1
|
Upadhyay A. SGLT2 Inhibitors and Kidney Protection: Mechanisms Beyond Tubuloglomerular Feedback. KIDNEY360 2024; 5:771-782. [PMID: 38523127 PMCID: PMC11146657 DOI: 10.34067/kid.0000000000000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/19/2024] [Indexed: 03/26/2024]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk for kidney failure and are a key component of guideline-directed therapy for CKD. While SGLT2 inhibitors' ability to activate tubuloglomerular feedback and reduce hyperfiltration-mediated kidney injury is considered to be the central mechanism for kidney protection, recent data from experimental studies raise questions on the primacy of this mechanism. This review examines SGLT2 inhibitors' role in tubuloglomerular feedback and summarizes emerging evidence on following of SGLT2 inhibitors' other putative mechanisms for kidney protection: optimization of kidney's energy substrate utilization and delivery, regulation of autophagy and maintenance of cellular homeostasis, attenuation of sympathetic hyperactivity, and improvement in vascular health and microvascular function. It is imperative to examine the effect of SGLT2 inhibition on these different physiologic processes to help our understanding of mechanisms underpinning kidney protection with this important class of drugs.
Collapse
Affiliation(s)
- Ashish Upadhyay
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| |
Collapse
|
2
|
Takeshita Y, Nomura C, Murai H, Mukai Y, Hirai T, Hamaoka T, Tokuno S, Tanaka T, Goto H, Nakano Y, Usui S, Nakajima K, Takamura M, Takamura T. Study Protocol for the Pleiotropic Effects of Sodium-Glucose Cotransporter 2 Inhibitor on Organ-Specific Sympathetic Nerve Activity and Insulin Sensitivity in Participants with Type 2 Diabetes. Diabetes Ther 2024; 15:269-280. [PMID: 37883004 PMCID: PMC10786788 DOI: 10.1007/s13300-023-01497-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION Hyperinsulinemia and hyperglycemia are associated with exaggerated systemic sympathetic nerve activity (SNA) in patients with type 2 diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors lower insulin levels, whereas sulfonylureas increase insulin levels. We will test whether these two classes of antidiabetic agents have different effects on SNA. METHODS The present study is an ongoing, 24-week, one-center (only Kanazawa University Hospital), open-label, randomized, parallel trial (jRCTs 041200035). Participants with type 2 diabetes with multiple atherosclerosis risk factors are randomly assigned in a 1:1 manner to receive 2.5 mg luseogliflozin or 0.5 mg glimepiride once daily. The sample size was calculated to be 14 in each group, with a significance level of 0.05 and a power of 0.80. The design required 40 evaluable study participants. Our primary endpoint will be the change in muscle SNA (MSNA). The secondary endpoints included organ-specific insulin sensitivity measured by a hyperinsulinemic-euglycemic clamp study using an artificial pancreas combined with a stable isotope-labeled glucose infusion, bioelectrical impedance analysis, and organ-specific (cardiac, renal, and hepatic) 123I-meta-iodobenzylguanidine (MIBG) innervation imaging. PLANNED OUTCOMES Study recruitment started in April 2020 and will end in June 2024, with 40 participants randomized into the two groups. The treatment follow-up of the participants is currently ongoing and is due to finish by March 2025. TRIAL REGISTRATION The study protocol has been approved by the Certified Review Board, Kanazawa University, Ishikawa, Japan, in accordance with the guidelines stipulated in the Declaration of Helsinki (CRB4180005, 2019-001). This trial is registered with the Japan Registry of Clinical Trials, jRCTs 041200035.
Collapse
Affiliation(s)
- Yumie Takeshita
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Chiaki Nomura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hisayoshi Murai
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yusuke Mukai
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Tadayuki Hirai
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Takuto Hamaoka
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Shota Tokuno
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Takeo Tanaka
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hisanori Goto
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yujiro Nakano
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
- Department of Comprehensive Metabology, Kanazawa University Graduate School of Medical Sciences, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
| |
Collapse
|
3
|
Tawhari MH, Aldahash RA, Almutairi FM, Albogami MS, Rokon AE, Alsomali FA, Alanazi KH, Alshehri AA, Almutairi TH, Alharbi AD, Alghamdi RM, Tawhari IH, Salih SAB. Impact of sodium-glucose cotransporter-2 inhibitors on kidney outcomes in type 2 diabetes: A tertiary center experience. J Family Community Med 2023; 30:267-272. [PMID: 38044971 PMCID: PMC10688587 DOI: 10.4103/jfcm.jfcm_111_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/12/2023] [Accepted: 08/05/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Diabetic nephropathy (DN) is a complication of chronic hyperglycemia associated with diabetes mellitus (DM). Several studies have demonstrated the positive impact of sodium-glucose cotransporter-2 (SGLT2) inhibitors on kidney outcomes. The objective of the study was to evaluate the effects of dapagliflozin, an SGLT2 inhibitor, on kidney outcomes in Saudi patients with type 2 DM. MATERIALS AND METHODS Study included all Saudi patients with type 2 DM who visited our center from August 1, 2021, to July 31, 2022, and had been on dapagliflozin for at least 3 months. Data was abstracted through chart review for all patients included in the study. Paired t-test or Wilcoxon signed-rank test were used to compare the results before and after treatment for continuous variables and the McNemar test was used to compare the results for categorical data. RESULTS Study included 184 Saudi patients with type 2 diabetes with a mean age of 61.32 years (SD=9.37). Dapagliflozin 10 mg/day significantly reduced hemoglobin A1C (HbA1C) from a mean (SD) of 9.00 to 8.40 (P < 0.001). Among a subgroup of patients with significant proteinuria (n = 83), dapagliflozin significantly reduced ACR from a median of 93.1 to 64.9 mg/g (P = 0.001). Following treatment, the estimated glomerular filtration rate improved from a mean of 69.83 to 71.68 mL/min and the mean arterial pressure (MAP) fell from 90.03 to 89.06 mmHg, both were not statistically significant. Despite a statistically insignificant increase in the episodes of urinary tract infections (UTIs), the hospitalization rate declined. No episodes of amputations or ketoacidosis occurred during the study period. CONCLUSION SGLT2 inhibitors had beneficial effects among Saudi patients with type 2 diabetes by improving diabetic control and lowering proteinuria. Dapagliflozin did not result in significant harm, including UTIs, amputations, and ketoacidosis.
Collapse
Affiliation(s)
- Mohammed H. Tawhari
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Medicine, Division of Nephrology, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Raed A. Aldahash
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Medicine, Division of Endocrinology, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Faisal M. Almutairi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mahdi S. Albogami
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ahmad E. Rokon
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Faisal A. Alsomali
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Khaled H. Alanazi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman A. Alshehri
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Talal H. Almutairi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman D. Alharbi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rayan M. Alghamdi
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ibrahim H. Tawhari
- Department of Internal Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Salih A. Bin Salih
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Ministry of the National Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| |
Collapse
|
4
|
van Poelgeest EP, Handoko ML, Muller M, van der Velde N. Diuretics, SGLT2 inhibitors and falls in older heart failure patients: to prescribe or to deprescribe? A clinical review. Eur Geriatr Med 2023; 14:659-674. [PMID: 36732414 PMCID: PMC10447274 DOI: 10.1007/s41999-023-00752-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Both heart failure and its treatment with diuretics or SGLT2 inhibitors increase fall risk in older adults. Therefore, decisions to continue or deprescribe diuretics or SGLT2 inhibitors in older heart failure patients who have fallen are generally highly complex and challenging for clinicians. However, a comprehensive overview of information required for rationale and safe decision-making is lacking. The aim of this clinical review was to assist clinicians in safe (de)prescribing of these drug classes in older heart failure patients. METHODS We comprehensively searched and summarized published literature and international guidelines on the efficacy, fall-related safety issues, and deprescribing of the commonly prescribed diuretics and SGLT2 inhibitors in older adults. RESULTS Both diuretics and SGLT2 inhibitors potentially cause various fall-related adverse effects. Their fall-related side effect profiles partly overlap (e.g., tendency to cause hypotension), but there are also important differences; based on the currently available evidence of this relatively new drug class, SGLT2 inhibitors seem to have a favorable fall-related adverse effect profile compared to diuretics (e.g., low/absent tendency to cause hyperglycemia or electrolyte abnormalities, low risk of worsening chronic kidney disease). In addition, SGLT2 inhibitors have potential beneficial effects (e.g., disease-modifying effects in heart failure, renoprotective effects), whereas diuretic effects are merely symptomatic. CONCLUSION (De)prescribing diuretics and SGLT2 inhibitors in older heart failure patients who have fallen is often highly challenging, but this clinical review paper assists clinicians in individualized and patient-centered rational clinical decision-making: we provide a summary of available literature on efficacy and (subclass-specific) safety profiles of diuretics and SGLT2 inhibitors, and practical guidance on safe (de)prescribing of these drugs (e.g. a clinical decision tree for deprescribing diuretics in older adults who have fallen).
Collapse
Affiliation(s)
- Eveline P van Poelgeest
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centers, De Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Majon Muller
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Institute, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine/Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| |
Collapse
|
5
|
Hsu CN, Hsuan CF, Liao D, Chang JKJ, Chang AJW, Hee SW, Lee HL, Teng SIF. Anti-Diabetic Therapy and Heart Failure: Recent Advances in Clinical Evidence and Molecular Mechanism. Life (Basel) 2023; 13:1024. [PMID: 37109553 PMCID: PMC10144651 DOI: 10.3390/life13041024] [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: 02/09/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Diabetic patients have a two- to four-fold increase in the risk of heart failure (HF), and the co-existence of diabetes and HF is associated with poor prognosis. In randomized clinical trials (RCTs), compelling evidence has demonstrated the beneficial effects of sodium-glucose co-transporter-2 inhibitors on HF. The mechanism includes increased glucosuria, restored tubular glomerular feedback with attenuated renin-angiotensin II-aldosterone activation, improved energy utilization, decreased sympathetic tone, improved mitochondria calcium homeostasis, enhanced autophagy, and reduced cardiac inflammation, oxidative stress, and fibrosis. The RCTs demonstrated a neutral effect of the glucagon-like peptide receptor agonist on HF despite its weight-reducing effect, probably due to it possibly increasing the heart rate via increasing cyclic adenosine monophosphate (cAMP). Observational studies supported the markedly beneficial effects of bariatric and metabolic surgery on HF despite no current supporting evidence from RCTs. Bromocriptine can be used to treat peripartum cardiomyopathy by reducing the harmful cleaved prolactin fragments during late pregnancy. Preclinical studies suggest the possible beneficial effect of imeglimin on HF through improving mitochondrial function, but further clinical evidence is needed. Although abundant preclinical and observational studies support the beneficial effects of metformin on HF, there is limited evidence from RCTs. Thiazolidinediones increase the risk of hospitalized HF through increasing renal tubular sodium reabsorption mediated via both the genomic and non-genomic action of PPARγ. RCTs suggest that dipeptidyl peptidase-4 inhibitors, including saxagliptin and possibly alogliptin, may increase the risk of hospitalized HF, probably owing to increased circulating vasoactive peptides, which impair endothelial function, activate sympathetic tones, and cause cardiac remodeling. Observational studies and RCTs have demonstrated the neutral effects of insulin, sulfonylureas, an alpha-glucosidase inhibitor, and lifestyle interventions on HF in diabetic patients.
Collapse
Affiliation(s)
- Chih-Neng Hsu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
| | - Chin-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung 824, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 840, Taiwan
| | - Daniel Liao
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Jack Keng-Jui Chang
- Biological Programs for Younger Scholar, Academia Sinica, Taipei 115, Taiwan
| | - Allen Jiun-Wei Chang
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Siow-Wey Hee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Hsiao-Lin Lee
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Sean I. F. Teng
- Department of Cardiology, Ming-Sheng General Hospital, Taoyuan 330, Taiwan
| |
Collapse
|
6
|
Sardu C, Massimo Massetti M, Rambaldi P, Gatta G, Cappabianca S, Sasso FC, Santamaria M, Volpicelli M, Ducceschi V, Signoriello G, Paolisso G, Marfella R. SGLT2-inhibitors reduce the cardiac autonomic neuropathy dysfunction and vaso-vagal syncope recurrence in patients with type 2 diabetes mellitus: the SCAN study. Metabolism 2022; 137:155243. [PMID: 35732222 DOI: 10.1016/j.metabol.2022.155243] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/02/2022] [Accepted: 06/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients with type 2 diabetes mellitus (T2DM) the vaso-vagal syncope (VVS) recurrence could be due to the alteration of autonomic system function, evaluated by heart rate variability (HRV), and by 123I-metaiodobenzylguanidine (123I-mIBG) myocardial scintigraphy indexes: Heart to Mediastinum ratio (H/Mlate), and Washout rate (WR). The SGLT2-I could modulate/reduce autonomic dysfunction in T2DM patients with VVS. This effect could reduce the VVS recurrence in T2DM patients. METHODS In a prospective multicenter study, after propensity score matching, we studied a population of 324 T2DM patients with VVS, divided into 161 SGLT2-I-users vs. 163 Non-SGLT2-I users. In these patients as SGLT2-I-users vs. Non-SGLT2-I users, we investigated the HRV and 123I-MIBG modifications and VVS recurrence at 12 months of follow-up. RESULTS At follow-up end, the SGLT2-I-users vs. Non-SGLT2-I users had best glucose homeostasis and lower values of inflammatory markers, and resting heart rate (p < 0.05). The SGLT2-I-users vs. Non-SGLT2-I users evidenced the lowest low frequency/high frequency ratio (LF/HFr), a significant difference for all the indexes of autonomic dysfunction via ECG Holter analysis, and higher values of H/Mlate (p < 0.05). Finally, comparing SGLT2-I-users vs. Non-SGLT2-I users, we found a higher rate of VVS recurrence events, specifically of the vasodepressor VVS recurrence at 1-year follow-up (p < 0.05). We did not find a significant difference of mixed and cardio-inhibitory VVS recurrence events at 1 year of follow-up in the study cohorts (p > 0.05). At the Cox regression analysis H/Mlate (0.710, [0.481-0.985]), and SGLT2-I therapy (0.550, [0.324-0.934]) predicted all causes of syncope recurrence at 1 year of follow-up. CONCLUSIONS Non-SGLT2-I users vs. SGLT2-I-users had alterations of the autonomic nervous system, with a higher rate of VVS recurrence at 1 year of follow-up. The indexes of cardiac denervation predicted the VVS recurrence, while the SGLT2-I reduced the risk of VVS recurrence. CLINICAL TRIAL REGISTRATION NUMBER NCT03717207.
Collapse
Affiliation(s)
- Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - M Massimo Massetti
- Cardiovascular and Arrhythmias Department "Gemelli Molise", Campobasso, Italy; Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Pietro Rambaldi
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Gianluca Gatta
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Matteo Santamaria
- Cardiovascular and Arrhythmias Department "Gemelli Molise", Campobasso, Italy.
| | - Mario Volpicelli
- Cardiovascular Diseases and Electrophysiology Unit, "S. Maria della Pietà Hospital", Naples, Italy
| | - Valentino Ducceschi
- Cardiovascular Diseases and Electrophysiology Unit, "Vecchio Pellegrini Hospital", Naples, Italy
| | - Giuseppe Signoriello
- Department of Mental Health, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; "Mediterranea Cardiocentro", Naples, Italy.
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; "Mediterranea Cardiocentro", Naples, Italy.
| |
Collapse
|
7
|
Kim HK, Ishizawa R, Fukazawa A, Wang Z, Bezan Petric U, Hu MC, Smith SA, Mizuno M, Vongpatanasin W. Dapagliflozin Attenuates Sympathetic and Pressor Responses to Stress in Young Prehypertensive Spontaneously Hypertensive Rats. Hypertension 2022; 79:1824-1834. [PMID: 35652337 PMCID: PMC9308730 DOI: 10.1161/hypertensionaha.122.19177] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND SGLT2i (sodium-glucose cotransporter 2 inhibitor), a class of anti-diabetic medications, is shown to reduce blood pressure (BP) in hypertensive patients with type 2 diabetes. Mechanisms underlying this action are unknown but SGLT2i-induced sympathoinhibition is thought to play a role. Whether SGLT2i reduces BP and sympathetic nerve activity (SNA) in a nondiabetic prehypertension model is unknown. METHODS Accordingly, we assessed changes in conscious BP using radiotelemetry and alterations in mean arterial pressure and renal SNA during simulated exercise in nondiabetic spontaneously hypertensive rats during chronic administration of a diet containing dapagliflozin (0.5 mg/kg per day) versus a control diet. RESULTS We found that dapagliflozin had no effect on fasting blood glucose, insulin, or hemoglobin A1C levels. However, dapagliflozin reduced BP in young (8-week old) spontaneously hypertensive rats as well as attenuated the age-related rise in BP in adult spontaneously hypertensive rat up to 17-weeks of age. The rises in mean arterial pressure and renal SNA during simulated exercise (exercise pressor reflex activation by hindlimb muscle contraction) were significantly reduced after 4 weeks of dapagliflozin (Δmean arterial pressure: 10±7 versus 25±14 mm Hg, Δrenal SNA: 31±17% versus 68±39%, P<0.05). Similarly, rises in mean arterial pressure and renal SNA during mechanoreflex stimulation by passive hindlimb stretching were also attenuated by dapagliflozin. Heart weight was significantly decreased in dapagliflozin compared with the control group. CONCLUSIONS These data demonstrate a novel role for SGLT2i in reducing resting BP as well as the activity of skeletal muscle reflexes, independent of glycemic control. Our study may have important clinical implications for preventing hypertension and hypertensive heart disease in young prehypertensive individuals.
Collapse
Affiliation(s)
- Han-Kyul Kim
- Departments of Internal Medicine-Hypertension Section (H.-K.K., Z.W., U.B.P., W.V.), University of Texas Southwestern Medical Center, Dallas, TX.,Applied Clinical Research (H.-K.K., R.I., A.F., S.A.S., M.M.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Rie Ishizawa
- Applied Clinical Research (H.-K.K., R.I., A.F., S.A.S., M.M.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Ayumi Fukazawa
- Applied Clinical Research (H.-K.K., R.I., A.F., S.A.S., M.M.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Zhongyun Wang
- Departments of Internal Medicine-Hypertension Section (H.-K.K., Z.W., U.B.P., W.V.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Ursa Bezan Petric
- Departments of Internal Medicine-Hypertension Section (H.-K.K., Z.W., U.B.P., W.V.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Ming Chang Hu
- Internal Medicine-Renal Division (M.C.H.), University of Texas Southwestern Medical Center, Dallas, TX.,Pak Center of Mineral Metabolism and Clinical Research (M.C.H., W.V.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Scott A Smith
- Applied Clinical Research (H.-K.K., R.I., A.F., S.A.S., M.M.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Masaki Mizuno
- Applied Clinical Research (H.-K.K., R.I., A.F., S.A.S., M.M.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Wanpen Vongpatanasin
- Departments of Internal Medicine-Hypertension Section (H.-K.K., Z.W., U.B.P., W.V.), University of Texas Southwestern Medical Center, Dallas, TX.,Pak Center of Mineral Metabolism and Clinical Research (M.C.H., W.V.), University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
8
|
Lim VG, He H, Lachlan T, Ng GA, Kyrou I, Randeva HS, Osman F. Impact of sodium-glucose co-transporter inhibitors on cardiac autonomic function and mortality: no time to die. Europace 2022; 24:1052-1057. [PMID: 35080624 DOI: 10.1093/europace/euab321] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/14/2021] [Indexed: 01/08/2023] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to improve cardiovascular outcomes not only in patients with diabetes but also in those with heart failure, irrespective of diabetic status. However, the mechanisms underlying the cardioprotective effects of these newer anti-diabetic drugs remain to be fully elucidated. One exciting avenue that has been recently explored in both preclinical and clinical studies is the modulation of the cardiovascular autonomic nervous system. A reduction in sympathetic nervous system activity by SGLT2 inhibitors may potentially translate into a reduction in arrhythmic risk and sudden arrhythmic death, which may explain, at least partly, the cardioprotection shown in the cardiovascular outcome trials with different SGLT2 inhibitors. Although some of the data from the preclinical and clinical studies are promising, overall the findings can be contradictory. This highlights the need for more studies to address gaps in our knowledge of these novel drugs. The present review offers an in depth overview of the existing literature regarding the role of SGLT2 inhibitors in modulating cardiovascular autonomic function as one of the possible pathways of their cardioprotective effects.
Collapse
Affiliation(s)
- Ven Gee Lim
- Department of Cardiology, University Hospital Coventry, Clifford Bridge Road, Coventry CV2 2DX, UK.,Warwick Medical School, University of Warwick, Gibbet Hill Rd, Coventry CV4 7HL, UK
| | - Hejie He
- Department of Cardiology, University Hospital Coventry, Clifford Bridge Road, Coventry CV2 2DX, UK.,Warwick Medical School, University of Warwick, Gibbet Hill Rd, Coventry CV4 7HL, UK
| | - Thomas Lachlan
- Department of Cardiology, University Hospital Coventry, Clifford Bridge Road, Coventry CV2 2DX, UK.,Warwick Medical School, University of Warwick, Gibbet Hill Rd, Coventry CV4 7HL, UK
| | - Ghulam Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital Leicester, Leicester LE3 9QP, UK
| | - Ioannis Kyrou
- Warwick Medical School, University of Warwick, Gibbet Hill Rd, Coventry CV4 7HL, UK.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK.,Centre for Sport, Exercise and Life Sciences, Research Institute for Health & Wellbeing, Coventry University, Coventry CV1 5FB, UK.,Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
| | - Harpal S Randeva
- Warwick Medical School, University of Warwick, Gibbet Hill Rd, Coventry CV4 7HL, UK.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK.,Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
| | - Faizel Osman
- Department of Cardiology, University Hospital Coventry, Clifford Bridge Road, Coventry CV2 2DX, UK.,Warwick Medical School, University of Warwick, Gibbet Hill Rd, Coventry CV4 7HL, UK
| |
Collapse
|
9
|
Lingli X, Wenfang X. Characteristics and molecular mechanisms through which SGLT2 inhibitors improve metabolic diseases: A mechanism review. Life Sci 2022; 300:120543. [PMID: 35421452 DOI: 10.1016/j.lfs.2022.120543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/26/2022]
Abstract
Metabolic diseases, such as diabetes, gout and hyperlipidemia are global health challenges. Among them, diabetes has been extensively investigated. Type 2 diabetes mellitus (T2DM), which is characterized by hyperglycemia, is a complex metabolic disease that is associated with various metabolic disorders. The newly developed oral hypoglycemic agent, sodium-glucose cotransporter 2 (SGLT2) inhibitor, has been associated with glucose-lowering effects and it affects metabolism in various ways. However, the potential mechanisms of SGLT2 inhibitors in metabolic diseases have not fully reviewed. Many of the effects beyond glycemic control must be considered off-target effects. Therefore, we reviewed the effects of SGLT2 inhibition on metabolic diseases such as obesity, hypertension, hyperlipidemia, hyperuricemia, fatty liver disease, insulin resistance, osteoporosis and fractures. Moreover, we elucidated their molecular mechanisms to provide a theoretical basis for metabolic disease treatment.
Collapse
Affiliation(s)
- Xie Lingli
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Xia Wenfang
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China.
| |
Collapse
|
10
|
Tang J, Ye L, Yan Q, Zhang X, Wang L. Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Water and Sodium Metabolism. Front Pharmacol 2022; 13:800490. [PMID: 35281930 PMCID: PMC8905496 DOI: 10.3389/fphar.2022.800490] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/24/2022] [Indexed: 12/19/2022] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors exert hypoglycemic and diuretic effects by inhibiting the absorption of sodium and glucose from the proximal tubule. Currently available data indicate that SGLT2 inhibitors transiently enhance urinary sodium excretion and urinary volume. When combined with loop diuretics, SGLT2 inhibitors exert a synergistic natriuretic effect. The favorable diuretic profile of SGLT2 inhibitors may confer benefits to volume management in patients with heart failure but this natriuretic effect may not be the dominant mechanism for the superior long-term outcomes observed with these agents in patients with heart failure. The first part of this review explores the causes of transient natriuresis and the diuretic mechanisms of SGLT2 inhibitors. The second part provides an overview of the synergistic effects of combining SGLT2 inhibitors with loop diuretics, and the third part summarizes the mechanisms of cardiovascular protection associated with the diuretic effects of SGLT2 inhibitors.
Collapse
Affiliation(s)
- Jun Tang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lifang Ye
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Qiqi Yan
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xin Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lihong Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| |
Collapse
|
11
|
Targeting Features of the Metabolic Syndrome Through Sympatholytic Effects of SGLT2 Inhibition. Curr Hypertens Rep 2022; 24:67-74. [PMID: 35235172 PMCID: PMC8942945 DOI: 10.1007/s11906-022-01170-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The moderate glucose-lowering effect of sodium glucose co-transporter 2 (SGLT2) inhibitors is unlikely to explain SGLT2 inhibitor-mediated beneficial outcomes, and unravelling the underlying mechanisms is a high priority in the research community. Given the dominant pathophysiologic role of the sympathetic nervous system activation in conditions such as hypertension and perturbed glucose homeostasis, it is pertinent to postulate that SGLT2 inhibitors may exert their beneficial effects at least in part via sympathetic inhibition. RECENT FINDINGS SGLT2 inhibitors have shown enormous potential to improve cardiovascular outcomes in patients with type 2 diabetes, and their therapeutic potential is currently being investigated in a range of associated comorbidities such as heart failure and chronic kidney disease. Indeed, recent experimental data in relevant animal models highlight a bidirectional interaction between sympathetic nervous system activation and SGLT2 expression, and this facilitates several of the features associated with SGLT2 inhibition observed in clinical trials including improved glucose metabolism, weight loss, increased diuresis, and lowering of blood pressure. Currently available data highlight the various levels of interaction between the sympathetic nervous system and SGLT2 expression and explores the potential for SGLT2 inhibition as a therapeutic strategy in conditions commonly characterised by sympathetic activation.
Collapse
|
12
|
Sato D, Nakamura T, Amarume J, Yano M, Nishina A, Feng Z, Kusunoki M. Effects of dapagliflozin on peripheral sympathetic nerve activity in standard chow- and high-fat-fed rats after a glucose load. J Pharmacol Sci 2022; 148:86-92. [PMID: 34924134 DOI: 10.1016/j.jphs.2021.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
To clarify the effects of long-term administration of SGLT2 inhibitor, a hypoglycemic agent, on basal sympathetic nerve activity (SNA) and on SNA under development of insulin resistance, we measured peripheral SNA in response to a glucose load in standard chow- (SCF) and high-fat-fed (HFF) rats treated with or without dapagliflozin for 7 weeks. We conducted an intravenous glucose administration (IVGA), and evaluated SNA microneurographically recorded in the unilateral sciatic nerve. Dapagliflozin did not affect the steady state action potential (AP) rate just before the IVGA (baseline) in both the SCF and HFF rats. After the IVGA, in the SCF rats, the AP rate in dapagliflozin-treated group transiently decreased within 20 min after the IVGA, and was significantly lower (P < 0.05) than non-treated group for 60 min. In the HFF rats, no significant difference was seen in the AP rate between dapagliflozin-treated and non-treated groups. The rate in the dapagliflozin-treated group after the IVGA was significantly lower (P < 0.05) than the baseline whereas such difference was not found in the non-treated group. In conclusion, dapagliflozin attenuate SNA in response to glucose load, and that the SNA response is different between standard chow-fed- and high-fat-fed rats.
Collapse
Affiliation(s)
- Daisuke Sato
- Department of Biochemical Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16 Johnan, Yonezawa 992-8510, Japan.
| | - Takao Nakamura
- Department of Biomedical Information Engineering, Graduate School of Medical Science, Yamagata University, 2-2-2 Iida-nishi, Yamagata 990-9585, Japan
| | - Jota Amarume
- Department of Bio-Systems Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16 Johnan, Yonezawa 992-8510, Japan
| | - Mizuna Yano
- Department of Bio-Systems Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16 Johnan, Yonezawa 992-8510, Japan
| | - Atsuyoshi Nishina
- Department of Materials and Applied Chemistry, College of Science and Technology, Nihon University, 1-8-14 Kandasurugadai, Chiyoda-ku, 101-8308, Japan
| | - Zhonggang Feng
- Department of Bio-Systems Engineering, Graduate School of Science and Engineering, Yamagata University, 4-3-16 Johnan, Yonezawa 992-8510, Japan
| | - Masataka Kusunoki
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Furo-cho, Chikusa-ku, Nagoya 464-8601, Japan
| |
Collapse
|
13
|
Takada S, Sabe H, Kinugawa S. Treatments for skeletal muscle abnormalities in heart failure: sodium-glucose transporter 2 and ketone bodies. Am J Physiol Heart Circ Physiol 2021; 322:H117-H128. [PMID: 34860594 DOI: 10.1152/ajpheart.00100.2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Various skeletal muscle abnormalities are known to occur in heart failure (HF), and are closely associated with exercise intolerance. Particularly, abnormal energy metabolism caused by mitochondrial dysfunction in skeletal muscle is a cause of decreased endurance exercise capacity. However, to date, no specific drug treatment has been established for the skeletal muscle abnormalities and exercise intolerance occurring in HF patients. Sodium-glucose transporter 2 (SGLT2) inhibitors promote glucose excretion by suppressing glucose reabsorption in the renal tubules, which has a hypoglycemic effect independent of insulin secretion. Recently, large clinical trials have demonstrated that treatment with SGLT2 inhibitors suppresses cardiovascular events in patients who have HF with systolic dysfunction. Mechanisms of the therapeutic effects of SGLT2 inhibitors for HF have been suggested to be diuretic, suppression of neurohumoral factor activation, renal protection, and improvement of myocardial metabolism, but has not been clarified to date. SGLT2 inhibitors are known to increase blood ketone bodies. This suggests that they may improve the abnormal skeletal muscle metabolism in HF, i.e., improve fatty acid metabolism, suppress glycolysis, and utilize ketone bodies in mitochondrial energy production. Ultimately, they may improve aerobic metabolism in skeletal muscle, and suppress anaerobic metabolism and improve aerobic exercise capacity at the level of the anaerobic threshold. The potential actions of such SGLT2 inhibitors explain their effectiveness in HF, and may be candidates for new drug treatments aimed at improving exercise intolerance. In this review, we outlined the effects of SGLT2 inhibitors on skeletal muscle metabolism, with a particular focus on ketone metabolism.
Collapse
Affiliation(s)
- Shingo Takada
- Department of Sports Education, Faculty of Lifelong Sport, Hokusho University, Ebetsu, Hokkaido, Japan
| | - Hisataka Sabe
- Department of Molecular Biology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shintaro Kinugawa
- Department of Experimental and Clinical Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| |
Collapse
|
14
|
Abstract
Sodium glucose cotransporter 2 (SGLT-2) inhibitors are the latest class of antidiabetic medications. They prevent glucose reabsorption in the proximal convoluted tubule to decrease blood sugar. Several animal studies revealed that SGLT-2 is profoundly involved in the inflammatory response, fibrogenesis, and regulation of numerous intracellular signaling pathways. Likewise, SGLT-2 inhibitors markedly attenuated inflammation and fibrogenesis and improved the function of damaged organ in animal studies, observational studies, and clinical trials. SGLT-2 inhibitors can decrease blood pressure and ameliorate hypertriglyceridemia and obesity. Likewise, they improve the outcome of cardiovascular diseases such as heart failure, arrhythmias, and ischemic heart disease. SGLT-2 inhibitors are associated with lower cardiovascular and all-cause mortality as well. Meanwhile, they protect against nonalcoholic fatty liver disease (NAFLD), chronic kidney disease, acute kidney injury, and improve micro- and macroalbuminuria. SGLT-2 inhibitors can reprogram numerous signaling pathways to improve NAFLD, cardiovascular diseases, and renal diseases. For instance, they enhance lipolysis, ketogenesis, mitochondrial biogenesis, and autophagy while they attenuate the renin-angiotensin-aldosterone system, lipogenesis, endoplasmic reticulum stress, oxidative stress, apoptosis, and fibrogenesis. This review explains the beneficial effects of SGLT-2 inhibitors on NAFLD and cardiovascular and renal diseases and dissects the underlying molecular mechanisms in detail. This narrative review explains the beneficial effects of SGLT-2 inhibitors on NAFLD and cardiovascular and renal diseases using the results of latest observational studies, clinical trials, and meta-analyses. Thereafter, it dissects the underlying molecular mechanisms involved in the clinical effects of SGLT-2 inhibitors on these diseases.
Collapse
Affiliation(s)
- Moein Ala
- School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| |
Collapse
|
15
|
Hamaoka T, Murai H, Hirai T, Sugimoto H, Mukai Y, Inoue O, Takashima S, Kato T, Takata S, Usui S, Sakata K, Kawashiri MA, Takamura M. Different Responses of Muscle Sympathetic Nerve Activity to Dapagliflozin Between Patients With Type 2 Diabetes With and Without Heart Failure. J Am Heart Assoc 2021; 10:e022637. [PMID: 34719241 PMCID: PMC8751957 DOI: 10.1161/jaha.121.022637] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Sodium-glucose cotransporter 2 inhibitors improve cardiovascular outcomes in patients with diabetes with and without heart failure (HF). However, their influence on sympathetic nerve activity (SNA) remains unclear. The purpose of this study was to evaluate the effect of sodium-glucose cotransporter 2 inhibitors on SNA and compare the responses of SNA to sodium-glucose cotransporter 2 inhibitors in patients with type 2 diabetes with and without HF. Methods and Results Eighteen patients with type 2 diabetes, 10 with HF (65.4±3.68 years) and 8 without HF (63.3±3.62 years), were included. Muscle SNA (MSNA), heart rate, and blood pressure were recorded before and 12 weeks after administration of dapagliflozin (5 mg/day). Sympathetic and cardiovagal baroreflex sensitivity were simultaneously calculated. Brain natriuretic peptide level increased significantly at baseline in patients with HF than those without HF, while MSNA, blood pressure, and hemoglobin A1c did not differ between the 2 groups. Fasting blood glucose and homeostatic model assessment of insulin resistance did not change in either group after administering dapagliflozin. MSNA decreased significantly in both groups. However, the reduction in MSNA was significantly higher in patients with HF than patients with non-HF (-20.2±3.46 versus -9.38±3.65 bursts/100 heartbeats; P=0.049), which was concordant with the decrease in brain natriuretic peptide. Conclusions Dapagliflozin significantly decreased MSNA in patients with type 2 diabetes regardless of its blood glucose-lowering effect. Moreover, the reduction in MSNA was more prominent in patients with HF than in patients with non-HF. These results indicate that the cardioprotective effects of sodium-glucose cotransporter 2 inhibitors may, in part, be attributed to improved SNA.
Collapse
Affiliation(s)
- Takuto Hamaoka
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Hisayoshi Murai
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan.,Kanazawa Municipal Hospital Kanazawa Japan
| | - Tadayuki Hirai
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Hiroyuki Sugimoto
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Yusuke Mukai
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Oto Inoue
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Shinichiro Takashima
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Takeshi Kato
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | | | - Soichiro Usui
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Sciences Kanazawa Japan
| |
Collapse
|
16
|
Hypertension in diabetes care: emerging roles of recent hypoglycemic agents. Hypertens Res 2021; 44:897-905. [PMID: 33990790 DOI: 10.1038/s41440-021-00665-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/21/2021] [Accepted: 03/25/2021] [Indexed: 02/03/2023]
Abstract
Patients with type 2 diabetes (T2D) frequently have multiple cardiovascular, metabolic, and renal comorbidities, such as hypertension, dyslipidemia, hyperuricemia, chronic kidney disease, and heart failure. Accordingly, this patient population often requires polypharmacy, which is associated with an increased risk of drug-drug interactions, poor adherence, and even adverse outcomes. Accumulating evidence on newer hypoglycemic agents, such as glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, has highlighted the marked improvements in cardiovascular and renal outcomes associated with the off-target benefits for relevant comorbidities, including hypertension. These classes of hypoglycemic agents are unique, as they achieve consistently modest but significant reductions in systolic and diastolic blood pressure (BP), an effect that has not been targeted and observed with conventional hypoglycemic agents. In addition to this BP-lowering effect, these agents also have multifaceted beneficial impacts on other cardiometabolic and renal parameters, which appear to be helpful for providing an important comprehensive therapeutic approach to improve the prognosis in patients with T2D. The clinical advantages of these agents may reduce the dose and number of concomitant medications used to treat T2D and related comorbidities. These positive spillover effects may also enhance the clinical use of agents to achieve better diabetes care. As a consequence, the clinical significance of these hypoglycemic agents now extends beyond their hypoglycemic effects, thereby providing a new-normal strategy to use in an evidence-based, patient-centric approach to diabetes care.
Collapse
|
17
|
Abstract
SGLT2 inhibitors increase renal glucose excretion and thus decrease both fasting and postprandial plasma glucose levels. The effects of SGLT2 inhibition outweigh those on glycemic control and are also associated with the induction of hemodynamic changes that improve cardiovascular and renal function in people with type 2 diabetes. The exact mechanisms have not yet been completely clarified. This review is focused on the potential relationship between SGLT2 inhibition and sympathetic nerve activity. There is accumulating evidence for a suppressive effect of SGLT2 inhibitors on the sympathetic nerve tone, which might be a putative mechanism for cardiovascular protection in subjects with type 2 diabetes.
Collapse
Affiliation(s)
- Rumyana Dimova
- Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| | - Tsvetalina Tankova
- Department of Endocrinology, Medical University of Sofia, Sofia, Bulgaria
| |
Collapse
|
18
|
Molecular Mechanisms of SGLT2 Inhibitor on Cardiorenal Protection. Int J Mol Sci 2020; 21:ijms21217833. [PMID: 33105763 PMCID: PMC7660105 DOI: 10.3390/ijms21217833] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 12/14/2022] Open
Abstract
The development of sodium-glucose transporter 2 inhibitor (SGLT2i) broadens the therapeutic strategies in treating diabetes mellitus. By inhibiting sodium and glucose reabsorption from the proximal tubules, the improvement in insulin resistance and natriuresis improved the cardiovascular mortality in diabetes mellitus (DM) patients. It has been known that SGLT2i also provided renoprotection by lowering the intraglomerular hypertension by modulating the pre- and post- glomerular vascular tone. The application of SGLT2i also provided metabolic and hemodynamic benefits in molecular aspects. The recent DAPA-CKD trial and EMPEROR-Reduced trial provided clinical evidence of renal and cardiac protection, even in non-DM patients. Therefore, the aim of the review is to clarify the hemodynamic and metabolic modulation of SGLT2i from the molecular mechanism.
Collapse
|
19
|
Nojima T, Matsubayashi Y, Yoshida A, Suganami H, Abe T, Ishizawa M, Fujihara K, Tanaka S, Kaku K, Sone H. Influence of an SGLT2 inhibitor, tofogliflozin, on the resting heart rate in relation to adipose tissue insulin resistance. Diabet Med 2020; 37:1316-1325. [PMID: 32096571 PMCID: PMC7496771 DOI: 10.1111/dme.14279] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2020] [Indexed: 12/12/2022]
Abstract
AIMS To examine the effects of a sodium-glucose co-transporter 2 (SGLT2) inhibitor, tofogliflozin, on resting heart rate by exploring baseline factors that independently influenced changes in the resting heart rate. METHODS Data on 419 participants in tofogliflozin phase 2/3 trials were analysed. Changes in resting heart rate from baseline to week 24 were analysed using an analysis of covariance (ANCOVA) model with groups (tofogliflozin/placebo) as a fixed effect and baseline values as covariates. The antilipolytic effect was evaluated as adipose tissue insulin resistance (Adipo-IR) and was calculated as the product of fasting insulin and free fatty acid. Multivariate analysis evaluated independent factors for changes in resting heart rate from baseline to week 24. RESULTS Of the participants, 58% were men, and mean age, HbA1c , BMI and resting heart rate were 57.6 years, 65 mmol/mol (8.1%), 25.5 kg/m2 and 66 bpm, respectively. At week 24, adjusted mean difference vs. placebo in the change from baseline was -2.3 bpm [95% confidence interval (CI) -4.6, -0.1] with tofogliflozin. Changes in resting heart rate were positively correlated with changes in Adipo-IR, whereas reductions in HbA1c , body weight and blood pressure were similar independent of changes in resting heart among quartiles of resting heart rate change. On multivariate analysis, higher baseline resting heart rates and Adipo-IR values were significantly associated with greater reductions in resting heart rate. CONCLUSIONS Tofogliflozin corrected resting heart rate levels in accordance with baseline levels. Correction of high resting heart rates may be attributed to improved adipose tissue insulin resistance, leading to correction of hyperinsulinaemia.
Collapse
Affiliation(s)
- T. Nojima
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
- Clinical Data Science DepartmentKowa Co., Ltd.TokyoJapan
| | - Y. Matsubayashi
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
| | - A. Yoshida
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
- Kowa Co., Ltd.TokyoJapan
| | - H. Suganami
- Clinical Data Science DepartmentKowa Co., Ltd.TokyoJapan
| | - T. Abe
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
| | - M. Ishizawa
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
| | - K. Fujihara
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
| | - S. Tanaka
- Department of Clinical BiostatisticsGraduate School of MedicineKyoto UniversityKyotoJapan
| | - K. Kaku
- Kawasaki Medical SchoolOkayamaJapan
| | - H. Sone
- Department of Hematology, Endocrinology and MetabolismNiigata University Faculty of MedicineNiigataJapan
| |
Collapse
|
20
|
Berra C, Manfrini R, Regazzoli D, Radaelli MG, Disoteo O, Sommese C, Fiorina P, Ambrosio G, Folli F. Blood pressure control in type 2 diabetes mellitus with arterial hypertension. The important ancillary role of SGLT2-inhibitors and GLP1-receptor agonists. Pharmacol Res 2020; 160:105052. [PMID: 32650058 DOI: 10.1016/j.phrs.2020.105052] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/09/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus and arterial hypertension are major cardiovascular risks factors which shares metabolic and haemodynamic abnormalities as well as pathophysiological mechanisms. The simultaneous presence of diabetes and arterial hypertension increases the risk of left ventricular hypertrophy, congestive heart failure, and stroke, as compared to either condition alone. A number of guidelines recommend lifestyle measures such as salt restriction, weight reduction and ideal body weight mainteinance, regular physical activity and smoking cessation, together with moderation of alcohol consumption and high intake of vegetables and fruits, as the basis for reduction of blood pressure and prevention of CV diseases. Despite the availability of multiple drugs effective for hypertension, BP targets are reached in only 50 % of patients, with even fewer individuals with T2DM-achieving goals. It is established that new emerging classes of type 2 diabetes mellitus treatment, SGLT2 inhibitors and GLP1-receptor agonists, are efficacious on glucose control, and safe in reducing HbA1c significantly, without increasing hypoglycemic episodes. Furthermore, in recent years, many CVOT trials have demonstrated, using GLP1-RA or SGLT2-inihibitors compared to placebo (in combination with the usual diabetes medications) important benefits on reducing MACE (cardio-cerebral vascular events) in the diabetic population. In this hypothesis-driven review, we have examined the anti-hypertensive effects of these novel molecules of the two different classes, in the diabetic population, and suggest that they could have an interesting ancillary role in controlling blood pressure in type 2 diabetic patients.
Collapse
Affiliation(s)
- C Berra
- Department of Endocrine and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy.
| | - R Manfrini
- Departmental Unit of Diabetes and Metabolic Disease, ASST Santi Paolo e Carlo, Milan, Italy
| | - D Regazzoli
- Department of Cardiovascular Disease, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - M G Radaelli
- Department of Endocrine and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - O Disoteo
- Endocrinology and Diabetology Service, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - C Sommese
- IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - P Fiorina
- University of Milano, Milan, Italy; TID International Center, Invernizzi Research Center, Milan, Italy; Endocrinology and Diabetology Unit, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, Milan, Italy
| | - G Ambrosio
- University of Perugia School of Medicine, Perugia, Italy
| | - F Folli
- Departmental Unit of Diabetes and Metabolic Disease, ASST Santi Paolo e Carlo, Milan, Italy; University of Milano, Milan, Italy; Endocrinology and Metabolism, Department of Health Science University of Milano, Italy
| |
Collapse
|
21
|
Lopaschuk GD, Verma S. Mechanisms of Cardiovascular Benefits of Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitors: A State-of-the-Art Review. JACC Basic Transl Sci 2020; 5:632-644. [PMID: 32613148 PMCID: PMC7315190 DOI: 10.1016/j.jacbts.2020.02.004] [Citation(s) in RCA: 423] [Impact Index Per Article: 105.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/05/2020] [Accepted: 02/05/2020] [Indexed: 12/20/2022]
Abstract
Recent clinical trials have shown that sodium glucose co-transport 2 (SGLT2) inhibitors have dramatic beneficial cardiovascular outcomes. These include a reduced incidence of cardiovascular death and heart failure hospitalization in people with and without diabetes, and those with and without prevalent heart failure. The actual mechanism(s) responsible for these beneficial effects are not completely clear. Several potential theses have been proposed to explain the cardioprotective effects of SGLT2 inhibition, which include diuresis/natriuresis, blood pressure reduction, erythropoiesis, improved cardiac energy metabolism, inflammation reduction, inhibition of the sympathetic nervous system, prevention of adverse cardiac remodeling, prevention of ischemia/reperfusion injury, inhibition of the Na+/H+-exchanger, inhibition of SGLT1, reduction in hyperuricemia, increasing autophagy and lysosomal degradation, decreasing epicardial fat mass, increasing erythropoietin levels, increasing circulating pro-vascular progenitor cells, decreasing oxidative stress, and improving vascular function. The strengths and weaknesses of these proposed mechanisms are reviewed in an effort to try to synthesize and prioritize the mechanisms as they relate to clinical event reduction.
Collapse
Affiliation(s)
- Gary D. Lopaschuk
- Cardiovascular Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Wan N, Fujisawa Y, Kobara H, Masaki T, Nakano D, Rahman A, Nishiyama A. Effects of an SGLT2 inhibitor on the salt sensitivity of blood pressure and sympathetic nerve activity in a nondiabetic rat model of chronic kidney disease. Hypertens Res 2020; 43:492-499. [PMID: 32060381 DOI: 10.1038/s41440-020-0410-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/09/2019] [Accepted: 12/23/2019] [Indexed: 12/20/2022]
Abstract
The glucose-lowering effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors is reduced in patients with diabetes who have chronic kidney disease (CKD). In the present study, we examined the effect of an SGLT2 inhibitor on the salt sensitivity of blood pressure (BP), circadian rhythm of BP, and sympathetic nerve activity (SNA) in nondiabetic CKD rats. Uninephrectomized Wistar rats were treated with adenine (200 mg/kg/day) for 14 days. After stabilization with a normal-salt diet (NSD, 0.3% NaCl), a high-salt diet (HSD, 8% NaCl) was administered. Mean arterial pressure (MAP) was continuously monitored using a telemetry system. We also analyzed the low frequency (LF) of systolic arterial pressure (SAP), which reflects SNA. In adenine-induced CKD rats, HSD consumption for 5 days significantly increased the mean MAP from 106 ± 2 to 148 ± 3 mmHg. However, MAP was decreased to 96 ± 3 mmHg within 24 h after switching back to a NSD (n = 7). Treatment with an SGLT2 inhibitor, luseogliflozin (10 mg/kg/day, p.o., n = 7), significantly attenuated the HSD-induced elevation of MAP, which was associated with a reduction in LF of SAP. These data suggest that treatment with an SGLT2 inhibitor attenuates the salt sensitivity of BP, which is associated with SNA inhibition in nondiabetic CKD rats.
Collapse
Affiliation(s)
- Ningning Wan
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshihide Fujisawa
- Life Science Research Center, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Daisuke Nakano
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Asadur Rahman
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, Kagawa, Japan.
| |
Collapse
|
23
|
Silva Dos Santos D, Polidoro JZ, Borges-Júnior FA, Girardi ACC. Cardioprotection conferred by sodium-glucose cotransporter 2 inhibitors: a renal proximal tubule perspective. Am J Physiol Cell Physiol 2019; 318:C328-C336. [PMID: 31721613 DOI: 10.1152/ajpcell.00275.2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors, also known as gliflozins, improve glycemia by suppressing glucose reuptake in the renal proximal tubule. Currently, SGLT2 inhibitors are primarily indicated as antidiabetic agents; however, their benefits extend far beyond glucose control. Cardiovascular outcome trials indicated that all studied SGLT2 inhibitors remarkably and consistently reduce cardiovascular mortality and hospitalization for heart failure (HF) in type 2 diabetes (T2D) patients. Nevertheless, the mechanisms underlying the unprecedented cardiovascular benefits of gliflozins remain elusive. Multiple processes that directly or indirectly improve myocardial performance may be involved, including the amelioration of proximal tubular dysfunction. Therefore, this paper provides a perspective on the potential cellular and molecular mechanisms of the proximal tubule that may, at least in part, mediate the cardioprotection conferred by SGLT2 inhibitors. Specifically, we focus on the effects of SGLT2 on extracellular volume homeostasis, including its plausible functional and physical association with the apical Na+/H+ exchanger isoform 3 as well as its complex and its possible bidirectional interactions with the intrarenal angiotensin system and renal sympathetic nervous system. We also discuss evidence supporting a potential benefit of gliflozins in reducing cardiovascular risk, attributable to their effect on proximal tubule handling of uric acid and albumin as well as in erythropoietin production. Unraveling the mechanisms behind the beneficial actions of SGLT2 inhibitors may not only contribute to a better understanding of the pathophysiology of cardiovascular diseases but also enable repurposing of gliflozins to improve the routine management of HF patients with or without T2D.
Collapse
Affiliation(s)
| | - Juliano Z Polidoro
- Heart Institute (InCor), University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Adriana C C Girardi
- Heart Institute (InCor), University of São Paulo, São Paulo, São Paulo, Brazil
| |
Collapse
|
24
|
Sakamoto M, Matsutani D, Kayama Y. Clinical Implications of Baroreflex Sensitivity in Type 2 Diabetes. Int Heart J 2019; 60:241-246. [PMID: 30799384 DOI: 10.1536/ihj.18-455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The evaluation of baroreflex sensitivity (BRS), which maintains systemic circulatory homeostasis, is an established tool to assess cardiovascular autonomic neuropathy in type 2 diabetes mellitus (T2DM). As BRS plays an important function in blood pressure regulation, reduced BRS leads to an increase in blood pressure variability, which further leads to reduced BRS. This sequence of events becomes a vicious cycle. The major risk factors for reduced BRS are T2DM and essential hypertension, but many other risk factors have been reported to influence BRS. In recent years, reports have indicated that glycemic variability (GV), such as short- and long-term GV that are considered important risk factors for macrovascular and microvascular complications, is involved in reductions in BRS independently of blood glucose levels. In this review, we discuss reduced BRS in T2DM, its features, and the potential for its reversal.
Collapse
Affiliation(s)
- Masaya Sakamoto
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Jikei University School of Medicine
| | - Daisuke Matsutani
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Jikei University School of Medicine
| | - Yosuke Kayama
- Department of Cardiology, Jikei University School of Medicine
| |
Collapse
|
25
|
Saad M, Gomceli U, Ravi P, Lacoste AG, Shah N, Vittorio TJ. The metabolic model of heart failure: the role of sodium glucose co-transporter-2 (SGLT-2) inhibition. Drugs Context 2018; 7:212549. [PMID: 30483350 PMCID: PMC6251384 DOI: 10.7573/dic.212549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 11/21/2022] Open
Abstract
Heart failure (HF) is one of the leading causes of hospital readmissions and health care expenditures. With a vast degree of advancements in the clinical approach and diagnosis, its management protocol is limited in terms of enhancing quality of life and prognosis. Type 2 diabetes mellitus (T2DM) is considered as one of the commonly associated comorbid conditions in the HF population. The understanding of the molecular and metabolic models of HF has led to the utilization of therapeutic goals of T2DM in improving HF-related complications. In the recent era, SGLT-2 inhibitors have shown success in decreasing cardiovascular mortality in the T2DM population. This article will help the reviewer to comprehend the pathophysiology of HF and the potential role of SGLT-2 inhibitors in the management algorithm of HF and its associated risk factors in T2DM.
Collapse
Affiliation(s)
- Muhammad Saad
- Department of Internal Medicine, Bronxcare Health System/Bronxcare Hospital Center, Bronx, NY, USA
| | - Umut Gomceli
- Department of Cardiology, Bronxcare Health System/Bronxcare Hospital Center, Bronx, NY, USA
| | - Pranav Ravi
- Department of Internal Medicine, Bronxcare Health System/Bronxcare Hospital Center, Bronx, NY, USA
| | - Andrisael G Lacoste
- Department of Internal Medicine, Bronxcare Health System/Bronxcare Hospital Center, Bronx, NY, USA
| | - Neil Shah
- Department of Internal Medicine, Bronxcare Health System/Bronxcare Hospital Center, Bronx, NY, USA
| | - Timothy J Vittorio
- Department of Cardiology, Bronxcare Health System/Bronxcare Hospital Center, Bronx, NY, USA
| |
Collapse
|
26
|
Chaudhary P, Schreihofer AM. Improved glucose homeostasis in male obese Zucker rats coincides with enhanced baroreflexes and activation of the nucleus tractus solitarius. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1195-R1209. [PMID: 30256679 DOI: 10.1152/ajpregu.00195.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Young adult male obese Zucker rats (OZR) develop insulin resistance and hypertension with impaired baroreflex-mediated bradycardia and activation of nucleus tractus solitarius (NTS). Because type 1 diabetic rats also develop impaired baroreflex-mediated NTS activation, we hypothesized that improving glycemic control in OZR would enhance compromised baroreflexes and NTS activation. Fasting blood glucose measured by telemetry was comparable in OZR and lean Zucker rats (LZR) at 12-17 wk. However, with access to food, OZR were chronically hyperglycemic throughout this age range. By 15-17 wk of age, tail samples yielded higher glucose values than those measured by telemetry in OZR but not LZR, consistent with reports of exaggerated stress responses in OZR. Injection of glucose (1g/kg ip) produced larger rises in glucose and areas under the curve in OZR than LZR. Treatment with metformin (300 mg·kg-1·day-1) or pioglitazone (5 mg·kg-1·day-1) in drinking water for 2-3 wk normalized fed glucose levels in OZR with no effect in LZR. After metformin treatment, area under the curve for blood glucose after glucose injection was reduced in OZR and comparable to LZR. Hyperinsulinemia was slightly reduced by each treatment in OZR, but insulin was still greatly elevated compared with LZR. Neither treatment reduced hypertension in OZR, but both treatments significantly improved the blunted phenylephrine-induced bradycardia and NTS c-Fos expression in OZR with no effect in LZR. These data suggest that restoring glycemic control in OZR enhances baroreflex control of heart rate by improving the response of the NTS to raising arterial pressure, even in the presence of hyperinsulinemia and hypertension.
Collapse
Affiliation(s)
- Parul Chaudhary
- Department of Physiology and Anatomy, University of North Texas Health Science Center , Fort Worth, Texas
| | - Ann M Schreihofer
- Department of Physiology and Anatomy, University of North Texas Health Science Center , Fort Worth, Texas
| |
Collapse
|
27
|
Kawada T, Shimizu S, Hayama Y, Yamamoto H, Saku K, Shishido T, Sugimachi M. Derangement of open-loop static and dynamic characteristics of the carotid sinus baroreflex in streptozotocin-induced type 1 diabetic rats. Am J Physiol Regul Integr Comp Physiol 2018; 315:R553-R567. [DOI: 10.1152/ajpregu.00092.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Although diabetes mellitus (DM) is a major risk factor for cardiovascular diseases, changes in open-loop static and dynamic characteristics of the arterial baroreflex in the early phase of DM remain to be clarified. We performed an open-loop systems analysis of the carotid sinus baroreflex in type 1 DM rats 4 to 5 wk after intraperitoneal streptozotocin injection ( n = 9) and we compared the results with control rats ( n = 9). The operating-point baroreflex gain was maintained in the DM rats compared with the control rats (2.07 ± 0.67 vs. 2.66 ± 0.22 mmHg/mmHg, P = 0.666). However, the range of arterial pressure (AP) control was narrower in the DM than in the control group (48.0 ± 5.0 vs. 77.1 ± 4.5 mmHg, P = 0.001), suggesting that the reserve for AP buffering is lost in DM. Although baroreflex dynamic characteristics were relatively preserved, coherences were lower in the DM than in the control group. The decreased coherence in the neural arc may be related to the narrowed quasi-linear range in the static relationship between carotid sinus pressure and sympathetic nerve activity in the DM group. Although the reason for the decreased coherences in the peripheral arc and the total reflex arc was inconclusive, the finding may indicate a loss of integrity of the baroreflex-mediated sympathetic AP control in the DM group. The derangement of the baroreflex dynamic characteristics is progressing occultly in this early stage of type 1 DM in a manner where dynamic gains are relatively preserved around the normal operating point.
Collapse
Affiliation(s)
- Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiromi Yamamoto
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Keita Saku
- Department of Advanced Risk Stratification for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Toshiaki Shishido
- Department of Research Promotion, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| |
Collapse
|
28
|
Baroreflex failure and beat-to-beat blood pressure variation. Hypertens Res 2018; 41:547-552. [DOI: 10.1038/s41440-018-0056-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/05/2018] [Accepted: 01/10/2018] [Indexed: 02/07/2023]
|
29
|
Matsutani D, Sakamoto M, Kayama Y, Takeda N, Horiuchi R, Utsunomiya K. Effect of canagliflozin on left ventricular diastolic function in patients with type 2 diabetes. Cardiovasc Diabetol 2018; 17:73. [PMID: 29788955 PMCID: PMC5963148 DOI: 10.1186/s12933-018-0717-9] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 05/17/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) greatly increases the risks of cardiovascular disease and heart failure. In particular, left ventricular diastolic dysfunction that develops from the early stages of T2DM is an important factor in the onset and exacerbation of heart failure. The effect of sodium-glucose cotransporter 2 inhibitors on left ventricular diastolic function has not been elucidated. We have performed the first prospective study on the effects of canagliflozin on left ventricular diastolic function in T2DM. METHODS This study was performed to evaluate the effects of additional treatment with canagliflozin for 3 months on left ventricular diastolic function in patients with T2DM. A total of 38 patients with T2DM were consecutively recruited for this study. Left ventricular diastolic function was assessed by echocardiography. The primary study outcome was a change in the septal E/e' as a parameter of left ventricular diastolic function. RESULTS A total of 37 patients (25 males and 12 females) were included in the analysis. Mean age of participants was 64.2 ± 8.1 years (mean ± SD), mean duration of diabetes was 13.5 ± 8.1 years, and mean HbA1c was 7.9 ± 0.7%. Of the participants, 86.5% had hypertension, 100% had dyslipidemia, and 32.4% had cardiovascular disease. Canagliflozin significantly improved left ventricular diastolic function (septal E/e' ratio 13.7 ± 3.5-12.1 ± 2.8, p = 0.001). Furthermore, among the various parameters that changed through the administration of canagliflozin, only changes in hemoglobin significantly correlated with changes in the septal E/e' ratio (p = 0.002). In multiple regression analysis, changes in hemoglobin were also revealed to be an independent predictive factor for changes in the septal E/e' ratio. CONCLUSIONS This study showed for the first time that canagliflozin could improve left ventricular diastolic function within 3 months in patients with T2DM. The benefit was especially apparent in patients with substantially improved hemoglobin values. Trial registration UMIN Clinical Trials Registry UMIN000028141.
Collapse
Affiliation(s)
- Daisuke Matsutani
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masaya Sakamoto
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Yosuke Kayama
- Department of Cardiology, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Norihiko Takeda
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8654, Japan
| | - Ryuzo Horiuchi
- Department of Pathology, Tsuruoka Kyoritsu Hospital, 9-34, Fumizonomachi, Tsuruoka-shi, Yamagata, 997-0816, Japan
| | - Kazunori Utsunomiya
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| |
Collapse
|
30
|
Hypertension with diabetes mellitus complications. Hypertens Res 2018; 41:147-156. [DOI: 10.1038/s41440-017-0008-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 09/02/2017] [Accepted: 09/06/2017] [Indexed: 12/17/2022]
|
31
|
Abstract
PURPOSE OF REVIEW We sought to review currently available data on the safety and efficacy of sodium-glucose cotransporter 2 (SGLT2) inhibitors in type 2 diabetes mellitus patients with hypertension. RECENT FINDINGS Inhibition of SGLT2 in the renal proximal tubule results in increased urinary glucose excretion and modest improvements of hemoglobin A1C. Treatment with any of the three currently FDA-approved SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) results in sustained systolic and diastolic blood pressure reduction, in part via minimal natriuresis and possible reductions in sympathetic tone. Recent randomized clinical trials in high cardiovascular risk patients with type 2 diabetes suggest that the unique effects of SGLT2 inhibitors on blood pressure and body weight may translate into reduced cardiovascular events and slowed kidney disease progression. However, concerns about volume depletion and acute kidney injury have been raised. SGLT2 inhibitors are viable second-line glucose-lowering agents for people with type 2 diabetes with high cardiovascular risk.
Collapse
|
32
|
Wan N, Rahman A, Hitomi H, Nishiyama A. The Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Sympathetic Nervous Activity. Front Endocrinol (Lausanne) 2018; 9:421. [PMID: 30093883 PMCID: PMC6070601 DOI: 10.3389/fendo.2018.00421] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/04/2018] [Indexed: 01/08/2023] Open
Abstract
The EMPA-REG OUTCOME study revealed that a sodium-glucose cotransporter 2 (SGLT2) inhibitor, empagliflozin, can remarkably reduce cardiovascular (CV) mortality and heart failure in patients with high-risk type 2 diabetes. Recently, the CANVAS program also showed that canagliflozin, another SGLT2 inhibitor, induces a lower risk of CV events. However, the precise mechanism by which an SGLT2 inhibitor elicits CV protective effects is still unclear. Possible sympathoinhibitory effects of SGLT2 inhibitor have been suggested, as significant blood pressure (BP) reduction, following treatment with an SGLT2 inhibitor, did not induce compensatory changes in heart rate (HR). We have begun to characterize the effects of SGLT2 inhibitor on BP and sympathetic nervous activity (SNA) in salt-treated obese and metabolic syndrome rats, who develop hypertension with an abnormal circadian rhythm of BP, a non-dipper type of hypertension, and do not exhibit a circadian rhythm of SNA. Treatment with SGLT2 inhibitors significantly decreased BP and normalized circadian rhythms of both BP and SNA, but did not change HR; this treatment was also associated with an increase in urinary sodium excretion. Taken together, these data suggest that an SGLT2 inhibitor decreases BP by normalizing the circadian rhythms of BP and SNA, which may be the source of its beneficial effects on CV outcome in high-risk patients with type 2 diabetes. In this review, we briefly summarize the effects of SGLT2 inhibitors on BP and HR, with a special emphasis on SNA.
Collapse
|
33
|
Tanaka A, Shimabukuro M, Okada Y, Taguchi I, Yamaoka-Tojo M, Tomiyama H, Teragawa H, Sugiyama S, Yoshida H, Sato Y, Kawaguchi A, Ikehara Y, Machii N, Maruhashi T, Shima KR, Takamura T, Matsuzawa Y, Kimura K, Sakuma M, Oyama JI, Inoue T, Higashi Y, Ueda S, Node K. Rationale and design of a multicenter placebo-controlled double-blind randomized trial to evaluate the effect of empagliflozin on endothelial function: the EMBLEM trial. Cardiovasc Diabetol 2017; 16:48. [PMID: 28403850 PMCID: PMC5389095 DOI: 10.1186/s12933-017-0532-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/04/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is characterized by systemic metabolic abnormalities and the development of micro- and macrovascular complications, resulting in a shortened life expectancy. A recent cardiovascular (CV) safety trial, the EMPA-REG OUTCOME trial, showed that empagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, markedly reduced CV death and all-cause mortality and hospitalization for heart failure in patients with T2DM and established CV disease (CVD). SGLT2 inhibitors are known to not only decrease plasma glucose levels, but also favorably modulate a wide range of metabolic and hemodynamic disorders related to CV pathways. Although some experimental studies revealed a beneficial effect of SGLT2 inhibitors on atherosclerosis, there is a paucity of clinical data showing that they can slow the progression of atherosclerosis in patients with T2DM. Therefore, the EMBLEM trial was designed to investigate whether empagliflozin treatment can improve endothelial function, which plays a pivotal role in the pathogenesis of atherosclerosis, in patients with T2DM and established CVD. METHODS The EMBLEM trial is an ongoing, prospective, multicenter, placebo-controlled double-blind randomized, investigator-initiated clinical trial in Japan. A total of 110 participants with T2DM (HbA1c range 6.0-10.0%) and with established CVD will be randomized (1:1) to receive either empagliflozin 10 mg once daily or a placebo. The primary endpoint of the trial is change in the reactive hyperemia (RH)-peripheral arterial tonometry-derived RH index at 24 weeks from baseline. For comparison of treatment effects between the treatment groups, the baseline-adjusted means and their 95% confidence intervals will be estimated by analysis of covariance adjusted for the following allocation factors: HbA1c (<7.0 or ≥7.0%), age (<65 or ≥65 years), systolic blood pressure (<140 or ≥140 mmHg), and current smoking status (nonsmoker or smoker). Key secondary endpoints include the change from baseline for other vascular-related markers such as arterial stiffness, sympathetic nervous activity, and parameters of cardiac and renal function. Importantly, serious adverse effects independently on the causal relationship to the trial drugs and protocol will be also evaluated throughout the trial period. DISCUSSION EMBLEM is the first trial to assess the effect of empagliflozin on endothelial function in patients with T2DM and established CVD. Additionally, mechanisms associating empagliflozin-mediated actions with endothelial function and other CV markers will be evaluated. Thus, the trial is designed to elucidate potential mechanisms by which empagliflozin protects CV systems and improves CV outcomes. Trial registration Unique Trial Number, UMIN000024502 ( https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028197 ).
Collapse
Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan.
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Okada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan
| | - Minako Yamaoka-Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences, Sagamihara, Japan
| | | | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Seigo Sugiyama
- Division of Cardiovascular Medicine, Diabetes Care Center, Jinnouchi Hospital, Kumamoto, Japan
| | | | - Yasunori Sato
- Department of Global Clinical Research, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Yumi Ikehara
- Clinical Research and Quality Management Center, University of the Ryukyus Hospital, Nishihara, Japan
| | - Noritaka Machii
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Tatsuya Maruhashi
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kosuke R Shima
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yasushi Matsuzawa
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Masashi Sakuma
- Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Japan
| | - Jun-Ichi Oyama
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus, Nishihara, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan.
| | | |
Collapse
|
34
|
Tanaka A, Node K. Amelioration of arterial pressure lability: an unmissable target for diabetes management. Hypertens Res 2017; 40:629-631. [PMID: 28298651 DOI: 10.1038/hr.2017.35] [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]
Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| |
Collapse
|