ketoacidosis, bone fractures) and more recent concerns (lower limb amputation, Fournier's gangrene). EXPERT OPINION Overall, the safety profile of SGLT2is is good. The only increased adverse event that was consistently reported in clinical trials and observational studies is genital mycotic infections, with only a borderline increase in urinary tract infections. Among clinical trials, only the CANVAS program reported an unexpected increase in bone fractures and peripheral amputations. A variety of rare adverse events have been described as case reports, including ketoacidosis, amputations and Fournier gangrene, which led to specific warnings by regulatory agencies. Identifying predisposing patient's characteristics and/or precipitating clinical conditions would help prevent the most severe complications. These adverse events should not mask the overall cardiovascular and renal benefit of SGLT2is, especially in patients with type 2 diabetes at high cardiovascular risk.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology , Center for Interdisciplinary Research on Medicines (CIRM), Liège University , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège , Belgium
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Grancini V, Resi V, Palmieri E, Pugliese G, Orsi E. Management of diabetes mellitus in patients undergoing liver transplantation. Pharmacol Res 2019; 141:556-573. [PMID: 30690071 DOI: 10.1016/j.phrs.2019.01.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 02/07/2023]
Abstract
Diabetes is a common feature in cirrhotic individuals both before and after liver transplantation and negatively affects prognosis. Certain aetiological agents of chronic liver disease and loss of liver function per se favour the occurrence of pre-transplant diabetes in susceptible individuals, whereas immunosuppressant treatment, changes in lifestyle habits, and donor- and procedure-related factors contribute to diabetes development/persistence after transplantation. Challenges in the management of pre-transplant diabetes include the profound nutritional alterations characterizing cirrhotic individuals and the limitations to the use of drugs with liver metabolism. Special issues in the management of post-transplant diabetes include the diabetogenic potential of immunosuppressant drugs and the increased cardiovascular risk characterizing solid organ transplant survivors. Overall, the pharmacological management of cirrhotic patients undergoing liver transplantation is complicated by the lack of specific guidelines reflecting the paucity of data on the impact of glycaemic control and the safety and efficacy of anti-hyperglycaemic agents in these individuals.
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Affiliation(s)
- Valeria Grancini
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Veronica Resi
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Eva Palmieri
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, and Diabetes Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Emanuela Orsi
- Diabetes Service, Endocrinology and Metabolic Diseases Unit, IRCCS "Cà Granda - Ospedale Maggiore Policlinico" Foundation, and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Kalra S, Kesavadev J, Chadha M, Kumar GV. Sodium-glucose Cotransporter-2 Inhibitors in Combination with Other Glucose-lowering Agents for the Treatment of Type 2 Diabetes Mellitus. Indian J Endocrinol Metab 2018; 22:827-836. [PMID: 30766826 PMCID: PMC6330851 DOI: 10.4103/ijem.ijem_162_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Involvement of multiple physiological pathways and complex pathogenesis is responsible for the onset and progression of type 2 diabetes mellitus (T2DM). Since it is difficult to manage multiple pathophysiological defects by monotherapy, a combination therapy with two or more oral antidiabetic agents (OADs) may help achieve euglycemia in T2DM patients. Choice of OADs is difficult with growing armamentarium of antidiabetic therapy. Ideally, drug combination should aim at reversal of known pathogenic abnormalities and demonstrate improvement in the overall metabolic health rather than simply reduce glycosylated hemoglobin (HbA1c) levels. Increased glucose reabsorption, a faulty pathological mechanism, is targeted by a novel class of drugs, namely, the sodium-glucose cotransporter-2 (SGLT2) inhibitors. Combination of SGLT2 inhibitors and other OADs complement each other due to their unique mechanism of action. In addition, the glucose-lowering effect of SGLT2 inhibitors remains independent of β-cell function and insulin sensitivity which reduces the chances of severe hypoglycemia in patients receiving these agents. Clinical studies from the past favor the use of SGLT2 inhibitors in combination with other agents to achieve better HbA1c levels, weight loss, and blood pressure control. In this review, we have made an attempt to explore the recommended guidelines for combination therapy, its advantages as either combination therapy or fixed-dose combinations therapy, and the role of SGLT2 inhibitors as a choice of drug as a combination with other OADs.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
| | - Jothydev Kesavadev
- Department of Diabetes, Jothydev's Diabetes and Research Centre, Thiruvananthapuram, Kerala, India
| | - Manoj Chadha
- P. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Aguillón AR, Mascarello A, Segretti ND, de Azevedo HFZ, Guimaraes CRW, Miranda LSM, de Souza ROMA. Synthetic Strategies toward SGLT2 Inhibitors. Org Process Res Dev 2018. [DOI: 10.1021/acs.oprd.8b00017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anderson R. Aguillón
- Biocatalysis and Organic Synthesis Group, Universidade Federal do Rio de Janeiro, 22941-909 Rio de Janeiro-RJ, Brazil
| | | | | | | | | | - Leandro S. M. Miranda
- Biocatalysis and Organic Synthesis Group, Universidade Federal do Rio de Janeiro, 22941-909 Rio de Janeiro-RJ, Brazil
| | - Rodrigo O. M. A. de Souza
- Biocatalysis and Organic Synthesis Group, Universidade Federal do Rio de Janeiro, 22941-909 Rio de Janeiro-RJ, Brazil
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19
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Scheen AJ. Pharmacokinetic Characteristics and Clinical Efficacy of an SGLT2 Inhibitor Plus DPP-4 Inhibitor Combination Therapy in Type 2 Diabetes. Clin Pharmacokinet 2018; 56:703-718. [PMID: 28039605 DOI: 10.1007/s40262-016-0498-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Type 2 diabetes (T2D) generally requires a combination of several pharmacological approaches to control hyperglycaemia. Combining a sodium-glucose cotransporter type 2 inhibitor (SGLT2I, also known as gliflozin) and a dipeptidyl peptidase-4 inhibitor (DPP-4I, also known as gliptin) appears to be an attractive strategy because of complementary modes of action. This narrative review analyzes the pharmacokinetics and clinical efficacy of different combined therapies with an SGLT2I (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin, luseogliflozin, tofogliflozin) and DPP-4I (linagliptin, saxagliptin, sitagliptin, teneligliptin). Drug-drug pharmacokinetic interaction studies do not show any significant changes in peak concentrations (C max) and total exposure (area under the curve of plasma concentrations [AUC]) of either drug when they were administered together orally compared with corresponding values when each of them was absorbed alone. Two fixed-dose combinations (FDCs) are already available (dapagliflozin-saxagliptin, empagliflozin-linagliptin) and others are in development (ertugliflozin-sitagliptin). Preliminary results show bioequivalence of the two medications administered as FDC tablets when compared with coadministration of the individual tablets. Dual therapy is more potent than either monotherapy in patients treated with diet and exercise or already treated with metformin. SGLT2I and DPP-4I could be used as initial combination or in a stepwise approach. The additional glucose-lowering effect appears to be more marked when a gliflozin is added to a gliptin than when a gliptin is added to a gliflozin. Combining the two pharmacological options is safe and does not induce hypoglycaemia.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, CHU Sart Tilman (B35), 4000, Liège 1, Belgium. .,Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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20
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Algeelani S, Alkhelb D, Greenblatt DJ. Inhibitory effects of sulfonylureas and non-steroidal anti-inflammatory drugs on in vitro metabolism of canagliflozin in human liver microsomes. Biopharm Drug Dispos 2018; 39:135-142. [PMID: 29319909 DOI: 10.1002/bdd.2120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/20/2017] [Accepted: 12/25/2017] [Indexed: 11/10/2022]
Abstract
Canagliflozin, used to treat type 2 diabetes mellitus (T2DM), is commonly co-administered with sulfonylureas. The objective of the present study was to evaluate the possible inhibitory effect of sulfonylureas and non-steroidal anti-inflammatory drugs (NSAIDs) on canagliflozin metabolism in vitro. Three sulfonylurea derivatives were evaluated as inhibitors: chlorpropamide, glimepiride and gliclazide. Two other NSAIDs were used as positive control inhibitors: niflumic acid and diclofenac. The rate of formation of canagliflozin metabolites was determined by HPLC analysis of in vitro incubations of canagliflozin as a substrate with and without inhibitors, using human liver microsomes (HLMs). Among sulfonylureas, glimepiride showed the most potent inhibitory effect against canagliflozin M7 metabolite formation, with an IC50 value of 88 μm, compared to chlorpropamide and gliclazide with IC50 values of more than 500 μm. Diclofenac inhibited M5 metabolite formation more than M7, with IC50 values of 32 μm for M5 and 80 μm for M7. Niflumic acid showed no inhibition activity against M5 formation, but had relatively selective inhibitory potency against M7 formation, which is catalysed by UGT1A9, with an IC50 value of 1.9 μm and an inhibition constant value of 0.8 μm. A clinical pharmacokinetic interaction between canagliflozin and sulfonylureas is unlikely. However, a possible clinically important drug interaction between niflumic acid and canagliflozin has been identified.
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Affiliation(s)
- Sara Algeelani
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences
| | - Dalal Alkhelb
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences
| | - David J Greenblatt
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences.,Tufts University School of Medicine, Boston, MA, 02111, USA
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21
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Goldberg N, Fralick M. Sodium-glucose cotransporter 2 inhibitors for treating diabetes mellitus. CMAJ 2017; 189:E724. [PMID: 28536128 DOI: 10.1503/cmaj.161455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Nicola Goldberg
- Department of Medicine (Goldberg), University of Toronto, Toronto, Ont.; Division of Pharmacoepidemiology and Pharmacoeconomics (Fralick), Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Fralick), Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ont
| | - Michael Fralick
- Department of Medicine (Goldberg), University of Toronto, Toronto, Ont.; Division of Pharmacoepidemiology and Pharmacoeconomics (Fralick), Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Fralick), Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ont.
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22
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Scheen AJ. Pharmacokinetic drug evaluation of saxagliptin plus dapagliflozin for the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2017; 13:583-592. [PMID: 28374622 DOI: 10.1080/17425255.2017.1315102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Combining a dipeptidyl peptidase-4 inhibitor and a sodium-glucose cotransporter type 2 inhibitor is an attractive option to treat hyperglycaemia in type 2 diabetes. Areas covered: The saxagliptin plus dapagliflozin combination is carefully analysed, focusing on: 1) pharmacokinetic properties, 2) pharmacodynamics data, and 3) results of randomised controlled trials (dual combination versus either monotherapy, sequential therapy saxagliptin added to dapagliflozin or dapagliflozin added to saxagliptin). Expert opinion: Pharmacokinetic findings demonstrate the absence of drug-drug interaction and the bioequivalence of the FDC compared with separated tablets. Pharmacodynamic observations confirm a complementary mode of action of the two agents. Dual saxagliptin-dapagliflozin therapy is more potent than either monotherapy. It may be used as an initial combination, although this approach remains debatable and should probably be reserved in case of high glycated hemoglobin, or a stepwise strategy, according to a personalized approach. The developed saxagliptin-dapagliflozin FDC may simplify anti-hyperglycemic therapy and improve drug compliance.
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Affiliation(s)
- André J Scheen
- a Department of Medicine , Division of Diabetes, Nutrition and Metabolic Disorders , CHU Liège, Liège , Belgium.,b Division of Clinical Pharmacology , Center for Interdisciplinary Research on Medicines (CIRM), University of Liège , Liège , Belgium
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Abstract
Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) reduce hyperglycemia by increasing urinary glucose excretion. They have been evaluated in patients with type 2 diabetes treated with diet/exercise, metformin, dual oral therapy or insulin. Three agents are available in Europe and the USA (canagliflozin, dapagliflozin, empagliflozin) and others are commercialized in Japan or in clinical development. SGLT2 inhibitors reduce glycated hemoglobin, with a minimal risk of hypoglycemia. They exert favorable effects beyond glucose control with consistent body weight, blood pressure, and serum uric acid reductions. Empagliflozin showed remarkable reductions in cardiovascular/all-cause mortality and in hospitalization for heart failure in patients with previous cardiovascular disease. Positive renal outcomes were also shown with empagliflozin. Mostly reported adverse events are genital mycotic infections, while urinary tract infections and events linked to volume depletion are rather rare. Concern about a risk of ketoacidosis and bone fractures has been recently raised, which deserves caution and further evaluation.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Department of Medicine, CHU Sart Tilman (B35), B-4000, Liege 1, Belgium.
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Tahrani AA, Barnett AH, Bailey CJ. Pharmacology and therapeutic implications of current drugs for type 2 diabetes mellitus. Nat Rev Endocrinol 2016; 12:566-92. [PMID: 27339889 DOI: 10.1038/nrendo.2016.86] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a global epidemic that poses a major challenge to health-care systems. Improving metabolic control to approach normal glycaemia (where practical) greatly benefits long-term prognoses and justifies early, effective, sustained and safety-conscious intervention. Improvements in the understanding of the complex pathogenesis of T2DM have underpinned the development of glucose-lowering therapies with complementary mechanisms of action, which have expanded treatment options and facilitated individualized management strategies. Over the past decade, several new classes of glucose-lowering agents have been licensed, including glucagon-like peptide 1 receptor (GLP-1R) agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors and sodium/glucose cotransporter 2 (SGLT2) inhibitors. These agents can be used individually or in combination with well-established treatments such as biguanides, sulfonylureas and thiazolidinediones. Although novel agents have potential advantages including low risk of hypoglycaemia and help with weight control, long-term safety has yet to be established. In this Review, we assess the pharmacokinetics, pharmacodynamics and safety profiles, including cardiovascular safety, of currently available therapies for management of hyperglycaemia in patients with T2DM within the context of disease pathogenesis and natural history. In addition, we briefly describe treatment algorithms for patients with T2DM and lessons from present therapies to inform the development of future therapies.
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Affiliation(s)
- Abd A Tahrani
- Centre of Endocrinology, Diabetes and Metabolism, 2nd Floor, Institute of Biomedical Research, University of Birmingham, Birmingham, B15 2TT, UK
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, B9 5SS, UK
| | - Anthony H Barnett
- Centre of Endocrinology, Diabetes and Metabolism, 2nd Floor, Institute of Biomedical Research, University of Birmingham, Birmingham, B15 2TT, UK
- Department of Diabetes and Endocrinology, Heart of England NHS Foundation Trust, Birmingham, B9 5SS, UK
| | - Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
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Vanhove T, Remijsen Q, Kuypers D, Gillard P. Drug-drug interactions between immunosuppressants and antidiabetic drugs in the treatment of post-transplant diabetes mellitus. Transplant Rev (Orlando) 2016; 31:69-77. [PMID: 27665059 DOI: 10.1016/j.trre.2016.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 02/06/2023]
Abstract
Post-transplant diabetes mellitus is a frequent complication of solid organ transplantation that generally requires treatment with lifestyle interventions and antidiabetic medication. A number of demonstrated and potential pharmacokinetic drug-drug interactions (DDIs) exist between commonly used immunosuppressants and antidiabetic drugs, which are comprehensively summarized in this review. Cyclosporine (CsA) itself inhibits the cytochrome P450 (CYP) 3A4 enzyme and a variety of drug transporters. As a result, it increases exposure to repaglinide and sitagliptin, will likely increase the exposure to nateglinide, glyburide, saxagliptin, vildagliptin and alogliptin, and could theoretically increase the exposure to gliquidone and several sodium-glucose transporter (SGLT)-2 inhibitors. Currently available data, although limited, suggest that these increases are modest and, particularly with regard to gliptins and SGLT-2 inhibitors, unlikely to result in hypoglycemia. The interaction with repaglinide is more pronounced but does not preclude concomitant use if repaglinide dose is gradually titrated. Mycophenolate mofetil and azathioprine do not engage in DDIs with any antidiabetic drug. Although calcineurin inhibitors (CNIs) and mammalian target of rapamycin inhibitors (mTORi) are intrinsically prone to DDIs, their disposition is not influenced by metformin, pioglitazone, sulfonylureas (except possibly glyburide) or insulin. An effect of gliptins on the disposition of CNIs and mTORi is unlikely, but has not been definitively ruled out. Based on their disposition profiles, glyburide and canagliflozin could affect CNI and mTORi disposition although this requires further study. Finally, delayed gastric emptying as a result of glucagon-like peptide-1 agonists seems to have a limited, but not necessarily negligible effect on CNI disposition.
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Affiliation(s)
- Thomas Vanhove
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, and Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.
| | - Quinten Remijsen
- Department of Medical Affairs, AstraZeneca BeLux, Uccle, Belgium
| | - Dirk Kuypers
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, and Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Gillard
- Laboratory and Clinic of Experimental Medicine and Endocrinology, KU Leuven - University of Leuven, and Department of Endocrinology, University Hospital Leuven, Leuven, Belgium
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Chino Y, Hasegawa M, Fukasawa Y, Mano Y, Bando K, Miyata A, Nakai Y, Endo H, Yamaguchi JI. In vitro evaluation of potential drug interactions mediated by cytochrome P450 and transporters for luseogliflozin, an SGLT2 inhibitor. Xenobiotica 2016; 47:314-323. [DOI: 10.1080/00498254.2016.1193913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Yukihiro Chino
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Masatoshi Hasegawa
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Yoshiki Fukasawa
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Yoko Mano
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Kagumi Bando
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Atsunori Miyata
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Yasuhiro Nakai
- Development Headquarters, Taisho Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Hiromi Endo
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
| | - Jun-ichi Yamaguchi
- Drug Safety and Pharmacokinetics Laboratories, Taisho Pharmaceutical Co., Ltd., Saitama, Japan and
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Kushner P. Benefits/risks of sodium-glucose co-transporter 2 inhibitor canagliflozin in women for the treatment of Type 2 diabetes. WOMEN'S HEALTH (LONDON, ENGLAND) 2016; 12:379-88. [PMID: 26928259 PMCID: PMC5384506 DOI: 10.2217/whe-2016-0001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 01/02/2023]
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors, such as canagliflozin, are used in patients with Type 2 diabetes mellitus (T2DM). In clinical studies, canagliflozin significantly reduced A1C, bodyweight and blood pressure, and was generally well tolerated with no increased risk of hypoglycemia. Most common adverse effects observed were genital mycotic infections and urinary tract infections, and increased urination. Approximately 10% of women treated with canagliflozin experienced a genital mycotic infection compared with 3% treated with placebo; those with a prior history were at greater risk. Approximately 9% of women treated with canagliflozin reported a urinary tract infection compared with 7% treated with placebo. Most adverse events were considered mild to moderate in intensity and responded to standard therapy. Treatment with canagliflozin was effective and generally well tolerated in both women (and men) with T2DM.
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Pharmacokinetics, Pharmacodynamics and Clinical Use of SGLT2 Inhibitors in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease. Clin Pharmacokinet 2016; 54:691-708. [PMID: 25805666 DOI: 10.1007/s40262-015-0264-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) are proposed as a novel approach for the management of type 2 diabetes mellitus. SGLT2 cotransporters are responsible for reabsorption of 90 % of the glucose filtered by the kidney. The glucuretic effect resulting from SGLT2 inhibition contributes to reduce hyperglycaemia and also assists weight loss and blood pressure reduction. Several SGLT2 inhibitors are already available in many countries (dapagliflozin, canagliflozin, empagliflozin) and in Japan (ipragliflozin, tofogliflozin). These SGLT2 inhibitors share similar pharmacokinetic characteristics with a rapid oral absorption, a long elimination half-life allowing once-daily administration, an extensive hepatic metabolism mainly via glucuronidation to inactive metabolites and a low renal elimination as a parent drug. Pharmacokinetic parameters are slightly altered in the case of chronic kidney disease (CKD). While no dose adjustment is required in the case of mild CKD, SGLT2 inhibitors may not be used or only at a lower daily dose in patients with moderate CKD. Furthermore, the pharmacodynamic response to SGLT2 inhibitors as assessed by urinary glucose excretion declines with increasing severity of renal impairment as assessed by a reduction in the estimated glomerular filtration rate. Nevertheless, the glucose-lowering efficacy and safety of SGLT2 inhibitors are almost comparable in patients with mild CKD as in patients with normal kidney function. In patients with moderate CKD, the efficacy tends to be dampened and safety concerns may occur. In patients with severe CKD, the use of SGLT2 inhibitors is contraindicated. Thus, prescribing information should be consulted regarding dosage adjustments or restrictions in the case of renal dysfunction for each SGLT2 inhibitor. The clinical impact of SGLT2 inhibitors on renal function and their potential to influence the course of diabetic nephropathy deserve attention because of preliminary favourable results in animal models.
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Staiger H, Schaeffeler E, Schwab M, Häring HU. Pharmacogenetics: Implications for Modern Type 2 Diabetes Therapy. Rev Diabet Stud 2016; 12:363-76. [PMID: 27111121 DOI: 10.1900/rds.2015.12.363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Many clinical treatment studies have reported remarkable interindividual variability in the response to pharmaceutical drugs, and uncovered the existence of inadequate treatment response, non-response, and even adverse drug reactions. Pharmacogenetics addresses the impact of genetic variants on treatment outcome including side-effects. In recent years, it has also entered the field of clinical diabetes research. In modern type 2 diabetes therapy, metformin is established as first-line drug. The latest pharmaceutical developments, including incretin mimetics, dipeptidyl peptidase 4 inhibitors (gliptins), and sodium/glucose cotransporter 2 inhibitors (gliflozins), are currently experiencing a marked increase in clinical use, while the prescriptions of α-glucosidase inhibitors, sulfonylureas, meglitinides (glinides), and thiazolidinediones (glitazones) are declining, predominantly because of reported side-effects. This review summarizes the current knowledge about gene-drug interactions observed in therapy studies with the above drugs. We report drug interactions with candidate genes involved in the pharmacokinetics (e.g., drug transporters) and pharmacodynamics (drug targets and downstream signaling steps) of the drugs, with known type 2 diabetes risk genes and previously unknown genes derived from hypothesis-free approaches such as genome-wide association studies. Moreover, some new and promising candidate genes for future pharmacogenetic assessment are highlighted. Finally, we critically appraise the current state of type 2 diabetes pharmacogenetics in the light of its impact on therapeutic decisions, and we refer to major problems, and make suggestions for future efforts in this field to help improve the clinical relevance of the results, and to establish genetically determined treatment failure.
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Affiliation(s)
- Harald Staiger
- Interfaculty Centre for Pharmacogenomics and Pharma Research at the University of Tübingen, Tübingen, Germany
| | - Elke Schaeffeler
- Interfaculty Centre for Pharmacogenomics and Pharma Research at the University of Tübingen, Tübingen, Germany
| | - Matthias Schwab
- Interfaculty Centre for Pharmacogenomics and Pharma Research at the University of Tübingen, Tübingen, Germany
| | - Hans-Ulrich Häring
- Interfaculty Centre for Pharmacogenomics and Pharma Research at the University of Tübingen, Tübingen, Germany
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Wang L, Wu C, Shen L, Liu H, Chen Y, Liu F, Wang Y, Yang J. Evaluation of drug–drug interaction between henagliflozin, a novel sodium-glucose co-transporter 2 inhibitor, and metformin in healthy Chinese males. Xenobiotica 2015; 46:703-8. [DOI: 10.3109/00498254.2015.1113576] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
INTRODUCTION Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) offer a new opportunity for the management of type 2 diabetes mellitus. These agents reduce hyperglycemia by decreasing the renal glucose threshold and thereby increasing urinary glucose excretion. Subsequent reduction of glucotoxicity improves beta-cell sensitivity to glucose and tissue insulin sensitivity. AREAS COVERED This article analyzes the efficacy and safety data of canagliflozin, dapagliflozin and empagliflozin in randomized controlled trials of 24 - 104 weeks duration, compared with placebo or an active comparator, in patients treated with diet/exercise, metformin, dual oral therapy or insulin. EXPERT OPINION SGLT2 inhibitors significantly and consistently reduce glycated hemoglobin, with a minimal risk of hypoglycemia. The improvement of glucose control is similar or slightly better compared with metformin, sulfonylureas or sitagliptin, with the add-on value of significant reductions in body weight and blood pressure. However, caution is recommended in fragile elderly patients and patients with chronic kidney disease. An increased risk of genital mycotic infections is observed, but urinary tract infections are rare. Concern about an unexpected risk of euglycemic ketoacidosis has been recently reported. A possible renal protection deserves further attention. A remarkable reduction in cardiovascular mortality was reported in EMPA-REG OUTCOME with empagliflozin.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM) , University of Liège , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège B-4000 , Belgium
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Pharmacodynamics, efficacy and safety of sodium-glucose co-transporter type 2 (SGLT2) inhibitors for the treatment of type 2 diabetes mellitus. Drugs 2015; 75:33-59. [PMID: 25488697 DOI: 10.1007/s40265-014-0337-y] [Citation(s) in RCA: 350] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inhibitors of sodium-glucose co-transporter type 2 (SGLT2) are proposed as a novel approach for the management of type 2 diabetes mellitus (T2DM). Several compounds are already available in many countries (dapagliflozin, canagliflozin, empagliflozin and ipragliflozin) and some others are in a late phase of development. The available SGLT2 inhibitors share similar pharmacokinetic characteristics, with a rapid oral absorption, a long elimination half-life allowing once-daily administration, an extensive hepatic metabolism mainly via glucuronidation to inactive metabolites, the absence of clinically relevant drug-drug interactions and a low renal elimination as parent drug. SGLT2 co-transporters are responsible for reabsorption of most (90 %) of the glucose filtered by the kidneys. The pharmacological inhibition of SGLT2 co-transporters reduces hyperglycaemia by decreasing renal glucose threshold and thereby increasing urinary glucose excretion. The amount of glucose excreted in the urine depends on both the level of hyperglycaemia and the glomerular filtration rate. Results of numerous placebo-controlled randomised clinical trials of 12-104 weeks duration have shown significant reductions in glycated haemoglobin (HbA1c), resulting in a significant increase in the proportion of patients reaching HbA1c targets, and a significant lowering of fasting plasma glucose when SGLT2 inhibitors were administered as monotherapy or in addition to other glucose-lowering therapies including insulin in patients with T2DM. In head-to-head trials of up to 2 years, SGLT2 inhibitors exerted similar glucose-lowering activity to metformin, sulphonylureas or sitagliptin. The durability of the glucose-lowering effect of SGLT2 inhibitors appears to be better; however, this remains to be more extensively investigated. The risk of hypoglycaemia was much lower with SGLT2 inhibitors than with sulphonylureas and was similarly low as that reported with metformin, pioglitazone or sitagliptin. Increased renal glucose elimination also assists weight loss and could help to reduce blood pressure. Both effects were very consistent across the trials and they represent some advantages for SGLT2 inhibitors when compared with other oral glucose-lowering agents. The pharmacodynamic response to SGLT2 inhibitors declines with increasing severity of renal impairment, and prescribing information for each SGLT2 inhibitor should be consulted regarding dosage adjustments or restrictions in moderate to severe renal dysfunction. Caution is also recommended in the elderly population because of a higher risk of renal impairment, orthostatic hypotension and dehydration, even if the absence of hypoglycaemia represents an obvious advantage in this population. The overall effect of SGLT2 inhibitors on the risk of cardiovascular disease is unknown and will be evaluated in several ongoing prospective placebo-controlled trials with cardiovascular outcomes. The impact of SGLT2 inhibitors on renal function and their potential to influence the course of diabetic nephropathy also deserve more attention. SGLT2 inhibitors are generally well-tolerated. The most frequently reported adverse events are female genital mycotic infections, while urinary tract infections are less commonly observed and generally benign. In conclusion, with their unique mechanism of action that is independent of insulin secretion and action, SGLT2 inhibitors are a useful addition to the therapeutic options available for the management of T2DM at any stage in the natural history of the disease. Although SGLT2 inhibitors have already been extensively investigated, further studies should even better delineate the best place of these new glucose-lowering agents in the already rich armamentarium for the management of T2DM.
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Swislocki ALM, Jialal I. The Novel Role of the Kidney in Diabetes Management: Sodium-Glucose Co-Transporter 2 Inhibitors. Metab Syndr Relat Disord 2015; 13:287-91. [DOI: 10.1089/met.2015.1504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Arthur L. M. Swislocki
- Medical Service, Department of Veterans Affairs Northern California Health Care System, Sacramento, California
- Department of Internal Medicine, UC Davis School of Medicine, Sacramento, California
| | - Ishwarlal Jialal
- Medical Service, Department of Veterans Affairs Northern California Health Care System, Sacramento, California
- Department of Pathology and Laboratory Medicine, UC Davis School of Medicine, Sacramento, California
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Abstract
Oral empagliflozin (Jardiance(®)), a sodium glucose cotransporter-2 (SGLT2) inhibitor, is a convenient once-daily treatment for adult patients with type 2 diabetes mellitus. By inhibiting reabsorption of glucose from the proximal tubules in the kidney via inhibition of SGLT2, empagliflozin provides a novel insulin-independent mechanism of lowering blood glucose. In several phase III trials (≤104 weeks' duration; typically 24 weeks' duration) and extension studies (typically ≥76 weeks' treatment), empagliflozin monotherapy or add-on therapy to other antihyperglycaemics, including insulin, improved glycaemic control and reduced bodyweight and systolic blood pressure in adult patients with type 2 diabetes. In a large phase III trial, as add-on therapy to metformin, empagliflozin was shown to be noninferior to glimepiride at 52 and 104 weeks and superior to glimepiride at 104 weeks, in terms of reductions in glycated haemoglobin level (primary endpoint). Empagliflozin was well tolerated by participants in these clinical trials, with most adverse events being mild or moderate in intensity. Empagliflozin treatment appeared to have no intrinsic risk of hypoglycaemia, although hypoglycaemia occurred more frequently when empagliflozin was coadministered with insulin and/or a sulfonylurea. With its insulin-independent mechanism of action, empagliflozin monotherapy or combination therapy with other antidiabetic drugs, including insulin, provides a useful addition to the therapeutic options for the management of type 2 diabetes. This article reviews the pharmacological properties and clinical use of empagliflozin in patients with type 2 diabetes.
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Kadokura T, Zhang W, Krauwinkel W, Leeflang S, Keirns J, Taniuchi Y, Nakajo I, Smulders R. Clinical pharmacokinetics and pharmacodynamics of the novel SGLT2 inhibitor ipragliflozin. Clin Pharmacokinet 2015; 53:975-88. [PMID: 25316572 DOI: 10.1007/s40262-014-0180-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ipragliflozin (Suglat(®)) is a potent and selective inhibitor of sodium-glucose cotransporter-2 that was recently launched in Japan. Its mechanism of action involves the suppression of glucose re-absorption in the kidney proximal tubules, causing excretion of glucose in the urine. The aim of this review is to provide a comprehensive overview of currently available pharmacokinetic and pharmacodynamic data on ipragliflozin, including studies in healthy subjects, patients with type 2 diabetes mellitus and special populations. In single- and multiple-dose studies, the maximum plasma concentration and area under the plasma concentration-time curve (AUC) for ipragliflozin increased in a dose-dependent manner. Although urinary excretion of ipragliflozin is low (approximately 1 %), tubular concentration of free ipragliflozin is adequate to provide pharmacological activities. No clinically relevant effects of age, gender or food on the exposure of ipragliflozin were observed. The AUC for ipragliflozin was 20-30 % greater in patients with moderate renal or hepatic impairment than in patients with normal renal or hepatic function. In drug-drug interaction studies, the pharmacokinetics of ipragliflozin and other oral antidiabetic drugs (metformin, sitagliptin, pioglitazone, glimepiride, miglitol and mitiglinide) were not significantly affected by their co-administration. Urinary glucose excretion (UGE) also increased in a dose-dependent manner, approaching a maximum effect at 50-100 mg dosages in Japanese healthy volunteers and patients with type 2 diabetes. The change in UGE from baseline (ΔUGE) tended to be lower in older subjects and female subjects, compared with younger subjects and male subjects, respectively. ΔUGE tended to decrease with decreasing renal function, especially in patients with type 2 diabetes with moderate or severe renal impairment.
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Affiliation(s)
- Takeshi Kadokura
- Clinical Pharmacology, Global Development, Astellas Pharma Inc., Tokyo, Japan,
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Hasegawa M, Chino Y, Horiuchi N, Hachiuma K, Ishida M, Fukasawa Y, Nakai Y, Yamaguchi JI. Preclinical metabolism and disposition of luseogliflozin, a novel antihyperglycemic agent. Xenobiotica 2015; 45:1105-15. [DOI: 10.3109/00498254.2015.1042947] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Devineni D, Polidori D. Clinical Pharmacokinetic, Pharmacodynamic, and Drug–Drug Interaction Profile of Canagliflozin, a Sodium-Glucose Co-transporter 2 Inhibitor. Clin Pharmacokinet 2015; 54:1027-41. [DOI: 10.1007/s40262-015-0285-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Canagliflozin (Invokana™) is an orally administered sodium-glucose co-transporter-2 (SGLT2) inhibitor used in the treatment of patients with type 2 diabetes. By inhibiting the transporter protein SGLT2 in the kidneys, canagliflozin reduces renal glucose reabsorption, thereby increasing urinary glucose excretion and reducing blood glucose levels. Several randomized placebo- or active comparator-controlled trials of 26-52 weeks' duration (plus extension phases) have shown that canagliflozin improves glycaemic control when used as monotherapy or as add-on therapy to metformin and/or other antihyperglycaemic agents, including insulin, in patients with type 2 diabetes. In addition to achieving reductions from baseline in glycosylated haemoglobin, canagliflozin also showed beneficial effects for other endpoints including reductions from baseline in fasting plasma glucose levels and bodyweight. Canagliflozin has a low risk of hypoglycaemia and was generally well tolerated in clinical trials. The most frequently reported adverse events with canagliflozin are female genital mycotic infections, urinary tract infections and increased urination. The pharmacodynamic response to canagliflozin declines with increasing severity of renal impairment, and prescribing information should be consulted regarding dosage adjustments or restrictions in moderate to severe renal dysfunction. Canagliflozin has modest effects on the serum lipid profile, some beneficial (increased high-density lipoprotein cholesterol and decreased triglycerides) and others not (increased low-density lipoprotein cholesterol). Most patients treated with canagliflozin also have a modest reduction in blood pressure. The overall effect of canagliflozin on the risk of cardiovascular disease is unknown and will be evaluated in the ongoing CANVAS trial; preliminary cardiovascular safety data suggest no increased risk. Thus, with its unique mechanism of action that is independent of insulin secretion and action, canagliflozin is a useful addition to the therapeutic options available for the management of type 2 diabetes, particularly by providing complementary treatment when used as add-on therapy.
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Affiliation(s)
- Greg L Plosker
- Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore, 0754, Auckland, New Zealand,
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Sasaki T, Seino Y, Fukatsu A, Ubukata M, Sakai S, Samukawa Y. Absence of Drug-Drug Interactions Between Luseogliflozin, a Sodium-Glucose Co-transporter-2 Inhibitor, and Various Oral Antidiabetic Drugs in Healthy Japanese Males. Adv Ther 2015; 32:404-17. [PMID: 25975816 PMCID: PMC4449380 DOI: 10.1007/s12325-015-0209-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Indexed: 01/13/2023]
Abstract
Introduction We investigated the possibilities of drug–drug interactions between luseogliflozin, a sodium–glucose co-transporter-2 inhibitor, and oral antidiabetic drugs (OADs) in healthy Japanese males. Methods We conducted six independent studies to investigate potential drug–drug interactions between 5 mg luseogliflozin and the following OADs usually used in Japan: 1 mg glimepiride, 250 mg metformin, 30 mg pioglitazone, 50 mg sitagliptin, 50 mg miglitol, or 0.6 mg voglibose (0.2 mg before each meal). Twelve subjects were enrolled in each study. The glimepiride, metformin, sitagliptin, and miglitol studies were randomized, open-label, single-dose, three-way crossover studies. The pioglitazone and voglibose studies were open-label studies, where a single dose of luseogliflozin was added to multiple doses of pioglitazone or voglibose. The endpoints were the area under the curve from 0 to 24 h (AUC0–24h) or to infinity (AUCinf) and the maximum concentration (Cmax) of each drug administered alone or in combination. Results The 90% confidence intervals (CIs) of the geometric mean ratio (GMR) for Cmax of luseogliflozin in the pioglitazone and miglitol studies were beyond the reference range for bioequivalence (0.80–1.25) (miglitol: 0.851 [0.761, 0.952]; pioglitazone: 1.16 [1.04, 1.30]). However, the 90% CIs for AUC0–24h were within the reference range. The 90% CIs of the GMRs for Cmax and AUC0–24h of pioglitazone were beyond the reference range (Cmax 0.884 [0.746, 1.05]; AUC0–24h 0.896 [0.774, 1.04]), but the 90% CIs for the active metabolites of pioglitazone were within the reference range. For the other combinations tested, the 90% CIs and GMRs for luseogliflozin and the individual OADs were within the reference range. Conclusion No clinically meaningful interactions were observed between luseogliflozin and six commonly used OADs in Japan, although there were some changes in the pharmacokinetics of pioglitazone co-administered with luseogliflozin and for luseogliflozin co-administered with miglitol or pioglitazone. Funding Taisho Pharmaceutical Co., Ltd. Electronic supplementary material The online version of this article (doi:10.1007/s12325-015-0209-1) contains supplementary material, which is available to authorized users.
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Whalen K, Miller S, Onge ES. The Role of Sodium-Glucose Co-Transporter 2 Inhibitors in the Treatment of Type 2 Diabetes. Clin Ther 2015; 37:1150-66. [PMID: 25891804 DOI: 10.1016/j.clinthera.2015.03.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE Diabetes is a chronic metabolic disorder characterized by hyperglycemia that results from insulin resistance, diminished or absent insulin secretion, or both. Approximately one-half of patients with diabetes fail to achieve acceptable glycemic control. Consequently, morbidity and mortality associated with diabetes is high, resulting from complications such as cardiovascular disease and nephropathy. The sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of medications for the treatment of type 2 diabetes. This article provides an overview of efficacy and safety data for the SGLT2 inhibitors and outlines their role in the management of diabetes. METHODS Relevant articles were identified through searches of PubMed and International Pharmaceutical Abstracts by using the key terms canagliflozin, dapagliflozin, empagliflozin, and sodium-glucose co-transporter 2 inhibitor. A review of bibliographies of retrieved articles was also performed to identify additional references. All identified trials published in English and that involved the efficacy and safety of SGLT2 inhibitors in the treatment of type 2 diabetes were reviewed. FINDINGS The SGLT2 inhibitors improve glucose control by increasing urinary glucose excretion. Effectiveness is decreased in the presence of renal dysfunction. These agents are efficacious as monotherapy and add-on therapy for patients with type 2 diabetes uncontrolled on metformin, sulfonylureas, insulin, and other antihyperglycemic combinations. The SGLT2 inhibitors lower glycosylated hemoglobin by 0.5% to 1% and fasting plasma glucose by ~15 to 35 mg/dL, depending on the agent and the dosage used, and are also associated with modest reductions in weight (-1.5 to -3.5 kg) and systolic blood pressure (-3 to -5 mm Hg). Genital mycotic infections and increased urination, owing to the mechanism of action, are the most common adverse effects. In general, the class is well tolerated, and the risk of hypoglycemia is low. IMPLICATIONS With their unique mechanism of action and good safety and tolerability profiles, the SGLT2 inhibitors are an important addition to existing treatments for type 2 diabetes. Because of the lack of data with this class of drugs when current treatment guidelines for diabetes were published, the SGLT2 inhibitors are recommended as second- or third-line therapies for diabetes. Forthcoming data on the long-term efficacy and safety profile of these agents should help to solidify the role of SGLT2 inhibitors in the management of diabetes.
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Affiliation(s)
- Karen Whalen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, Florida.
| | - Shannon Miller
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando Campus, Orlando, Florida
| | - Erin St Onge
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando Campus, Orlando, Florida
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Hedrington MS, Davis SN. Ipragliflozin, a sodium–glucose cotransporter 2 inhibitor, in the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2015; 11:613-23. [DOI: 10.1517/17425255.2015.1009893] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
SGLT2 inhibition offers a novel mechanism to mitigate hyperglycemia in patients with diabetes and the introduction of SGLT2 has added a significant new tool to the antihyperglycemic armamentarium. At present, 2 agents are approved for use in the United States and several more are in development. SGLT2 inhibitors are generally associated with a reduction in A1C of between 0.5% and 1%. SGLT2 inhibitors are associated with an increased incidence of urinary tract and genital infections but these infections are typically mild, responsive to treatment, and are not use limiting.
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Affiliation(s)
- John R White
- Department of Pharmacotherapy, Washington State University, Health Sciences Building, Suite 210, PO Box 1459, Spokane, WA 99210, USA.
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Maranghi M, Carnovale A, Durante C, Tarquini G, Tiseo G, Filetti S. Pharmacokinetics, pharmacodynamics and clinical efficacy of dapagliflozin for the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2014; 11:125-37. [PMID: 25418019 DOI: 10.1517/17425255.2015.986457] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Dapagliflozin (DAPA) (Farxiga or Forxiga) is a sodium glucose cotransporter 2 (SGLT2) inhibitor approved for type 2 diabetes mellitus(T2DM) treatment. AREAS COVERED The review focuses on the pharmacokinetics (PK), pharmacodynamics(PD) and clinical studies published on DAPA. The authors searched PubMed database for English language studies describing DAPA characteristics and use in T2DM subjects published through June 2014. EXPERT OPINION DAPA exhibits favorable PK and PD properties and is effective in reducing glycemic levels. In addition, DAPA shows beneficial/neutral effects on other risk factors contributing to T2DM metabolic control. Increased risk of genital and urinary infections and episodes of volume depletion represent the major concerns for its use. FDA requires additional data to assess imbalances in bladder cancer and drug cardiovascular safety. The mechanism of action and the very low risk of drug-drug interaction make it an ideal drug for rapidly reducing glucotoxicity and restoring clinical response to other antidiabetic drugs.
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Affiliation(s)
- Marianna Maranghi
- University of Rome "Sapienza", Department of Internal Medicine and Clinical Specialities , V.le del Policlinico, 155, 00161, Rome , Italy +39 0 6 49978301 ; +39 0 6 4463783 ;
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45
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Pharmacokinetic drug interactions are unlikely when sodium–glucose cotransporters type 2 inhibitors are used to treat type 2 diabetes mellitus. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0147-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sodium-Glucose linked transporter 2 (SGLT2) inhibitors--fighting diabetes from a new perspective. Adv Ther 2014; 31:579-91. [PMID: 24972995 DOI: 10.1007/s12325-014-0127-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Indexed: 12/13/2022]
Abstract
Sodium-Glucose linked transporter 2 (SGLT2) inhibitors are a new family of antidiabetic pharmaceutical agents whose action is based on the inhibition of the glucose reabsorption pathway, resulting in glucosuria and a consequent reduction of the blood glucose levels, in patients with type 2 diabetes mellitus. Apart from lowering both fasting and postprandial blood glucose levels, without causing hypoglycemia, SGLT2 inhibitors have also shown a reduction in body weight and the systolic blood pressure. This review paper explores the renal involvement in glucose homeostasis providing also the latest safety and efficacy data for the European Medicines Agency and U.S. Food and Drug Administration approved SGLT2 inhibitors, looking, finally, into the future of this novel antidiabetic category of pharmaceutical agents.
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