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Phillips JA, Taub ME, Bogdanffy MS, Yuan J, Knight B, Smith JD, Ku WW. Mode of Action and Human Relevance Assessment of Male CD-1 Mouse Renal Adenocarcinoma Associated With Lifetime Exposure to Empagliflozin. J Appl Toxicol 2022; 42:1570-1584. [PMID: 35393688 DOI: 10.1002/jat.4329] [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: 12/23/2021] [Revised: 03/30/2022] [Accepted: 04/05/2022] [Indexed: 11/11/2022]
Abstract
Inhibition of sodium-glucose cotransporter-2 (SGLT2) has been shown to be a safe and efficacious approach to support managing Type 2 diabetes. In the 2-year carcinogenicity study with the SGLT2 inhibitor empagliflozin in CD-1 mice, an increased incidence of renal tubular adenomas and carcinomas was identified in the male high-dose group but was not observed in female mice. An integrated review of available nonclinical data was conducted to establish a mode-of-action hypothesis for male mouse-specific tumorigenesis. Five key events were identified through systematic analysis to form the proposed mode-of-action: (1) Background kidney pathology in CD-1 mice sensitizes the strain to (2) pharmacology-related diuretic effects associated with SGLT2 inhibition. (3) In male mice, metabolic demand increases with the formation of a sex- and species-specific empagliflozin metabolite. These features converge to (4) deplete oxidative stress handling reserve, driving (5) constitutive cellular proliferation in male CD-1 mice. The proposed mode of action requires all five key events for empagliflozin to present a carcinogenicity risk in the CD-1 mouse. Considering that empagliflozin is not genotoxic in the standard battery of genotoxicity tests, and not all five key events are present in the context of female mice, rats or humans, nor for other osmotic diuretics or other SGLT2 inhibitors, the observed male mouse renal tumors are not considered relevant to humans.
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Affiliation(s)
- Jonathan A Phillips
- Boehringer Ingelheim Pharmaceuticals, Inc., Nonclinical Drug Safety, Ridgefield, CT
| | - Mitchell E Taub
- Boehringer Ingelheim Pharmaceuticals, Inc., Drug Metabolism and Pharmacokinetics, Ridgefield, CT
| | - Matthew S Bogdanffy
- Boehringer Ingelheim Pharmaceuticals, Inc., Nonclinical Drug Safety, Ridgefield, CT
| | | | - Brian Knight
- Boehringer Ingelheim Pharmaceuticals, Inc., Nonclinical Drug Safety, Ridgefield, CT
| | - James D Smith
- Boehringer Ingelheim Pharmaceuticals, Inc., Nonclinical Drug Safety, Ridgefield, CT
| | - Warren W Ku
- Boehringer Ingelheim Pharmaceuticals, Inc., Nonclinical Drug Safety, Ridgefield, CT
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2
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Belosludtseva NV, Starinets VS, Belosludtsev KN. Effect of Dapagliflozin on the Functioning of Rat Liver Mitochondria In Vitro. Bull Exp Biol Med 2021; 171:601-605. [PMID: 34617185 PMCID: PMC8494602 DOI: 10.1007/s10517-021-05277-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Indexed: 11/15/2022]
Abstract
We studied the effect of a new hypoglycemic compound dapagliflozin on the functioning of rat liver mitochondria. Dapagliflozin in concentrations of 10-20 μM had no effect on the parameters of respiration and oxidative phosphorylation of rat liver mitochondria. Increasing dapagliflozin concentration to 50 μM led to a significant inhibition of mitochondrial respiration in states 3 and 3UDNP. Dapagliflozin in this concentration significantly reduced calcium retention capacity of rat liver mitochondria. These findings indicate a decline in the resistance of rat liver mitochondria to induction of Ca2+-dependent mitochondrial permeability transition pore. In a concentration of 10 μM, dapagliflozin significantly decreases the rate of H2O2 formation in rat liver mitochondria, which attested to an antioxidant effect of this compound. Possible mitochondrion-related mechanisms of the protective action of dapagliflozin on liver cells are discussed.
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Affiliation(s)
- N V Belosludtseva
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Pushchino, Russia
| | - V S Starinets
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Pushchino, Russia
| | - K N Belosludtsev
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Pushchino, Russia.
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3
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Kalaitzoglou E, Fowlkes JL, Popescu I, Thrailkill KM. Diabetes pharmacotherapy and effects on the musculoskeletal system. Diabetes Metab Res Rev 2019; 35:e3100. [PMID: 30467957 PMCID: PMC6358500 DOI: 10.1002/dmrr.3100] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022]
Abstract
Persons with type 1 or type 2 diabetes have a significantly higher fracture risk than age-matched persons without diabetes, attributed to disease-specific deficits in the microarchitecture and material properties of bone tissue. Therefore, independent effects of diabetes drugs on skeletal integrity are vitally important. Studies of incretin-based therapies have shown divergent effects of different agents on fracture risk, including detrimental, beneficial, and neutral effects. The sulfonylurea class of drugs, owing to its hypoglycemic potential, is thought to amplify the risk of fall-related fractures, particularly in the elderly. Other agents such as the biguanides may, in fact, be osteo-anabolic. In contrast, despite similarly expected anabolic properties of insulin, data suggests that insulin pharmacotherapy itself, particularly in type 2 diabetes, may be a risk factor for fracture, negatively associated with determinants of bone quality and bone strength. Finally, sodium-dependent glucose co-transporter 2 inhibitors have been associated with an increased risk of atypical fractures in select populations, and possibly with an increase in lower extremity amputation with specific SGLT2I drugs. The role of skeletal muscle, as a potential mediator and determinant of bone quality, is also a relevant area of exploration. Currently, data regarding the impact of glucose lowering medications on diabetes-related muscle atrophy is more limited, although preclinical studies suggest that various hypoglycemic agents may have either aggravating (sulfonylureas, glinides) or repairing (thiazolidinediones, biguanides, incretins) effects on skeletal muscle atrophy, thereby influencing bone quality. Hence, the therapeutic efficacy of each hypoglycemic agent must also be evaluated in light of its impact, alone or in combination, on musculoskeletal health, when determining an individualized treatment approach. Moreover, the effect of newer medications (potentially seeking expanded clinical indication into the pediatric age range) on the growing skeleton is largely unknown. Herein, we review the available literature regarding effects of diabetes pharmacotherapy, by drug class and/or by clinical indication, on the musculoskeletal health of persons with diabetes.
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Affiliation(s)
- Evangelia Kalaitzoglou
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
| | - John L Fowlkes
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Iuliana Popescu
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kathryn M Thrailkill
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
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4
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Abstract
The important renal tumors that can be induced by exposure of rats to chemical carcinogens are renal tubule tumors (RTTs) derived from tubule epithelium; renal pelvic carcinoma derived from the urothelial lining of the pelvis; renal mesenchymal tumors (RMTs) derived from the interstitial connective tissue; and nephroblastoma derived from the metanephric primordia. However, almost all of our knowledge concerning mechanisms of renal carcinogenesis in the rodent pertains to the adenomas and carcinomas originating from renal tubule epithelium. Currently, nine mechanistic pathways can be identified in either the rat or mouse following chemical exposure. These include direct DNA reactivity, indirect DNA reactivity through free radical formation, multiphase bioactivation involving glutathione conjugation, mitotic disruption, sustained cell proliferation from direct cytotoxicity, sustained cell proliferation by disruption of a physiologic process (alpha 2u-globulin nephropathy), exaggerated pharmacologic response, species-dominant metabolic pathway, and chemical exacerbation of chronic progressive nephropathy. Spontaneous occurrence of RTTs in the rat will be included since one example is a confounder for interpreting kidney tumor results in chemical carcinogenicity studies in rats.
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5
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Edwards A, Bonny O. A model of calcium transport and regulation in the proximal tubule. Am J Physiol Renal Physiol 2018; 315:F942-F953. [PMID: 29846115 PMCID: PMC6230728 DOI: 10.1152/ajprenal.00129.2018] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The objective of this study was to examine theoretically how Ca2+ reabsorption in the proximal tubule (PT) is modulated by Na+ and water fluxes, parathyroid hormone (PTH), Na+-glucose cotransporter (SGLT2) inhibitors, and acetazolamide. We expanded a previously published mathematical model of water and solute transport in the rat PT (Layton AT, Vallon V, Edwards A. Am J Physiol Renal Physiol 308: F1343–F1357, 2015) that did not include Ca2+. Our results indicate that Ca2+ reabsorption in the PT is primarily driven by the transepithelial Ca2+ concentration gradient that stems from water reabsorption, which is itself coupled to Na+ reabsorption. Simulated variations in permeability or transporter activity elicit opposite changes in paracellular and transcellular Ca2+ fluxes, whereas a simulated decrease in filtration rate lowers both fluxes. The model predicts that PTH-mediated inhibition of the apical Na+/H+ exchanger NHE3 reduces Na+ and Ca2+ transport to a similar extent. It also suggests that acetazolamide- and SGLT2 inhibitor-induced calciuria at least partly stems from reduced Ca2+ reabsorption in the PT. In addition, backleak of phosphate (PO4) across tight junctions is predicted to reduce net PO4 reabsorption by ~20% under normal conditions. When transcellular PO4 transport is substantially reduced by PTH, paracellular PO4 flux is reversed and contributes significantly to PO4 reabsorption. Furthermore, PTH is predicted to exert an indirect impact on PO4 reabsorption via its inhibitory action on NHE3. This model thus provides greater insight into the mechanisms that modulate Ca2+ and PO4 reabsorption in the PT.
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Affiliation(s)
- Aurélie Edwards
- Department of Biomedical Engineering, Boston University , Boston, Massachusetts
| | - Olivier Bonny
- Department of Pharmacology and Toxicology, University of Lausanne, and Service of Nephrology, Lausanne University Hospital , Lausanne , Switzerland
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6
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Secker PF, Beneke S, Schlichenmaier N, Delp J, Gutbier S, Leist M, Dietrich DR. Canagliflozin mediated dual inhibition of mitochondrial glutamate dehydrogenase and complex I: an off-target adverse effect. Cell Death Dis 2018; 9:226. [PMID: 29445145 PMCID: PMC5833677 DOI: 10.1038/s41419-018-0273-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 12/23/2022]
Abstract
Recent FDA Drug Safety Communications report an increased risk for acute kidney injury in patients treated with the gliflozin class of sodium/glucose co-transport inhibitors indicated for treatment of type 2 diabetes mellitus. To identify a potential rationale for the latter, we used an in vitro human renal proximal tubule epithelial cell model system (RPTEC/TERT1), physiologically representing human renal proximal tubule function. A targeted metabolomics approach, contrasting gliflozins to inhibitors of central carbon metabolism and mitochondrial function, revealed a double mode of action for canagliflozin, but not for its analogs dapagliflozin and empagliflozin. Canagliflozin inhibited the glutamate dehydrogenase (GDH) and mitochondrial electron transport chain (ETC) complex I at clinically relevant concentrations. This dual inhibition specifically prevented replenishment of tricarboxylic acid cycle metabolites by glutamine (anaplerosis) and thus altered amino acid pools by increasing compensatory transamination reactions. Consequently, canagliflozin caused a characteristic intracellular accumulation of glutamine, glutamate and alanine in confluent, quiescent RPTEC/TERT1. Canagliflozin, but none of the classical ETC inhibitors, induced cytotoxicity at particularly low concentrations in proliferating RPTEC/TERT1, serving as model for proximal tubule regeneration in situ. This finding is testimony of the strong dependence of proliferating cells on glutamine anaplerosis via GDH. Our discovery of canagliflozin-mediated simultaneous inhibition of GDH and ETC complex I in renal cells at clinically relevant concentrations, and their particular susceptibility to necrotic cell death during proliferation, provides a mechanistic rationale for the adverse effects observed especially in patients with preexisting chronic kidney disease or previous kidney injury characterized by sustained regenerative tubular epithelial cell proliferation.
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Affiliation(s)
- Philipp F Secker
- Human and Environmental Toxicology, University of Konstanz, 78457, Konstanz, Germany
| | - Sascha Beneke
- Human and Environmental Toxicology, University of Konstanz, 78457, Konstanz, Germany
| | - Nadja Schlichenmaier
- Human and Environmental Toxicology, University of Konstanz, 78457, Konstanz, Germany
| | - Johannes Delp
- In-vitro Toxicology and Biomedicine, University of Konstanz, 78457, Konstanz, Germany
| | - Simon Gutbier
- In-vitro Toxicology and Biomedicine, University of Konstanz, 78457, Konstanz, Germany
| | - Marcel Leist
- In-vitro Toxicology and Biomedicine, University of Konstanz, 78457, Konstanz, Germany
| | - Daniel R Dietrich
- Human and Environmental Toxicology, University of Konstanz, 78457, Konstanz, Germany.
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7
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Mishima E, Fukuda S, Kanemitsu Y, Saigusa D, Mukawa C, Asaji K, Matsumoto Y, Tsukamoto H, Tachikawa T, Tsukimi T, Fukuda NN, Ho HJ, Kikuchi K, Suzuki C, Nanto F, Suzuki T, Ito S, Soga T, Tomioka Y, Abe T. Canagliflozin reduces plasma uremic toxins and alters the intestinal microbiota composition in a chronic kidney disease mouse model. Am J Physiol Renal Physiol 2017; 315:F824-F833. [PMID: 29167170 DOI: 10.1152/ajprenal.00314.2017] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Accumulation of uremic toxins, which exert deleterious effects in chronic kidney disease, is influenced by the intestinal environment; the microbiota contributes to the production of representative uremic toxins, including p-cresyl sulfate and indoxyl sulfate. Canagliflozin is a sodium-glucose cotransporter (SGLT) 2 inhibitor, and it also exerts a modest inhibitory effect on SGLT1. The inhibition of intestinal SGLT1 can influence the gastrointestinal environment. We examined the effect of canagliflozin on the accumulation of uremic toxins in chronic kidney disease using adenine-induced renal failure mice. Two-week canagliflozin (10 mg/kg po) treatment did not influence the impaired renal function; however, it significantly reduced the plasma levels of p-cresyl sulfate and indoxyl sulfate in renal failure mice (a 75% and 26% reduction, respectively, compared with the vehicle group). Additionally, canagliflozin significantly increased cecal short-chain fatty acids in the mice, suggesting the promotion of bacterial carbohydrate fermentation in the intestine. Analysis of the cecal microbiota showed that canagliflozin significantly altered microbiota composition in the renal failure mice. These results indicate that canagliflozin exerts intestinal effects that reduce the accumulation of uremic toxins including p-cresyl sulfate. Reduction of accumulated uremic toxins by canagliflozin could provide a potential therapeutic option in chronic kidney disease.
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Affiliation(s)
- Eikan Mishima
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
| | - Shinji Fukuda
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan.,Intestinal Microbiota Project, Kanagawa Institute of Industrial Science and Technology , Kawasaki , Japan.,Transborder Medical Research Center, University of Tsukuba , Tsukuba , Japan.,PRESTO, Japan Science and Technology Agency, Kawaguchi, Japan
| | - Yoshitomi Kanemitsu
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Daisuke Saigusa
- Department of Integrative Genomics, Tohoku Medical Megabank Organization, Tohoku University , Sendai , Japan
| | - Chikahisa Mukawa
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Kei Asaji
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Yotaro Matsumoto
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Hiroki Tsukamoto
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Tatsuki Tachikawa
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Tomoya Tsukimi
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | - Noriko N Fukuda
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | - Hsin-Jung Ho
- Department of Medical Science, Tohoku University Graduate School of Biomedical Engineering , Sendai , Japan
| | - Koichi Kikuchi
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
| | - Chitose Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
| | - Fumika Nanto
- Department of Medical Science, Tohoku University Graduate School of Biomedical Engineering , Sendai , Japan
| | - Takehiro Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan
| | - Tomoyoshi Soga
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | - Yoshihisa Tomioka
- Laboratory of Oncology, Pharmacy Practice and Sciences, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Takaaki Abe
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine , Sendai , Japan.,Department of Medical Science, Tohoku University Graduate School of Biomedical Engineering , Sendai , Japan.,Department of Clinical Biology and Hormonal Regulation, Tohoku University Graduate School of Medicine , Sendai , Japan
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8
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Smith JD, Huang Z, Escobar PA, Foppiano P, Maw H, Loging W, Yu H, Phillips JA, Taub M, Ku WW. A Predominant Oxidative Renal Metabolite of Empagliflozin in Male Mice Is Cytotoxic in Mouse Renal Tubular Cells but not Genotoxic. Int J Toxicol 2017; 36:440-448. [PMID: 29130831 DOI: 10.1177/1091581817735090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In a previously reported CD-1 mouse 2-year carcinogenicity study with the sodium glucose cotransporter-2 inhibitor empagliflozin, an increased incidence of renal tubular adenomas and carcinomas was identified only in the male high-dose group. Follow-up investigative studies have shown that the renal tumors in male high-dose mice were preceded by a number of renal degenerative/regenerative findings. Prior cross-species in vitro metabolism studies using microsomes identified an oxidative metabolite (M466/2) predominantly formed in the male mouse kidney and which spontaneously degrades to a metabolite (M380/1) and reactive 4-OH crotonaldehyde (CTA). In order to further evaluate potential modes of action for empagliflozin-associated male mouse renal tumors, we report here a series of in vitro investigative toxicology studies conducted to evaluate the cytotoxic and genotoxic potential of empagliflozin and M466/2. To assess the cytotoxic potential of empagliflozin and M466/2, a primary mouse renal tubular epithelial (mRTE) cell model was used. In mRTE cells, M466/2-derived in vitro 4-OH CTA exposure was cytotoxic, while empagliflozin was not cytotoxic or mitogenic. Empagliflozin and M466/2 were not genotoxic, supporting an indirect mode of action for empagliflozin-associated male mouse renal tumorigenesis. In conclusion, these in vitro data show that M466/2-derived 4-OH CTA exposure is associated with cytotoxicity in renal tubule cells and may be involved in promoting compound-related in vivo renal metabolic stress and chronic low-level renal injury, in turn supporting a nongenotoxic mode of tumor pathogenesis specific to the male mouse.
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Affiliation(s)
- James D Smith
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | - Zimei Huang
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | | | - Pamela Foppiano
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | - Hlaing Maw
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | - William Loging
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | - Hongbin Yu
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | | | - Mitchell Taub
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
| | - Warren W Ku
- 1 Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, USA
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Renal tubular and adrenal medullary tumors in the 2-year rat study with canagliflozin confirmed to be secondary to carbohydrate (glucose) malabsorption in the 15-month mechanistic rat study. Chem Biol Interact 2017; 277:85-90. [PMID: 28916336 DOI: 10.1016/j.cbi.2017.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 08/08/2017] [Accepted: 09/11/2017] [Indexed: 11/23/2022]
Abstract
During preclinical development of canagliflozin, an SGLT2 inhibitor, treatment-related pheochromocytomas, renal tubular tumors (RTT), and testicular Leydig cell tumors were reported in the 2-year rat toxicology study. In a previous 6-month rat mechanistic study, feeding a glucose free diet prevented canagliflozin effects on carbohydrate malabsorption as well as the increase in cell proliferation in adrenal medulla and kidneys, implicating carbohydrate malabsorption as the mechanism for tumor formation. In this chronic study male Sprague-Dawley rats were dosed orally with canagliflozin at high dose-levels (65 or 100 mg/kg/day) for 15 months and received either a standard diet or a glucose-free diet. Canagliflozin-dosed rats on standard diet showed presence of basophilic renal tubular tumors (6/90) and an increased incidence of adrenal medullary hyperplasia (35/90), which was fully prevented by feeding a glucose-free diet (no RTT's; adrenal medullary hyperplasia in ≤5/90). These data further confirm that kidney and adrenal medullary tumors in the 2-year rat study were secondary to carbohydrate (glucose) malabsorption and were not due to a direct effect of canagliflozin on these target tissues.
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Abstract
Diabetes be it type 1 or type 2 is associated with an increased risk of fragility fractures. The mechanisms underlying this increased risk are just being elucidated. Anti-diabetes medications are crucial for maintaining glucose control and for preventing micro- and macrovascular complications in diabetes. However, they may modulate fracture risk in diabetes in different ways. Thiazolidinediones have demonstrated an unfavorable effect on the skeleton, while metformin and sulfonylureas may have a neutral if not beneficial effect on bone. The use of insulin has been associated with an increased risk of fragility fractures though it is not clear whether it is due to direct influence of insulin or whether it is mediated through hypoglycemia and increased falls risk. The overall effect of incretin mimetics appears to be beneficial; however, this has to be elucidated further. The bone effects of pramlintide, a synthetic analog of amylin, have not been explored fully. Finally, issues regarding bone safety of SGLT2 (sodium-dependent glucose transporter 2) inhibitors, the newest anti-diabetic medications on the market are of concern. The purpose of this review is to provide a comprehensive overview of the effect of these medications on bone metabolism and the studies exploring the risk or lack thereof of these medications on bone loss and fragility fractures.
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Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20 College Road, Singapore, 169856, Singapore.
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11
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Blevins TC, Farooki A. Bone effects of canagliflozin, a sodium glucose co-transporter 2 inhibitor, in patients with type 2 diabetes mellitus. Postgrad Med 2016; 129:159-168. [DOI: 10.1080/00325481.2017.1256747] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | - Azeez Farooki
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Alba M, Xie J, Fung A, Desai M. The effects of canagliflozin, a sodium glucose co-transporter 2 inhibitor, on mineral metabolism and bone in patients with type 2 diabetes mellitus. Curr Med Res Opin 2016; 32:1375-85. [PMID: 27046479 DOI: 10.1080/03007995.2016.1174841] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Sodium glucose co-transporter 2 (SGLT2) inhibitors lower blood glucose levels in patients with type 2 diabetes mellitus (T2DM) by increasing urinary glucose excretion. This review provides a comprehensive summary of preclinical and clinical data on the effects of the SGLT2 inhibitor canagliflozin on mineral balance and bone. METHODS Published articles and internal study reports through November 2015 were included. RESULTS In clinical studies, canagliflozin was not associated with meaningful changes in serum or urine calcium, parathyroid hormone, or vitamin D. Canagliflozin was associated with increases in serum magnesium and phosphate without changes in their urinary excretion. Increases in serum collagen type-1 beta-carboxy-telopeptide (beta-CTX), a bone resorption marker, and osteocalcin, a bone formation marker, were observed with canagliflozin. Decreases in total hip bone mineral density (BMD) of up to 1.2% were seen with canagliflozin after 2 years; no changes in BMD were seen at other skeletal sites. Changes in total hip BMD and serum beta-CTX with canagliflozin correlated with decreases in body weight. In a clinical program-wide analysis, canagliflozin was associated with increased fracture risk that was driven by a higher incidence in the cardiovascular safety study (CANVAS), with no fracture imbalance seen in pooled data from other Phase 3 studies. The fracture imbalance occurred within 12 weeks after initiating treatment, most frequently in the distal portion of the upper and lower extremities. CONCLUSIONS Across clinical studies, canagliflozin did not meaningfully affect calcium homeostasis or hormones regulating calcium homeostasis. Increases in bone turnover markers and decreases in BMD at the total hip, but not at other sites, that correlated with weight loss were seen with canagliflozin. Canagliflozin was associated with a higher fracture incidence within 12 weeks, primarily in distal extremities. Data from ongoing canagliflozin studies will provide additional information on fracture risk.
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Affiliation(s)
- Maria Alba
- a Janssen Research & Development, LLC , Raritan , NJ , USA
| | - John Xie
- a Janssen Research & Development, LLC , Raritan , NJ , USA
| | - Albert Fung
- a Janssen Research & Development, LLC , Raritan , NJ , USA
| | - Mehul Desai
- a Janssen Research & Development, LLC , Raritan , NJ , USA
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13
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Bilezikian JP, Watts NB, Usiskin K, Polidori D, Fung A, Sullivan D, Rosenthal N. Evaluation of Bone Mineral Density and Bone Biomarkers in Patients With Type 2 Diabetes Treated With Canagliflozin. J Clin Endocrinol Metab 2016; 101:44-51. [PMID: 26580234 PMCID: PMC4701848 DOI: 10.1210/jc.2015-1860] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Canagliflozin is a sodium glucose cotransporter 2 inhibitor developed to treat type 2 diabetes mellitus (T2DM). OBJECTIVE Our objective is to describe the effects of canagliflozin on bone mineral density (BMD) and bone biomarkers in patients with T2DM. DESIGN This was a randomized study, consisting of a 26-week, double-blind, placebo-controlled period and a 78-week, double-blind, placebo-controlled extension. SETTING This study was undertaken in 90 centers in 17 countries. PATIENTS Patients were aged 55-80 years (N = 716) and whose T2DM was inadequately controlled on a stable antihyperglycemic regimen. INTERVENTIONS Canagliflozin 100 or 300 mg or placebo were administered once daily. OUTCOME AND MEASURES BMD was assessed using dual-energy x-ray absorptiometry at weeks 26, 52, and 104. Bone strength was assessed using quantitative computed tomography and finite element analysis at week 52. Serum collagen type 1 β-carboxy-telopeptide, osteocalcin, and estradiol were assessed at weeks 26 and 52. RESULTS Canagliflozin doses of 100 and 300 mg were associated with a decrease in total hip BMD over 104 weeks, (placebo-subtracted changes: -0.9% and -1.2%, respectively), but not at other sites measured (femoral neck, lumbar spine, or distal forearm). No meaningful changes in bone strength were observed. At week 52, canagliflozin was associated with an increase in collagen type 1 β-carboxy-telopeptide that was significantly correlated with a reduction in body weight, an increase in osteocalcin, and, in women, a decrease in estradiol. CONCLUSIONS In older patients with T2DM, canagliflozin showed small but significant reductions in total hip BMD and increases in bone formation and resorption biomarkers, due at least in part to weight loss.
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
| | - Nelson B Watts
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
| | - Keith Usiskin
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
| | - David Polidori
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
| | - Albert Fung
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
| | - Daniel Sullivan
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
| | - Norm Rosenthal
- Division of Endocrinology (J.P.B.), College of Physicians and Surgeons, Columbia University, New York, New York 10032; Mercy Health Osteoporosis and Bone Health Services (N.B.W.), Cincinnati, Ohio 45236; Janssen Research & Development, LLC (K.U., A.F., D.S., N.R.), Raritan, New Jersey 08869; and Janssen Research & Development, LLC (D.P.), San Diego, California 92121
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Ways K, Johnson MD, Mamidi RNVS, Proctor J, De Jonghe S, Louden C. Successful integration of nonclinical and clinical findings in interpreting the clinical relevance of rodent neoplasia with a new chemical entity. Toxicol Pathol 2014; 43:48-56. [PMID: 25398756 DOI: 10.1177/0192623314557179] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Canagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, has been developed for the treatment of adults with type 2 diabetes mellitus (T2DM). During the phase 3 program, treatment-related pheochromocytomas, renal tubular tumors, and testicular Leydig cell tumors were reported in the 2-year rat toxicology study. Treatment-related tumors were not seen in the 2-year mouse study. A cross-functional, mechanism-based approach was undertaken to determine whether the mechanisms responsible for tumorigenesis in the rat were of relevance to humans. Based on findings from nonclinical and clinical studies, the treatment-related tumors observed in rats were not deemed to be of clinical relevance. Here, we describe the scientific and regulatory journey from learning of the 2-year rat study findings to the approval of canagliflozin for the treatment of T2DM.
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Affiliation(s)
- Kirk Ways
- Janssen Research & Development, LLC, Raritan, New Jersey, USA
| | - Mark D Johnson
- Janssen Research & Development, LLC, Raritan, New Jersey, USA
| | | | - James Proctor
- Janssen Research & Development, LLC, Raritan, New Jersey, USA
| | | | - Calvert Louden
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
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De Jonghe S, Proctor J, Vinken P, Feyen B, Wynant I, Marien D, Geys H, Mamidi RNVS, Johnson MD. Carcinogenicity in rats of the SGLT2 inhibitor canagliflozin. Chem Biol Interact 2014; 224:1-12. [PMID: 25289773 DOI: 10.1016/j.cbi.2014.09.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/29/2014] [Accepted: 09/23/2014] [Indexed: 12/20/2022]
Abstract
The carcinogenicity potential of canagliflozin, an inhibitor of SGLT2, was evaluated in a 2-year rat study (10, 30, and 100 mg/kg). Rats showed an increase in pheochromocytomas, renal tubular tumors, and testicular Leydig cell tumors. Systemic exposure multiples at the highest dose relative to the maximum clinical dose were 12- to 21-fold. Pheochromocytomas and renal tubular tumors were noted in both sexes at 100 mg/kg. Leydig cell tumors were observed in males in all dose groups and were associated with increased luteinizing hormone levels. Hyperplasia was increased in the adrenal medulla at 100 mg/kg, but only a limited increase in simple tubular hyperplasia was observed in the kidney of males at 100 mg/kg. Hyperostosis occurred and was accompanied by substantial effects on calcium metabolism, including increased urinary calcium excretion and decreased levels of calcium regulating hormones (1,25-dihydroxyvitamin D and parathyroid hormone). A separate study with radiolabeled calcium confirmed that increased urinary calcium excretion was mediated via increased calcium absorption from the gastrointestinal tract. It was hypothesized that, at high doses, canagliflozin might have inhibited glucose absorption in the intestine via SGLT1 inhibition that resulted in glucose malabsorption, which increased calcium absorption by stimulating colonic glucose fermentation and reducing intestinal pH. Pheochromocytomas and adrenal medullary hyperplasia were attributed to altered calcium homeostasis, which have a known relationship in the rat. In conclusion, Leydig cell tumors were associated with increased luteinizing hormone levels and pheochromocytomas were most likely related to glucose malabsorption and altered calcium homeostasis. Renal tubular tumors may also have been linked to glucose malabsorption.
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Affiliation(s)
- Sandra De Jonghe
- Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Jim Proctor
- Janssen Research & Development, LLC, 1000 Route 202 South, Raritan, NJ 08869, United States
| | - Petra Vinken
- Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Bianca Feyen
- Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Inneke Wynant
- Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Dirk Marien
- Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Helena Geys
- Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Rao N V S Mamidi
- Janssen Research & Development, LLC, 1000 Route 202 South, Raritan, NJ 08869, United States
| | - Mark D Johnson
- Janssen Research & Development, LLC, 1000 Route 202 South, Raritan, NJ 08869, United States.
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