Selective Sodium-glucose Cotransporter 2 Research Articles

The effect of renal function on the pharmacokinetics and pharmacodynamics of enavogliflozin, a potent and selective sodium-glucose cotransporter-2 inhibitor, in type 2 diabetes.

To explore the effect of renal function on the pharmacokinetic (PK) and pharmacodynamic (PD) profile and safety of enavogliflozin, a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor, in patients with type 2 diabetes mellitus (T2DM). An open-label, two-part clinical trial was conducted in T2DM patients, stratified by renal function: Group 1, normal renal function; Group 2, mild renal impairment (RI); Group 3, moderate RI; and Group 4, severe RI. In Part A, Groups 2 and 4 received enavogliflozin 0.5 mg once. In Part B, Groups 1 and 3 received enavogliflozin 0.5 mg once daily for 7 days. Serial blood and timed urine samples were collected to analyse the PK and PD characteristics of enavogliflozin. Pearson's correlation coefficients were calculated to assess the correlations between PK or PD parameters and creatinine clearance (CrCL). A total of 21 patients completed the study as planned. The area under the curve (AUC) for enavogliflozin was not significantly correlated with CrCL, although the maximum concentration slightly decreased as renal function decreased. By contrast, daily urinary glucose excretion (UGE) was positively correlated with CrCL after both single- (r = 0.7866, p < 0.0001) and multiple-dose administration (r = 0.6606, p = 0.0438). Systemic exposure to oral enavogliflozin 0.5 mg was similar among the patients with T2DM regardless of their renal function levels. However, the glucosuric effect of enavogliflozin decreased with RI. Considering the UGE observed and approved therapeutic use of other SGLT2 inhibitors, the efficacy of enavogliflozin with regard to glycaemic control could be explored in patients with mild and moderate RI (estimated glomerular filtration rate ≥30 or ≥45 mL/min/1.73 m2) in a subsequent larger study.

A272 EFFECTS OF EMPAGLIFLOZIN ON CHEMICALLY INDUCED COLITIS IN A MOUSE MODEL ARE MODULATED BY SEX AND DIETARY INTERACTIONS

Abstract Background High sugar diets have been shown to dramatically increase disease severity in mouse models of colitis. Empagliflozin (EMPA) is a highly selective sodium glucose cotransporter-2 (SGLT2) inhibitor that is used therapeutically as an antihyperglycemic agent in the management of type 2 diabetes. In human trials EMPA treatment exerts potent anti-inflammatory effects independently of glycemic control. Further, we have previously demonstrated in a genetic mouse model of colitis that EMPA treatment was highly effective in improving colonic inflammation. Based on these findings, we hypothesized that EMPA treatment may also be effective in mitigating disease severity in chemically induced colitis in mice fed a high sugar diet. Aims The aim of this study was to examine the effects of treatment with EMPA on chemically induced colitis in mice fed a high sugar diet Methods At 6-8 weeks of age, wild-type 129/SvEv mice were placed on chow (CH) or high sugar diet (HS) (50% sucrose: AIN76A) ± EMPA (10mg/kg). After two days on the diet, mice were administered dextran sodium sulfate (DSS) for 5 days in drinking water followed by water alone for 2 days (n=4-6 mice for all groups). Disease activity index (DAI) was calculated daily from animal weight change, stool consistency, and stool hemoccult. As a measurement of degree of healing, colonic tissues were evaluated at day 9 for histological changes, weight-to-length ratio, and cytokine levels by ELISA. As a measure of EMPA functionality, urinary and blood glucose levels were measured. Results Mice on the HS diet demonstrated increased susceptibility to colitis compared with chow fed mice with increased colonic levels of IL-1β, weight loss, and DAI. Significant interactions between sex and diet were seen in responses to EMPA treatment. EMPA treatment did not alter severity of colitis but did significantly delay healing in male mice on both the HS and chow diets as evidenced by increased DAI and increased enterocyte injury with increased levels of lamina propria neutrophils and lymphocytes. EMPA treatment did not increase disease severity in females on either diet. No differences were seen in colonic TNFα, IL-10, IL-12p70, or IL-22 between any of the groups. Urinary glucose levels were elevated in mice receiving EMPA and significantly higher in males compared with females (pampersand:003C0.05). EMPA treatment did not alter fasting blood glucose levels. Conclusions A high sugar diet strongly exacerbates disease severity in a sex-dependent manner in a chemically induced model of colitis. Further, contrary to our hypothesis, EMPA treatment did not improve colitis in females and worsened disease in males suggesting that the documented anti-inflammatory effects of EMPA may be condition dependent. Funding Agencies CCC

Selective sodium-glucose cotransporter-2 inhibitors in the improvement of hemoglobin and hematocrit in patients with type 2 diabetes mellitus: a network meta-analysis.

To compare the effects of different selective sodium-glucose cotransporter-2 inhibitors (SGLT2i) on hemoglobin and hematocrit in patients with type 2 diabetes mellitus (T2DM) with a network meta-analysis (NMA). Randomized controlled trials (RCTs) on SGLT2i for patients with T2DM were searched in PubMed, Embase, Cochrane Library, and Web of Science from inception of these databases to July 1, 2023. The risk of bias (RoB) tool was used to evaluate the quality of the included studies, and R software was adopted for data analysis. Twenty-two articles were included, involving a total of 14,001 T2DM patients. SGLT2i included empagliflozin, dapagliflozin, and canagliflozin. The NMA results showed that compared with placebo, canagliflozin 100mg, canagliflozin 300mg, dapagliflozin 10mg, dapagliflozin 2mg, dapagliflozin 50mg, dapagliflozin 5mg, empagliflozin 25mg, and dapagliflozin 20mg increased hematocrit in patients with T2DM, while canagliflozin 100mg, canagliflozin 200mg, canagliflozin 300mg increased hemoglobin in patients with T2DM. In addition, the NMA results indicated that canagliflozin 100mg had the best effect on the improvement of hematocrit, and canagliflozin 200mg had the best effect on the improvement of hemoglobin. Based on the existing studies, we concluded that SGLT2i could increase hematocrit and hemoglobin levels in patients with T2DM, and canagliflozin 100mg had the best effect on the improvement of hematocrit, while canagliflozin 200mg had the best effect on the improvement of hemoglobin. https://www.crd.york.ac.uk/PROSPERO/#loginpage, identifier PROSPERO (CRD42023477103).

An Updated Review on the Chemistry, Biological Characteristics and Analytical Techniques of Dapagliflozin

Background: Globally, type 2 diabetes mellitus (T2DM) prevalence is increasing. A patient must have lifetime therapy for diabetes to manage it and prevent any complications. There are many different medications that can be used to treat Type 2 diabetes. Still, almost all of them concentrate on the declining insulin sensitivity and secretion that are associated with the onset of the illness. Methods: There is growing interest in the development of innovative anti-diabetic medications that are not insulin-reliant because treatments with such insulin-dependent mechanisms of action usually lose their effectiveness over time. One such technique is the inhibition of renal glucose reuptake. Results: Dapagliflozin, the first line of selective sodium-glucose cotransporter 2 inhibitors that re-duce renal glucose reabsorption, is currently being developed as a therapy for Type 2 diabetes. Numerous analytical techniques have been developed for its detection, measurement, and regular quality control procedures. Conclusion: This review deliberates a thorough discussion on the chemistry of Dapagliflozin, all of its pharmacological actions with analytical and bioanalytical analyses, and more information on the clinical trials.

Reversal of fibrosis and portal hypertension by Empagliflozin treatment of CCl4-induced liver fibrosis: Emphasis on gal-1/NRP-1/TGF-β and gal-1/NRP-1/VEGFR2 pathways

To date, liver fibrosis has no clinically approved treatment. Empagliflozin (EMPA), a highly selective sodium-glucose-cotransporter-2 (SGLT2) inhibitor, has shown ameliorative potential in liver diseases without revealing its full mechanisms. Neuropilin-1 (NRP-1) is a novel regulator of profibrogenic signaling pathways related to hepatic stellate cells (HSCs) and hepatic sinusoidal endothelial cells (HSECs) that modulates intrahepatic profibrogenic and angiogenic pathways. Herein, EMPA's antifibrotic potentials and effects on galactin-1 (Gal-1)/NRP-1 signaling pathways have been evaluated in an experimental liver fibrosis rat model by testing different EMPA dose regimens. EMPA treatment brought a dose-dependent decrease in Gal-1/NRP-1 hepatic expression. This was coupled with suppression of major HSCs pro-fibrotic pathways; transforming growth factor-β (TGF-β)/TGF-βRI/Smad2 and platelet-derived growth factor-beta (PDGF-β) with a diminution of hepatic Col 1A1 level. In addition, EMPA prompted a protuberant suppression of the angiogenic pathway; vascular endothelial growth factor (VEGF)/VEGF-receptor-2 (VEGFR-2)/SH2-Domain Containing Adaptor Protein-B (Shb), and reversal of altered portal hypertension (PHT) markers; endothelin-1 (ET-1) and endothelial nitric oxide synthase (eNOS). The amelioration of liver fibrosis was coupled with a remarkable improvement in liver aminotransferases and histologic hepatic fibrosis Ishak scores. The highest EMPA dose showed a good safety profile with minimal changes in renal function and glycemic control. Thus, the current study brought about novel findings for a potential liver fibrosis treatment modality via targeting NRP-1 signaling pathways by EMPA.

Efficacy of Empagliflozin as Add-on Therapy in Patients with Uncontrolled Type 2 Diabetes Mellitus

Background: Metformin is recommended as first-line pharmacotherapy for patients with type 2 Diabetes Mellitus (T2DM) who fail to achieve glycemic control through lifestyle modification. Metformin initially lowers blood glucose, but as diabetes progresses, it alone frequently fails to maintain glycemic control, and additional therapies are required. Empagliflozin is a potent and selective sodium-glucose co-transporter 2 (SGLT2) inhibitor that is effective in reducing blood sugar levels as monotherapy or add-on to existing therapy with significant improvements in glycemic control and weight.&#x0D; Materials &amp; Methods: This quasi-experimental study was conducted in the Department of Pharmacology and Therapeutics in collaboration with Rajshahi Diabetic Association General Hospital, Rajshahi, for one year from January 2021 to December 2021 on 50 uncontrolled T2DM patients (glycosylated hemoglobin, HbA1c &gt; 7.0 to ≤ 10.5%) for more than 12 weeks. The investigating drug, empagliflozin 10 mg (1 tablet) as a once-daily dose, was added to the ongoing treatment of each patient as 3rd line treatment and was followed up at 6 and 12 weeks.&#x0D; Results: The mean FBS at baseline was 10.8 mmol/L, which declined to 8.5 mmol/L at six weeks and then to 7.2 mmol/L after 12 weeks of intervention with Empagliflozin as add-on therapy in patients with uncontrolled T2DM. The overall reduction of FBS from baseline to 12 weeks of intervention was statistically significant (p &lt; 0.001). Simultaneously the mean HbA1c also reduced from 9.4% to 7.7% after six weeks and to 7.1% after 12 weeks of intervention (p &lt; 0.001). The mean systolic and diastolic blood pressures decreased from 129 mmHg to below 120 mmHg (p &lt; 0.001) and 82.3 mmHg to below 80 mmHg (p = 0.029), respectively, after three months of intervention.&#x0D; Conclusion: Empagliflozin as add-on therapy responded well in patients with uncontrolled T2DM (previously treated with metformin combined with either sulfonylurea or DPP-4 inhibitors and/or supplemented by insulin) in achieving glycemic control. &#x0D; TAJ 2022; 36: No-1: 89-95

Canagliflozin alleviates experimentally induced benign prostate hyperplasia in a rat model: exploring potential mechanisms involving mir-128b/EGFR/EGF and JAK2/STAT3 signaling pathways through in silico and in vivo investigations

Benign prostatic hyperplasia (BPH) poses a significant health concern amongst elderly males. Canagliflozin (Cana), a selective sodium-glucose co-transporter 2 (SGLT2) inhibitor, has a powerful anti-inflammatory influence. Nevertheless, its role in treating BPH has not been clarified. Therefore, the study aimed to investigate the potential ameliorative effect of Cana on experimentally induced BPH in rats and explore the underlying mechanisms compared to the standard finasteride (Fin). The study employed histological analysis, biochemical assays using ELISA, and western blotting. Animals were categorized into four groups: Control (2.5 ml/kg CMC, orally + 3 ml/kg olive oil, subcutaneous), BPH (3 mg/kg testosterone, subcutaneous + CMC orally), Fin-treated BPH (5 mg/kg, orally), and Cana-treated BPH (5 mg/kg, orally), for 28 days. The BPH group showed obvious BPH manifestations including an increase in prostate weight (PW), prostate index (PI), dihydrotestosterone (DHT) level, and histological aberrations compared to control. Fin and Cana therapy had a comparable impact. Cana treatment significantly reduced PW and PI, besides it improved prostatic biochemical, and histopathological features compared to BPH, consistent with in silico study findings. Cana was associated with downregulation of the androgen axis, increased miR-128b expression, with a lowered expression of epidermal growth factor (EGF) and its receptor. Phosphorylation of STAT3 and its downstream proliferative markers were significantly reduced suggesting apoptotic activity. Cana markedly rescued the BPH-induced upregulation of IL-1β, and iNOS levels. Altogether, the current study demonstrates that Cana could impede BPH progression, possibly by modulating miR-128b/EGFR/EGF and JAK2/STAT3 pathways and downregulating AR, cyclin D1, and PCNA immunoreactivity.

Pharmacokinetic and Pharmacodynamic Interactions Between Henagliflozin, a Novel Selective SGLT-2 Inhibitor, and Warfarin in Healthy Chinese Subjects

PurposeWhile controlling blood glucose, patients with diabetes and abnormal coagulation should be treated with positive anticoagulation because the hypercoagulable state of their blood is the primary cause of macroangiopathy. The goal of this study was to evaluate the pharmacokinetic and pharmacodynamic (PK/PD) interactions between henagliflozin, a novel selective sodium-glucose cotransporter 2 inhibitor, and warfarin in healthy subjects. MethodsThis single-center, open-label, single-arm clinical study was conducted in 16 healthy male Chinese subjects. According to the study protocol, the PK properties of henagliflozin 10 mg/d and warfarin 5 mg/d were collected and tabulated in accordance with sampling time. All study drugs were given with once-daily administration. Subjects were monitored for adverse reactions and their severity, outcomes, and relationship to study drug. This influences of warfarin on the PK properties of henagliflozin (Cmax,ss and AUCτ,ss), the effects of henagliflozin on the PK properties of warfarin (Cmax, AUC0–t, and AUC0–∞), and the influences of henagliflozin on the PD properties of warfarin (PTmax, PTAUC, INRmax, and INRAUC) were evaluated. FindingsThe geometric mean ratios (GMRs; 90% CIs) of henagliflozin Cmax,ss and AUCτ,ss were 101.75% (96.11%–107.72%) and 102.21% (100.04%–104.42%), respectively. The GMRs (90% CIs) of S- and R-warfarin Cmax, AUC0–t, and AUC0–∞ were as follows: Cmax, 114.31% (106.30%–122.91%) and 115.09% (109.46%–121.01%), respectively; AUC0–t, 120.15% (116.71%–123.69%) and 119.01% (116.32%–121.76%); and AUC0–∞, 120.81% (117.17%–124.58%) and 121.94% (118.90%–125.05%). The GMRs (90% CIs) of warfarin PTmax and PTAUC were 92.73% (91.25%–94.22%) and 97.42% (96.61%–98.24%). The GMRs (90% CIs) of warfarin INRmax and INRAUC were 92.66% (91.17%–94.17%) and 97.36% (96.52%–98.21%). A total of 32 cases of mild adverse events were reported, and were recovered/resolved. There were no serious adverse events reported. ImplicationsNo significant clinically relevant effects on the PK/PD properties of henagliflozin or warfarin were found with coadministration of the two drugs in these healthy male Chinese subjects. Based on these findings, it is expected that henagliflozin and warfarin can be used in combination without dose adjustment. Chinadrugtrials.org.cn identifier: CTR20190240.

Aspects of the safety of hypoglycemic drugs according to the results of clinical trials

The results and the degree of safety of various groups of hypoglycemic drugs are presented. The current work analyzes the safety of the use of glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (iDPP-4) inhibitors, insulins, and inhibitors of sodium glucose cotransporter type 2 (iSGLT-2) according to clinical studies published in the scientific literature. Macrovascular complications in diabetes mellitus (DM) develop much earlier than microvascular complications and are the cause of death in 75–80% of patients. The safety of ongoing hypoglycemic therapy is based on the stabilization of its cardiovascular effect. GLP type 1 receptor agonists (lixisenatide) and DPP-4 idiopathic agonists (alogliptin) demonstrated a positive effect on the prognosis of patients with cardiovascular diseases. In addition to metformin, selective sodium-glucose cotransporter type 2 inhibitors, in particular empagliflozin and GLP type 1 analogs, act as first-line drugs from the position of cardiovascular safety in the treatment of patients with type 2 diabetes with a very high cardiovascular risk (liraglutide). The action of iSGLT-2 is glucose-dependent, which leads to a lower risk of hypoglycemia and, accordingly, cardiovascular safety for this class of drugs. Empagliflozin prevents the progression of cardiovascular disease in patients with type 2 diabetes, with heart failure with reduced ejection fraction, regardless of the presence of diabetes, providing a holistic approach to the management of patients with a cardiac profile.

Abstract 362: Pharmacologic Blockade Of Sodium-glucose Cotransporter-2 Inhibits Vascular Smooth Muscle Cell Calcification

Background: Empagliflozin (Empa) is a highly selective sodium glucose cotransporter-2 (SGLT2) inhibitor used to reduce the risk of cardiovascular death. Empa reduces arterial stiffness and blood pressure in humans, as well as atherosclerosis and intimal hyperplasia in preclinical models, though the mechanisms underlying these effects are poorly defined. We investigated effects of Empa on the calcification of human coronary artery smooth muscle cells (SMCs). Methods: To determine the effect of Empa on SMC calcification triggered by high phosphate (HP) conditions, SMCs were cultured in standard ( i.e. , normal phosphate [NP]) medium, HP medium, or HP medium containing Empa (2.5 μM). After 12-days, SMC calcification was quantified by the alizarin red staining method with results quantified by comparison to a standard curve and normalized to NP control. Similar methods were used to study effects of Empa on SMC calcification induced by platelet-derived growth factor-BB (50 ng/mL). Effects of Empa on angiotensin II-induced SMC senescence, a precursor of cell calcification, were studied by quantifying senescence-associated β galactosidase activity. Real-time reverse transcriptase PCR was used to study gene expression of Runx2, a master regulator of SMC osteogenic transition. Results: Empa significantly decreased HP-induced SMC calcification (1.14±0.11 vs . 1.32±0.11 AU/mL, n=5, p&lt;0.05) and PDGF-BB-induced calcification (1.20±0.17 vs . 1.94±0.22 AU/mL, n=5, p&lt;0.05). Empa significantly inhibited SMC senescence (1.03±0.06 vs . 1.39±0.04, n=5, p&lt;0.05), while decreasing Runx2 gene expression by 77±35% (n=6, p &lt;0.01). Conclusion: Empa significantly inhibits SMC calcification triggered by clinically relevant pathophysiologic stimuli. Empa significantly inhibits SMC senescence and Runx2 gene expression, identifying molecular pathways underpinning Empa’s anti-calcific effect. These findings identify an additional mechanism by which Empa may decrease vascular stiffness and provide insights into how SGLT2 inhibitors exert beneficial effects on vascular diseases dependent on SMC calcification and senescence, including hypertension and atherosclerosis.

Preventive effect of empagliflozin and ezetimibe on hepatic steatosis in adults and murine models

BackgroundEven though many oral glucose-lowering or lipid-lowering agents have already been reported to improve hepatic steatosis to some degree, which drug had a more beneficial effect on hepatic steatosis among those drugs has not been precisely explored. We analysed the effect of empagliflozi, a selective sodium-glucose cotransporter 2 inhibitor, and ezetimibe on developing hepatic steatosis. Methods and resultsUsing 4005,779 patients with type 2 diabetes mellitus (T2DM) or dyslipidemia provided by the Korean National Health Insurance Service (NHIS) between January 2015 and December 2015, we analyzed the odds ratio (OR) of fatty liver development (fatty liver index [FLI] >60). Additionally, we examined the metabolic effects of ezetimibe and empagliflozin in mice fed with a choline-deficient high-fat diet, mimicking the features of human NAFLD. The experiment for agents was performed for the non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH) mouse models independently. In the NHIS data, ORs for the development of fatty liver were significantly lower in all treatment groups than in the reference group, which did not receive ezetimibe or empagliflozin. (Ezetimibe therapy; OR=0.962, empagliflozin therapy; OR=0.527, ezetimibe plus empagliflozin; OR=0.509 compared to reference therapy). Unlike non-alcoholic steatohepatitis mouse model, ezetimibe, empagliflozin, and combination therapy also reduced liver steatosis in the non-alcoholic fatty liver mouse model. ConclusionsCompared with other agents, empagliflozin and/or ezetimibe treatment reduced the risk of developing hepatic steatosis. Our data suggest that empagliflozin or ezetimibe can be primarily considered in type 2 DM or dyslipidemia patients to prevent hepatic steatosis.

Dapagliflozin: A molecule for type-2 diabetes mellitus

Dapagliflozin which is also known as Farxiga in the US and Forxiga in the EU is a drug which was developed by Bristol-Myers Squibb in partnership with Astra Zeneca. It is also available in Oxra and it is marking by Sun Pharmaceutical Industries Ltd. It contains the active substance Dapagliflozin which is the second member of selective sodium glucose co-transporter-2 (SGLT-2) inhibitor and it is the first group among oral anti-diabetic agents which are independent of insulin secretion. The drug Dapagliflozin shows the action of reducing the blood glucose by preventing the reabsorption of glucose at the renal proximal tubule and avoids insulin resistance. It is a new molecule that helps in maintaining the glycemic control either in mono therapy or combinational therapy or add on therapy. This is a review article which summarizes the details of Dapagliflozin.

The Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor Empagliflozin Reverses Hyperglycemia-Induced Monocyte and Endothelial Dysfunction Primarily through Glucose Transport-Independent but Redox-Dependent Mechanisms

Hyperglycaemia-induced oxidative stress and inflammation contribute to vascular cell dysfunction and subsequent cardiovascular events in T2DM. Selective sodium-glucose co-transporter-2 (SGLT-2) inhibitor empagliflozin significantly improves cardiovascular mortality in T2DM patients (EMPA-REG trial). Since SGLT-2 is known to be expressed on cells other than the kidney cells, we investigated the potential ability of empagliflozin to regulate glucose transport and alleviate hyperglycaemia-induced dysfunction of these cells. Primary human monocytes were isolated from the peripheral blood of T2DM patients and healthy individuals. Primary human umbilical vein endothelial cells (HUVECs) and primary human coronary artery endothelial cells (HCAECs), and fetoplacental endothelial cells (HPECs) were used as the EC model cells. Cells were exposed to hyperglycaemic conditions in vitro in 40 ng/mL or 100 ng/mL empagliflozin. The expression levels of the relevant molecules were analysed by RT-qPCR and confirmed by FACS. Glucose uptake assays were carried out with a fluorescent derivative of glucose, 2-NBDG. Reactive oxygen species (ROS) accumulation was measured using the H2DFFDA method. Monocyte and endothelial cell chemotaxis were measured using modified Boyden chamber assays. Both primary human monocytes and endothelial cells express SGLT-2. Hyperglycaemic conditions did not significantly alter the SGLT-2 levels in monocytes and ECs in vitro or in T2DM conditions. Glucose uptake assays carried out in the presence of GLUT inhibitors revealed that SGLT-2 inhibition very mildly, but not significantly, suppressed glucose uptake by monocytes and endothelial cells. However, we detected the significant suppression of hyperglycaemia-induced ROS accumulation in monocytes and ECs when empagliflozin was used to inhibit SGLT-2 function. Hyperglycaemic monocytes and endothelial cells readily exhibited impaired chemotaxis behaviour. The co-treatment with empagliflozin reversed the PlGF-1 resistance phenotype of hyperglycaemic monocytes. Similarly, the blunted VEGF-A responses of hyperglycaemic ECs were also restored by empagliflozin, which could be attributed to the restoration of the VEGFR-2 receptor levels on the EC surface. The induction of oxidative stress completely recapitulated most of the aberrant phenotypes exhibited by hyperglycaemic monocytes and endothelial cells, and a general antioxidant N-acetyl-L-cysteine (NAC) was able to mimic the effects of empagliflozin. This study provides data indicating the beneficial role of empagliflozin in reversing hyperglycaemia-induced vascular cell dysfunction. Even though both monocytes and endothelial cells express functional SGLT-2, SGLT-2 is not the primary glucose transporter in these cells. Therefore, it seems likely that empagliflozin does not directly prevent hyperglycaemia-mediated enhanced glucotoxicity in these cells by inhibiting glucose uptake. We identified the reduction of oxidative stress by empagliflozin as a primary reason for the improved function of monocytes and endothelial cells in hyperglycaemic conditions. In conclusion, empagliflozin reverses vascular cell dysfunction independent of glucose transport but could partially contribute to its beneficial cardiovascular effects.

Emerging treatment of heart failure

The use of selective sodium-glucose cotransporter-2 for heart failure is a new and emerging practice that's imperative for nurses to learn about.

Evaluation of the effects of empagliflozin on acute lung injury in rat intestinal ischemia-reperfusion model.

Empagliflozin is a selective sodium-glucose co-transporter (SGLT2) inhibitor that is approved for the treatment of type 2 diabetes. The beneficial effects of empagliflozin on other organ systems including the heart and kidneys have been proven. The aim of this study is to evaluate the role of empagliflozin on acute lung injury induced by intestinal ischemia-reperfusion (I/R). A total of 27 male Wistar albino rats were divided into three groups: sham, I/R, and I/R + empagliflozin; each group containing nine animals. Sham group rats underwent laparotomy without I/R injury. Rats in the I/R group underwent laparotomy, 1h of after ischemia-reperfusion injury (superior mesenteric artery ligation was followed by 2h of reperfusion). Rats in I/R were given empagliflozin (30mg/kg) by gastric gavage for 7days before the ischemia-reperfusion injury. All animals were killed at the end of reperfusion and lung tissue samples were obtained for immunohistochemical staining and histopathological investigation in all groups. Serum glucose, AST, ALT, creatinine, native thiol, total thiol, and disulfide levels and disulfide-native thiol, disulfide-total thiol, and native thiol-total thiol ratios as well as the IMA levels were analyzed and compared among the groups. While intestinal I/R significantly increases serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatinine levels; did not cause any change in homeostasis parameters and IMA level. Empagliflozin treatment had no significant effect on biochemical parameters. Empagliflozin treatment induced a significant decrease in positive immunostaining for IL-1, IL-6, TNF-alpha, caspase 3, caspase 8, and caspase 9 compared to the I/R group in lung tissue samples. Intestinal I/R caused severe histopathological injury including edema, hemorrhage, increased thickness of the alveolar wall, and infiltration of inflammatory cells into alveolar spaces. Empagliflozin treatment significantly attenuated the severity of intestinal I/R injury. It was concluded that empagliflozin treatment may have beneficial effects in acute lung injury, and, therefore, has the potential for clinical use.

Comparative study on the cardioprotective effect of selective sodium glucose co-transporter 2 inhibitors in a non-diabetic mouse model of myocardial ischemia/reperfusion injury

Comparative study on the cardioprotective effect of selective sodium glucose co-transporter 2 inhibitors in a non-diabetic mouse model of myocardial ischemia/reperfusion injury

Clinical Evaluation of Dapagliflozin in the Management of CKD: Focus on Patient Selection and Clinical Perspectives.

Dapagliflozin is a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor that was recently approved in the USA and the EU for the treatment of adults with chronic kidney disease (CKD) with or without diabetes mellitus (DM). The DAPA-CKD trial showed a 39% decline in the risk of worsening kidney function, onset of end-stage kidney disease, or kidney failure-related death. Patients with lower levels of eGFR and higher levels of albuminuria are among those who stand to gain the greatest absolute benefits. These benefits were similar in both patients with or without diabetes, thus undermining the hypothesis that these drugs mitigate glycemia-related nephrotoxicity. Suggested mechanisms for renal protection include hemodynamic effects; BP reduction and improving salt sensitivities and metabolic effects; and glucose, uric acid and triglycerides (TG)-lowering effects. There have been already many excellent reviews on dapagliflozin and CKD management. Most of them cover both efficacy and safety. This review will focus on clinical perspectives and patient selection for the practicing clinician.

Cardioprotection by selective SGLT2 inhibitors in a non-diabetic mouse model of myocardial ischemia/reperfusion injury: a class or a drug effect?

Abstract Background Empagliflozin (EMPA), Dapagliflozin (DAPA) and Ertugliflozin (ERTU) are selective sodium glucose co-transporter 2 inhibitors (SGLT2i) acting against type 2 diabetes mellitus. Purpose Due to differences in clinical trial outcomes, we aimed to 1) compare the cardioprotective effects of selective SGLT2i in terms of infarct size (IS) reduction and 2) reveal the mechanism of cardioprotection in non-diabetic mice. Methods C57BL/6 mice were randomized and orally received EMPA (10mg/kg/day), DAPA (9.0mg/kg/day), ERTU (9.7mg/kg/day) or vehicle for 7 days. IS was measured after 30' ischemia (I), and 120' reperfusion (R). EMPA, DAPA and ERTU were given at equivalent stoichiometrically doses (ESD). Body weight and fasting blood glucose (FBG) levels were determined at baseline and at the end of the treatment. On the 7th day, mice were housed in metabolic cages for 24 hours. Urine volume (UV), food and water uptake and 24h-glucose levels were determined to examine the extend of SGLT-2 inhibition by the drugs. In a second series, the ischemic myocardium was taken (10'R), shotgun proteomics were performed and several cardioprotective pathways were evaluated. In a third series, the dominant pathways were evaluated through molecular analyses and mitochondrial functionality. The causal relationships in the mechanism of protection, was established by inhibiting the concomitant cardioprotective pathways. Static, the specific STAT-3 inhibitor and wortmannin (a PI3K inhibitor) were administered and IS was measured upon 30'I/120' R. Results EMPA and DAPA but not ERTU reduced IS at this dose. Body weight and FBG levels were not affected by the treatments. EMPA, DAPA and ERTU lead to significant increase in UV and urinary glucose levels compared to the control group independently of the water and food intake. There was no significant difference in the parameters among the different SGLT-2i indicating that the chosen doses are sufficient to produce the same pharmacological SGLT-2 inhibition in mice. Proteomics revealed mitochondrial metabolism and NF-kB signaling as significant. Only EMPA preserved mitochondrial functionality in complex I &amp; II linked oxidative phosphorylation. NF-kB, RISK and STAT-3 activation and the downstream reduction in apoptosis were evident in EMPA and DAPA groups coinciding with IS reduction. Static and wortmannin significantly attenuated IS reduction both in EMPA and DAPA groups indicating that STAT-3 and PI3K activation are the leading mechanisms of cardioprotection. Among several upstream mediators, fibroblast growth factor 2 (FGF-2) and caveolin-3 were increased in EMPA and DAPA groups. Conclusions Short term EMPA, DAPA and ERTU at the chosen ESD inhibit SGLT-2i in a similar extent but only EMPA and DAPA reduce IS. Our study reveals drug specific effects on cardioprotection against I/R injury. Cardioprotection afforded by EMPA and DAPA are STAT-3 and PI3K dependent and associated with increased FGF-2 and Cav-3 expression. Funding Acknowledgement Type of funding sources: None.

Empagliflozin rescues primary murine cardiac fibroblasts, but not cardiomyocytes, from hypoxia-reoxygenation injury through STAT3-mediated cascades

Abstract Introduction Empagliflozin (EMPA) is a selective sodium glucose co-transporter 2 inhibitor (SGLT2i) and an established drug against type 2 diabetes mellitus. Cardiovascular clinical outcome trials on EMPA have shown a reduced mortality rate related to major cardiovascular events, but the precise mechanism of action remains elusive. We have previously proved that chronic EMPA administration reduces infarct size in an in vivo murine model of ischemia / reperfusion injury, irrespective of the diabetic status. The cardioprotective effect of EMPA was attributed to the increase of Signal Transducer and Activator of Transcription 3 (STAT3) phosphorylation. Purpose In this study we aimed to decipher the cell specific effects of EMPA on primary adult ventricular murine cardiomyocytes (pAVMCs) and primary murine cardiac fibroblasts (pMCFs), subjected to hypoxia/reoxygenation (HYP/REO) and to 1) investigate the effect of EMPA on cell death, and 2) reveal the mechanism of cardioprotection. Methods PAVMCs and pMCFs were isolated from adult C57BL/6 murine hearts (n=4–6) and were incubated with EMPA (500nM–100nM) for 24 hours. Cells were then subjected to 3 hours of HYP (99% N2), followed by 1 hour of REO. STATTIC, a selective STAT3 inhibitor was used (500nM–1μM) to determine the contribution of STAT3 on the observed effect. MTT assay was performed at the end of REO to determine cell viability. To unravel the mechanism of cardioprotection, the experimental protocol was repeated, and the cells were either stained with dihydroethidium (DHE) dye to determine relative oxidative stress changes or were harvested for isolation of total protein content. We focused on STAT3 and Akt kinase as key mediators of the cardioprotective survivor activating factor enhancement (SAFE) and the reperfusion injury salvage kinase (RISK) pathways. We also investigated the expression of Cardiotrophin-1 (CT-1), as a potential upstream mediator of STAT3 phosphorylation. Results The evaluation of cell death revealed that pMCFs viability was significantly increased upon EMPA treatment. Added to this, STATTIC co-treatment with EMPA blunted the protective effect on pMCFs, which indicates that EMPA's protection is STAT3-mediated. Oxidative stress remained unaltered by the treatments. Investigation of the molecular pathways that are responsible for the increased viability of pMCFs revealed that EMPA treatment induces an increased phosphorylation of STAT3 and an increase in CT-1 expression, which are both reversed by STATTIC. Akt phosphorylation and expression remained unchanged by EMPA treatment. Notably, the effect of EMPA on pAVMCs' viability was negligible. Conclusion(s) EMPA does not protect pAVMCs, from HYP/REO injury. EMPA rescues the pMCFs in a STAT-3 dependent manner which indicates that EMPA's cardioprotective effect is cell specific and implicates the SAFE pathway. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim International GmbHGrant title: “Investigation of the distinct effects of Empagliflozin on different cell populations of the healthy myocardium”

SGLT-2 inhibition by empagliflozin exerts neutral effects on experimental arterial thrombosis in a murine model of low-grade inflammation

Abstract Introduction Low-grade inflammation couples dysmetabolic states to insulin resistance and atherosclerotic cardiovascular disease (ASCVD). Selective sodium-glucose co-transporter 2 (SGLT-2) inhibition by empagliflozin improves clinical outcomes in patients with ASCVD independently of glucose-lowering. Yet, its mechanism of action remains largely undetermined. Purpose We aimed to test whether empagliflozin affects arterial thrombus formation in baseline conditions or low-grade inflammation, a systemic milieu shared among patients with ASCVD. Methods Sixteen-week-old C57BL/6 mice were randomly assigned to acute administration of empagliflozin (25 mg/kg BW) or vehicle, of which a subgroup was pre-treated biweekly over 4 weeks with super-low-dose lipopolysaccharide (LPS; 5 ng/kg BW), before carotid thrombosis was induced by photochemical injury. The translational value of these findings was investigated in primary human aortic endothelial cells (HAECs) and plasma samples of patients randomized to empagliflozin therapy. Results The between-group difference in doppler-flow probe detected time-to-occlusion (TTO) remained within the predefined equivalence margin (Δ=|10.50|), irrespective of low-grade inflammation (95% confidence interval [CI], −9.82 to 8.85 and −9.20 to 9.69), while glucose dropped by 1.64 and 4.84 mmol/l, respectively (Fig. 1). Ex vivo platelet aggregometry suggests similar platelet activation status, corroborated by unchanged circulating platelet-factor 4 (PF4) plasma levels. In concert, carotid PAI-1 expression and TF activity remained unaltered upon SGLT-2 inhibition, and no difference in plasma D-dimer levels was detected, suggesting comparable coagulation cascade activation and fibrinolytic activity (Fig. 1). In HAECs pre-treated with LPS, empagliflozin neither changed TF activity nor PAI-1 expression (Fig. 2). Accordingly, among patients with established ASCVD or at high cardiovascular (CV) risk randomized to 10 mg empagliflozin daily signatures of thrombotic (i.e., TF) and fibrinolytic activity (i.e., PAI-1) remained unchanged, while plasma glucose declined significantly during 3 months of follow-up (Fig. 2). Conclusion SGLT-2 inhibition by empagliflozin does not impact experimental arterial thrombus formation, neither under baseline conditions nor during sustained low-grade inflammation, and has no impact on proxies of thrombotic/fibrinolytic activity in patients with ASCVD. The beneficial pleiotropic effects of empagliflozin are likely independent of pathways mediating thrombosis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart FoundationFoundation for Cardiovascular Research–Zurich Heart House