SGLT2 inhibitors: a promising new therapeutic option for treatment of type 2 diabetes mellitus

Repurposing the inhibitors of MMP-9 and SGLT-2 against ubiquitin specific protease 30 in Parkinson's disease: computational modelling studies

Ubiquitin specific protease 30 (USP30) has been attributed to mitochondrial dysfunction and impediment of mitophagy in Parkinson's disease (PD). This happens once ubiquitin that supposed to bind with deformed mitochondria at the insistence of Parkin, it's been recruited by USP30 via the distal ubiquitin binding domain. This is a challenge when PINK1 and Parkin loss their functions due to mutation. Although, there are reports on USP30s' inhibitors but no study on the repurposing of inhibitors approved against MMP-9 and SGLT-2 as potential inhibitors of USP30 in PD. Thus, the highlight therein, is to repurpose approved inhibitors of MMP-9 and SGLT-2 against USP30 in PD using extensive computational modelling framework. 3D structures of Ligands and USP30 were obtained from PubChem and protein database (PDB) servers respectively, and were subjected to molecular docking, ADMET evaluation, DFT calculation, molecular dynamics simulation (MDS) and free energy calculations. Out of the 18 drugs, 2 drugs showed good binding affinity to the distal ubiquitin binding domain, moderate pharmacokinetic properties and good stability. The findings showed canagliflozin and empagliflozin as potential inhibitors of USP30. Thus, we present these drugs as repurposing candidates for the treatment of PD. However, the findings in this current study needs to be validated experimentally.Communicated by Ramaswamy H. Sarma.

Frequency of Urinary Tract Infections in Type 2 Diabetic Patients Taking Dapagliflozin

Background

Urinary tract infections (UTIs) are common in patients with diabetes. The use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) to achieve good glycemic control increases glucose levels in urine. This glycosuria further enhances the risk of UTIs. This study aimed to evaluate the frequency of UTIs in patients with type 2 diabetes receiving the SGLT2i dapagliflozin as an add-on therapy.

Methods

We conducted this cross-sectional study at the Endocrinology Department of Hayatabad Medical Complex in Peshawar from April 2020 to September 2020. A total of 400 patients with diabetes receiving either 5 mg or 10 mg of dapagliflozin as an add-on therapy for the treatment of type 2 diabetes were included in this study. We collected blood and urine samples from participants and measured glycosylated hemoglobin levels. Urine samples were cultured on cysteine lactose electrolyte deficient agar. We used IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY) to analyze our data.

Results

The prevalence of UTIs in diabetic patients receiving 5 mg or 10 mg of dapagliflozin was 5.3%. Women were more affected (76.2%) than men (p < 0.05). UTIs were more prevalent in patients older than 50 years (85.7%) than in any other age group. The dose strength of dapagliflozin was not associated with UTIs (p > 0.05).

Conclusion

This study examined UTIs in patients taking dapagliflozin for the treatment of type 2 diabetes. These infections were mild to moderate and were treated easily. None of these infections caused the patient to discontinue the treatment. Dapagliflozin is well-tolerated in patients with diabetes but should be used with appropriate caution and monitoring.

Comparison of Efficacy and Safety Profile of Sodium-Glucose Cotransporter-2 Inhibitors as Add-On Therapy in Patients With Type 2 Diabetes

Background Type 2 diabetes is a chronic metabolic disorder that is escalating at an alarming rate worldwide. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are recent oral antihyperglycemic drugs (OADs) with a unique mechanism of action. Objectives This study aimed compared the efficacy and safety profiles of two SGLT-2 inhibitors, empagliflozin and dapagliflozin, in patients with type 2 diabetes as add-on therapy to traditional first-line OADs. Methods We conducted a randomized controlled trial comparing empagliflozin and dapagliflozin in patients with type 2 diabetes. Patients were included in the study if they had type 2 diabetes with inadequate glycemic control, defined as glycated hemoglobin (HbA1c) of 7.5% to 11.0%, treated with conventional first-line OADs. Study participants were randomly assigned into two groups. Group A patients received oral empagliflozin, 10 to 25 mg, and Group B patients received oral dapagliflozin, 5 to 10 mg, for 12 weeks. The primary endpoint was the efficacy profile for each SGLT-2 agent in terms of body weight changes, body mass index (BMI), fasting blood glucose (FBG), and HbA1c. The secondary endpoint was to determine the safety and tolerability profiles of each SGLT-2 agent. Results After 12 weeks of treatment, the mean body weight was reduced significantly in both groups from baseline (empagliflozin: -3.2 kg ± 5.5 kg, p = 0.003; dapagliflozin -2.1 kg ± 4.6 kg, p = 0.008). However, the mean body weight reduction between groups was not statistically significant (p = 0.078). BMI was significantly reduced in both groups (empagliflozin from 28.5 ± 4.9 kg/m2 to 25.8 ± 5.2 kg/m2, p = 0.002; dapagliflozin from 29 ± 5.2 kg/m2 to 27.7 ± 4.8 kg/m2, p = 0.003). However, the patients who received empagliflozin experienced a significantly greater reduction in BMI than patients who received dapagliflozin (p = 0.007). The mean FBG was also reduced in both study groups (empagliflozin: -88.5 mg/dL ± 39.7 mg/dl, p = 0.003; dapagliflozin: -59.8 mg/dL ± 48.5 mg/dL; p = 0.007). However, the patients who received empagliflozin experienced a significantly greater reduction in mean FBG than patients who received dapagliflozin (p = 0.001). HbA1c was also significantly reduced in both groups (empagliflozin: -2.1% ± 1.1%, p = 0.002; dapagliflozin: -1.4% ± 0.9%; p = 0.004). However, patients who received empagliflozin experienced a significantly greater reduction in HbA1c than patients who received dapagliflozin (p = 0.001). The tolerability profiles of both SGLT-2 agents were quite good, and no major adverse effects were reported in the study groups. Urinary infection occurred more often in patients who received dapagliflozin (9.3%) than in patients who received empagliflozin (4.5%; p = 0.002). Patients in the dapagliflozin group also had a higher incidence of genital infections (7.3%) than those in the empagliflozin group (3.8%; p = 0.001). Conclusion Both empagliflozin and dapagliflozin demonstrated excellent efficacy and safety profiles in our study. These agents should be considered as add-on therapy in patients with type 2 diabetes taking conventional first-line OADs.

The effect of metformin on carotid intima-media thickness (CIMT): A systematic review and meta-analysis of randomized clinical trials

Metformin administration has been reported to influence the carotid intima-media thickness (CIMT) in humans. However, since previously conducted studies have yielded inconsistent results, the exact effect of metformin on CIMT remains unclear. Causes that could lead to inconsistency in reported research could be the duration and dose of the intervention, as well as the sample size. To address this inconsistency, we conducted a systematic review and meta-analysis to evaluate the influence of metformin on CIMT in human subjects. We identified eligible studies by searching several electronic databases (EMBASE, PubMed-MEDLINE, Web of Science and Google Scholar) up to December 12, 2019. Data were pooled using the random-effects model. Combining data from 1087 participants (9 studies), our meta-analysis revealed that the administration of metformin resulted in a significant reduction in CIMT (WMD = -0.049 mm; 95% CI: -0.095, -0.004). Stratified analyses showed that an intervention lasting ≥12 months (WMD: -0.084 mm, 95% CI: -0.145, -0.024) and an intake of metformin ≤1500 mg/day (WMD: -0.081 mm, 95% CI: -0.132, -0.029) resulted in a significantly greater reduction in CIMT. However, an intervention duration of less than 12 months and an intake of metformin ˃1500 mg/day yielded no significant effects on CIMT. The results of the current study confirm that metformin administration is associated with a significant reduction in CIMT. Taking into account that CIMT reflects the burden of atherosclerosis, the clinical utility of metformin might also be related to its anti-atherogenic effects.

SGLT inhibitors as antidiabetic agents: a comprehensive review

Diabetes is one of the most common disorders that substantially contributes to an increase in global health burden. As a metabolic disorder, diabetes is associated with various medical conditions and diseases such as obesity, hypertension, cardiovascular diseases, and atherosclerosis. In this review, we cover the scientific studies on sodium/glucose cotransporter (SGLT) inhibitors published during the last decade. Our focus on providing an exhaustive overview of SGLT inhibitors enabled us to present their chemical classification for the first time.

Residual Effect of Sodium Glucose Cotransporter 2 Inhibitor, Tofogliflozin, on Body Weight After Washout in Japanese Men With Type 2 Diabetes

Background

We investigated the potential mechanism underlying body weight reduction by the sodium glucose cotransporter 2 (SGLT2) inhibitor, tofogliflozin, during treatment and after subsequent washout.

Methods

Ten Japanese men with type 2 diabetes (average age: 66.3 years) were orally administered tofogliflozin (20 mg/day) for 8 weeks followed by a subsequent 8-week washout period (16 weeks).

Results

Significant reductions were observed in blood glucose, hemoglobin A1c (HbA1c), uric acid, body weight and waist circumference with an increase in high-molecular weight (HMW) adiponectin at 8 weeks. We also evaluated these markers at 16 weeks and found that unlike HbA1c and uric acid, body weight and HMW adiponectin did not return to baseline levels. To clarify the potential mechanism underlying the body weight reduction during treatment with tofogliflozin (8 weeks) and after washout (at 16 weeks), we investigated the correlations between changes from baseline (0 week) in body weight and those in waist circumference (or HMW adiponectin). The changes in body weight between 0 weeks versus 8 weeks were not significantly correlated with those in waist circumference or HMW adiponectin. In contrast, changes in body weight between 0 and 16 weeks did show a significant correlation to those in waist circumference and HMW adiponectin.

Conclusion

The body weight reduction caused by tofogliflozin may be due to several factors as well as fat reduction at 8 weeks, but is most likely due to fat reduction alone after a subsequent 8 weeks of washout of this agent.

The Effect of Tofogliflozin Treatment on Postprandial Glucose and Lipid Metabolism in Japanese Men With Type 2 Diabetes: A Pilot Study

Background

Postprandial hyperglycemia and hyperlipidemia are highly related to the development of atherosclerosis. Sodium/glucose cotransporter-2 (SGLT2) inhibitors have attracted attention as a new class of anti-diabetic agents for the treatment of type 2 diabetes. We investigated the effect of tofogliflozin on postprandial glucose and lipid metabolism in Japanese male patients with type 2 diabetes.

Methods

Ten Japanese men with type 2 diabetes (average age 66.3 years) were orally administered tofogliflozin (20 mg per day) for 8 weeks followed by a subsequent 8 weeks of washout of the agent. At 0, 8 and 16 weeks, postprandial metabolic parameters were measured at 0, 60 and 120 min after cookie ingestion.

Results

There were significant reductions in body weight and body mass index at 8 weeks. There was a reduction in HbA1c at 8 weeks, which returned to pretreatment levels at 16 weeks. Serum insulin levels did not change during the entire study period under either fasting or postprandial state. The area under the curve of plasma glucagon significantly increased at 8 weeks. There were no changes in lipid and lipoprotein levels either in fasting or postprandial state except for tendency toward reduction in postprandial triglycerides at 8 weeks and increase in HDL-C at 16 weeks.

Conclusions

Tofogliflozin treatment causes an improvement of postprandial glucose metabolism but not considerable postprandial lipid metabolism.

The renal effects of SGLT2 inhibitors and a mini-review of the literature

Sodium-glucose linked transporter 2 (SGLT2) inhibitors are a new and promising class of antidiabetic agents which target renal tubular glucose reabsorption. Their action is based on the blockage of SGLT2 sodium-glucose cotransporters that are located at the luminal membrane of tubular cells of the proximal convoluted tubule, inducing glucosuria. It has been proven that they significantly reduce glycated hemoglobin (HbA1c), along with fasting and postprandial plasma glucose in patients with type 2 diabetes mellitus (T2DM). The glucosuria-induced caloric loss as well as the osmotic diuresis significantly decrease body weight and blood pressure, respectively. Given that SGLT2 inhibitors do not interfere with insulin action and secretion, their efficacy is sustained despite the progressive β-cell failure in T2DM. They are well tolerated, with a low risk of hypoglycemia. Their most frequent adverse events are minor: genital and urinal tract infections. Recently, it was demonstrated that empagliflozin presents a significant cardioprotective effect. Although the SGLT2 inhibitors' efficacy is affected by renal function, new data have been presented that some SGLT2 inhibitors, even in mild and moderate renal impairment, induce significant HbA1c reduction. Moreover, recent data indicate that SGLT2 inhibition has a beneficial renoprotective effect. The role of this review paper is to explore the current evidence on the renal effects of SGLT2 inhibitors.

Sodium-glucose co-transporter-2 inhibitors suppress atrial natriuretic peptide secretion in patients with newly diagnosed Type 2 diabetes

AIMS

To observe changes in atrial natriuretic peptide levels after treatment with sodium-glucose co-transporter-2 inhibitors in patients with newly diagnosed type 2 diabetes.

METHODS

A total of 28 patients with newly diagnosed Type 2 diabetes and HbA_1c levels of 58 -91 mmol/mol (7.5-10.5%) were randomly selected to receive sodium-glucose co-transporter-2 inhibitor treatment (n = 18) or placebo (n = 10) for 24 weeks. We analysed atrial natriuretic peptide concentrations, using an enzyme-linked immunosorbent assay. In addition, sodium and HbA_1c levels were measured at baseline, 12 weeks and 24 weeks and blood lipid levels and insulin sensitivities at baseline and 24 weeks.

RESULTS

Compared with patients treated with placebo, patients who received sodium-glucose co-transporter-2 inhibitor treatment exhibited lower atrial natriuretic peptide levels (36.74 vs 56.90 pg/ml in the placebo group; P < 0.05) and higher sodium levels (144.3 vs 141.4 mmol/l in the placebo group; P < 0.01) at 24 weeks, after adjusting for baseline values. HbA_1c levels were lower after sodium-glucose co-transporter-2 inhibitor treatment compared with placebo (51 vs 60 mmol/mol; P < 0.01). No correlation was found between atrial natriuretic peptide and HbA_1c levels. Homeostatic model assessment of β-cell function values and lipid profiles were generally similar after 24 weeks of treatment with placebo or sodium-glucose co-transporter-2 inhibitor.

CONCLUSIONS

This study shows the ability of sodium-glucose co-transporter-2 inhibitors to lower atrial natriuretic peptide levels and improve glycaemic control, which may benefit the cardiovascular system.

Rationale and design of a randomized trial to test the safety and non-inferiority of canagliflozin in patients with diabetes with chronic heart failure: the CANDLE trial

Background

Because type 2 diabetes mellitus is associated strongly with an increased risk of cardiovascular diseases, the number of patients with diabetes with chronic heart failure is increasing steadily. However, clinical evidence of therapeutic strategies in such patients is still lacking. A recent randomized, placebo-controlled trial in patients with type 2 diabetes with high cardiovascular risk demonstrated that the SGLT2 inhibitor, empagliflozin, reduced the incidence of hospitalization for heart failure. Because SGLT2 inhibitors cause a reduction in body weight and blood pressure in addition to improving glycemic control, they have the potential to exert beneficial effects on the clinical pathophysiology of heart failure. The aim of the ongoing CANDLE trial is to test the safety and non-inferiority of canagliflozin, another SGLT2 inhibitor, compared with glimepiride, a sulfonylurea agent, in patients with type 2 diabetes mellitus and chronic heart failure.

Methods

A total of 250 patients with type 2 diabetes who are drug-naïve or taking any anti-diabetic agents and suffering from chronic heart failure with a New York Heart Association classification I to III will be randomized centrally into either canagliflozin or glimepiride groups (1: 1) using the dynamic allocation method stratified by age (<65, ≥65 year), HbA1c level (<6.5, ≥6.5 %), and left ventricular ejection fraction (<40, ≥40 %). After randomization, all the participants will be given the add-on study drug for 24 weeks in addition to their background therapy. The primary endpoint is the percentage change from baseline in NT-proBNP after 24 weeks of treatment. The key secondary endpoints after 24 weeks of treatment are the change from baseline in glycemic control, blood pressure, body weight, lipid profile, quality of life score related to heart failure, and cardiac and renal function.

Discussion

The CANDLE trial is the first to assess the safety and non-inferiority of canagliflozin in comparison with glimepiride in patients with type 2 diabetes with chronic heart failure. This trial has the potential to evaluate the clinical safety and efficacy of canagliflozin on heart failure.

Trial registration Unique trial Number, UMIN000017669

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0381-x) contains supplementary material, which is available to authorized users.

Ipragliflozin: first global approval

Ipragliflozin (Suglat® [Japan]), an orally active, next-generation sodium-glucose transporter 2 (SGLT2) inhibitor, has been developed by Astellas Pharma and Kotobuki Pharmaceutical for the treatment of type 2 diabetes mellitus. Ipragliflozin has received its first global approval in this indication in Japan, for use as monotherapy or in combination with another antihyperglycaemic agent (metformin, pioglitazone, a sulfonylurea, an α-glucosidase inhibitor, a dipeptidylpeptidase-4 inhibitor or nateglinide). Ipragliflozin is the first SGLT2 inhibitor to be approved in Japan. This article summarizes the milestones in the development of ipragliflozin leading to this first approval for the treatment of type 2 diabetes mellitus.

Analysis of the efficacy of SGLT2 inhibitors using semi-mechanistic model

The Renal sodium-dependent glucose co-transporter 2 (SGLT2) is one of the most promising targets for the treatment of type 2 diabetes. Two SGLT2 inhibitors, dapagliflozin, and canagliflozin, have already been approved for use in USA and Europe; several additional compounds are also being developed for this purpose. Based on the in vitro IC₅₀ values and plasma concentration of dapagliflozin measured in clinical trials, the marketed dosage of the drug was expected to almost completely inhibit SGLT2 function and reduce glucose reabsorption by 90%. However, the administration of dapagliflozin resulted in only 30–50% inhibition of reabsorption. This study was aimed at investigating the mechanism underlying the discrepancy between the expected and observed levels of glucose reabsorption. To this end, systems pharmacology models were developed to analyze the time profile of dapagliflozin, canagliflozin, ipragliflozin, empagliflozin, and tofogliflozin in the plasma and urine; their filtration and active secretion from the blood to the renal proximal tubules; reverse reabsorption; urinary excretion; and their inhibitory effect on SGLT2. The model shows that concentration levels of tofogliflozin, ipragliflozin, and empagliflozin are higher than levels of other inhibitors following administration of marketed SGLT2 inhibitors at labeled doses and non-marketed SGLT2 inhibitors at maximal doses (approved for phase 2/3 studies). All the compounds exhibited almost 100% inhibition of SGLT2. Based on the results of our model, two explanations for the observed low efficacy of SGLT2 inhibitors were supported: (1) the site of action of SGLT2 inhibitors is not in the lumen of the kidney's proximal tubules, but elsewhere (e.g., the kidneys proximal tubule cells); and (2) there are other transporters that could facilitate glucose reabsorption under the conditions of SGLT2 inhibition (e.g., other transporters of SGLT family).

A Novel Therapeutic Agent for Type 2 Diabetes Mellitus: SGLT2 Inhibitor

Type 2 diabetes mellitus (T2DM) is a complex endocrine and metabolic disorder, and a major public health problem that is rapidly increasing in prevalence. Although a wide range of pharmacotherapies for glycemic control is now available, management of T2DM remains complex and challenging. The kidneys contribute immensely to glucose homeostasis by reabsorbing glucose from the glomerular filtrate. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, a new class of antidiabetic agents that inhibit glucose absorption from the kidney independent of insulin, offer a unique opportunity to improve the outcomes of patients with T2DM. In this review, we provide an overview of two globally-approved SGLT2 inhibitors, dapagliflozin and canagliflozin, and discuss their effects and safety. This information will help clinicians to decide whether these drugs will benefit their patients.

Efficacy and safety of monotherapy with the novel sodium/glucose cotransporter-2 inhibitor tofogliflozin in Japanese patients with type 2 diabetes mellitus: a combined Phase 2 and 3 randomized, placebo-controlled, double-blind, parallel-group comparative study

BACKGROUND

In recent years, several oral antidiabetic drugs with new mechanisms of action have become available, expanding the number of treatment options. Sodium/glucose cotransporter-2 (SGLT2) inhibitors are a new class of oral antidiabetic drugs with an insulin-independent mechanism promoting urinary glucose excretion. We report the results of a combined Phase 2 and 3 clinical study (Japic CTI-101349) of the SGLT2 inhibitor tofogliflozin (CSG452, RG7201) in Japanese patients with type 2 diabetes mellitus.

METHODS

The efficacy and safety of tofogliflozin were assessed in this multicenter, placebo-controlled, randomized, double-blind parallel-group study involving 230 patients with type 2 diabetes mellitus with inadequate glycemic control on diet/exercise therapy. Between 30 October 2010 and 28 February 2012, patients at 33 centers were randomized to either placebo (n = 56) or tofogliflozin (10, 20, or 40 mg; n = 58 each) orally, once daily for 24 weeks. The primary efficacy endpoint was the change from baseline in HbA1c at week 24.

RESULTS

Overall, 229 patients were included in the full analysis set (placebo: n = 56; tofogliflozin 10 mg: n = 57; tofogliflozin 20 and 40 mg: n = 58 each). The least squares (LS) mean change (95% confidence interval) from baseline in HbA1c at week 24 was -0.028% (-0.192 to 0.137) in the placebo group, compared with -0.797% (-0.960 to -0.634) in the tofogliflozin 10 mg group, -1.017% (-1.178 to -0.856) in the tofogliflozin 20 mg group, and -0.870% (-1.031 to -0.709) in the tofogliflozin 40 mg group (p < 0.0001 for the LS mean differences in all tofogliflozin groups vs placebo). There were also prominent decreases in fasting blood glucose, 2-h postprandial glucose, and body weight in all tofogliflozin groups compared with the placebo group. The main adverse events were hyperketonemia, ketonuria, and pollakiuria. The incidence of hypoglycemia was low. Furthermore, most adverse events were classified as mild or moderate in severity.

CONCLUSIONS

Tofogliflozin 10, 20, or 40 mg administered once daily as monotherapy significantly decreased HbA1c and body weight, and was generally well tolerated in Japanese patients with type 2 diabetes mellitus. Phase 3 studies were recently completed and support the findings of this combined Phase 2 and 3 study.

TRIAL REGISTRATION

This study was registered in the JAPIC clinical trials registry (ID: Japic CTI-101349).

Drug treatment of type 2 diabetes mellitus in patients for whom metformin is contraindicated

Metformin is considered an initial drug of choice for type 2 diabetes mellitus by leading recommendations. When contraindications to its use exist or patients cannot tolerate it due to adverse effects, clinicians have a variety of other classes of agents to treat hyperglycemia associated with type 2 diabetes mellitus. Each class of agent has its own benefit and safety profile. There are numerous factors to consider when selecting another agent in lieu of metformin including, but not limited to, overall efficacy in A1c reduction, adverse effect profile, cost, and patient preference. The number of factors influencing the decision process presents challenges and often no one specific agent is ideal. Each pharmacotherapeutic class of agents alternative to metformin for the treatment of hyperglycemia in type 2 diabetes mellitus as initial monotherapy is reviewed.

Sodium glucose co-transport 2 inhibitors in the treatment of type 2 diabetes mellitus: a meta-analysis of randomized double-blind controlled trials

BACKGROUND

The discovery of sodium-glucose co-transporter 2 (SGLT2) inhibitors, with a novel mechanism independent of insulin secretion or sensitization, bring about a new therapeutic approach to the management of type 2 diabetes mellitus. The aim of this meta-analysis was to evaluate the safety and efficacy of SGLT2 inhibitors at different doses in randomized double blind clinical trials.

METHODS

This meta-analysis was conducted by including randomized double-blind controlled trials of SGLT2 inhibitors in patients with type 2 diabetes irrespective of their antidiabetic drug exposure history but with an inadequate glycemic control. All the effect sizes were computed using the random effects model. Standardized mean differences (SMDs) and odds ratios (OR) were computed for continuous and dichotomous variables, respectively. Additional analyses like sensitivity analysis, subgroup analysis and meta-regression were also performed.

RESULTS

The pooled analyses demonstrated a significant reduction in mean changes in Hemoglobin A1c (HbA1c) (SMD = -0.78%, 95% CI, -0.87 to -0.69), fasting plasma glucose (FPG) (SMD = -0.70 mg/dl, 95% CI, -0.79 to -0.61), body weight (overall SMD = -0.59 kg, 95% CI, -0.65 to -0.52) and blood pressure from baseline with SGLT2 inhibitors based therapy. Consistently a significant number of patients treated with SGLT2 inhibitors achieved HbA1c < 7% (OR = 2.09, 95% CI, 1.77 to 2.46). SGLT2 inhibitors based therapy was associated with adverse events like genital and urinary tract infections.

CONCLUSION

All studied doses of SGLT2 inhibitors, either as monotherapy or in combination with other antidiabetic agents, consistently improved glycemic control in patients with type 2 diabetes. However, a small percentage of patients suffer from genital and urinary tract infections.

Investigational anti-hyperglycemic agents: the future of type 2 diabetes therapy?

As the pandemic of type 2 diabetes spreads globally, clinicians face many challenges in treating an increasingly diverse patient population varying in age, comorbidities, and socioeconomic status. Current therapies for type 2 diabetes are often unable to alter the natural course of the disease and provide durable glycemic control, and side effects in the context of individual patient characteristics often limit treatment choices. This often results in the progression to insulin use and complex regimens that are difficult to maintain. Therefore, a number of agents are being developed to better address the pathogenesis of type 2 diabetes and to overcome limitations of current therapies. The hope is to provide more options for glucose lowering and complication reduction with less risk for hypoglycemia and other adverse effects. These agents include newer incretin-based therapies and PPAR agonists, as well as new therapeutic classes such as sodium-coupled glucose cotransporter 2 inhibitors, free fatty acid receptor agonists, 11-β-hydroxysteroid dehydrogenase type 1 inhibitors, glucokinase activators, and several others that may enter clinical use over the next decade. Herein we review these agents that are advancing through clinical trials and describe the rationale behind their use, mechanisms of action, and potential for glucose lowering, as well as what is known of their limitations.