SGLT2 inhibitor

Source: Wikipedia, the free encyclopedia.


SGLT2 inhibitors (also called gliflozins or flozins) are a class of medications that inhibit

body weight and systolic and diastolic blood pressure.[5]

Medical uses

The 2022

pharmacological therapy for type 2 diabetes (usually together with metformin), specifically in patients with chronic kidney disease, cardiovascular disease or heart failure.[6]

A

DPP-4 inhibitors demonstrated that use of SGLT2 inhibitors was associated with a 20% reduction in death compared with placebo or no treatment.[7] Another systematic review discussed the mechanisms by which SGLT-2 inhibitors improve cardio-renal function in patients with type 2 diabetes, emphasizing the impacts in improving neural tone.[8]

A meta-analysis including 13 cardiovascular outcome trials found that SGLT-2 inhibitors reduce the risk for three-point

GLP-1 receptor agonists were more beneficial in persons with higher eGFR.[9] Likewise, the risk reduction due to SGLT-2 inhibitors was larger in populations with a higher proportion of albuminuria, but this relationship was not observed for GLP-1 receptor agonists. This suggests a differential use of the two substance classes in patients with preserved and reduced renal function or with and without diabetic nephropathy, respectively.[9]

Two reviews have concluded that SGLT2 inhibitors benefit patients with atherosclerotic major adverse cardiovascular events (MACE).[10][11] One of those studies defined MACE as the composite of myocardial infarction, stroke, or cardiovascular death.[10]

Adverse effects

Genital infections seem to be the most common

osmotic diuresis were higher in patients treated with gliflozins.[citation needed
]

In May 2015, the

FDA issued a warning that gliflozins can increase risk of diabetic ketoacidosis (DKA, a serious condition in which the body produces high levels of blood acids called ketones).[12] By reducing glucose blood circulation, gliflozins cause less stimulation of endogenous insulin secretion or lower dose of exogenous insulin that results in diabetic ketoacidosis. They can specifically cause euglycemic DKA (euDKA, DKA where the blood sugar is not elevated) because of the renal tubular absorption of ketone bodies.[13] A particularly high risk period for ketoacidosis is the perioperative period. SGLT2 inhibitors may need to be discontinued before surgery, and only recommended when someone is not unwell, is adequately hydrated and able to consume a regular diet.[14] Symptoms of ketoacidosis include nausea, vomiting, abdominal pain, tiredness, and trouble breathing.[15] To lessen the risk of developing ketoacidosis after surgery, the FDA has approved changes to the prescribing information for SGLT2 inhibitor diabetes medicines to recommend they be stopped temporarily before scheduled surgery. Canagliflozin, dapagliflozin, and empagliflozin should each be stopped at least three days before, and ertugliflozin should be stopped at least four days before scheduled surgery.[15]

In September 2015, the FDA issued a warning related to canagliflozin (Invokana) and canagliflozin/metformin (Invokamet) due to decreased bone mineral density and therefore increased risk of bone fractures. Using gliflozins in combination therapy with metformin can lower the risk of hypoglycemia compared to other type 2 diabetes treatments such as sulfonylureas and insulin.[12]

Increased risk of lower

limb amputation is associated with canagliflozin but further data is needed to confirm this risk associated with different gliflozins.[16] A European Medicines Agency review concluded that there is a potential increased risk of lower limb amputation (mostly affecting the toes) in people taking canagliflozin, dapagliflozin and empagliflozin.[17]

In August 2018, the FDA issued a warning of an increased risk of Fournier gangrene in patients using SGLT2 inhibitors.[18] The absolute risk is considered very low.[19]

In the FDA Adverse Event Reporting System an increase was reported in events of acute kidney injury associated with SGLT2 inhibitors,[20][21] though data from clinical trials actually showed a reduction in such events with SGLT-2 treatment.[22]

Interactions

Interactions are important for SGLT2 inhibitors because most people with type 2 diabetes are taking many other medications. Gliflozins appear to increase the diuretic effect of

diuretics and may increase the risk of dehydration and hypotension.[23] It is important to adjust the dose of antidiabetics if the treatment is combination therapy to avoid hypoglycemia. For example, interactions with sulfonylureas have led to severe hypoglycemia presumably due to cytochrome P450.[24]

Members

These are the known members of the gliflozin class:

  • Bexagliflozin was approved in the United States under the brand name Brenzavvy in January 2023.[25]
  • Canagliflozin was the first SGLT2 inhibitor to be approved for use in the United States. It was approved in March 2013, under the brand name Invokana and it was also marketed throughout the EU under the same name.[26][27]
  • Dapagliflozin, approved under the name Forxiga, was approved by the EU in 2012, the first SGLT2 inhibitor approved anywhere.[28] It was approved for use in the United States under the brand name Farxiga by the FDA in January 2014.[29] It was the first oral treatment, in combination with insulin, to treat type 1 diabetes in the UK and EU.
  • Empagliflozin, approved in the United States in August 2014, under the brand name Jardiance by Boehringer Ingelheim.[30] Of the gliflozins, empagliflozin and tofogliflozin have the highest specificity for SGLT2 inhibition.[1] This oral medicine for type 2 diabetes has been shown to reduce the risk of cardiovascular death.[31]
  • Ertugliflozin was approved in the United States under the brand name Steglatro in December 2017.[32]
  • Ipragliflozin, produced by the Japanese company Astellas Pharma Inc. under the brand name Suglat, approved in Japan January 2014.[33][34]
  • Luseogliflozin, developed by Taisho Pharmaceutical, was approved in Japan in March 2014 under the brand name Lusefi.[35]
  • Remogliflozin etabonate was commercially launched first in India by Glenmark in May 2019.
  • Sergliflozin etabonate discontinued after Phase II trials.[36]
  • Sotagliflozin (Inpefa) is a dual SGLT1/SGLT2 inhibitor approved by the FDA in May 2023, to reduce the risk of cardiovascular death, hospitalization for heart failure, and urgent heart failure visit in adults with heart failure or type 2 diabetes, chronic kidney disease, and other cardiovascular risk factors.[37][38]
  • Tofogliflozin, developed by Sanofi and Kowa Pharmaceutical, was approved in Japan in March 2014, under the brand names Apleway and Deberza.[39]
  • Henagliflozin, selective SGLT2 inhibitor. Approved in China.
  • Janagliflozin.
  • Mizagliflozin
  • Velagliflozin Proline hydrate
  • Enavogliflozin

Mechanism of action

Sodium Glucose cotransporters (SGLTs) are proteins that occur primarily in the kidneys and play an important role in maintaining glucose balance in the blood.

glucosuria).[41][42]

Reabsorption of glucose in the nephron

The mechanism of action on a cellular level is not well understood. Work is underway to define this mechanism as a prodiuretic with great promise. However, it has been shown that binding of different sugars to the glucose site affects the orientation of the aglycone in the access vestibule. So when the aglycone binds it affects the entire inhibitor. Together these mechanisms lead to a synergistic interaction. Therefore, variations in the structure of both the sugar and the aglycone are crucial for the pharmacophore of SGLT inhibitors.[43]

Dapagliflozin is an example of an SGLT-2 inhibitor, it is a competitive, highly selective inhibitor of SGLT. It acts via selective and potent inhibition of SGLT-2, and its activity is based on each patient's underlying

antidiabetic medications. Functional pancreatic β-cells are not necessary for the activity of the medication so it is convenient for patients with diminished β-cell function.[41][42]

endothelial cells into the interstitial glucose transporter protein.[41][42][44]

TABLE 1: Where are SGLTs expressed?
SGLT Expressed in human tissues
SGLT1 Intestine, trachea, kidney, heart, brain, testis, prostate
SGLT2 Kidney, brain, liver, thyroid, muscle, heart

Ratios of activity between SGLT1 and SGLT2 may be helpful in defining expression.

Pharmacology

The

pharmacokinetic parameters of various medications of this class are present in table 2. These medications are excreted in the urine as inactive metabolites.[44][45][46][47]

TABLE 2: PHARMACOKINETIC PARAMETERS OF VARIOUS SGLT-2 INHIBITORS[48]
Name of drug Bioavailability Protein binding tmax (hours) t1/2 (hours) Cmax SGLT2 selectivity over SGLT1
Canagliflozin 65% (300 mg dose) 99% 1–2 10.6 (100 mg dose); 13.1 (300 mg dose) 1096 ng/mL (100 mg dose); 3480 ng/mL (300 mg dose) 250 fold
Dapagliflozin 78% 91% 1–1.5 12.9 79.6 ng/mL (5 mg dose); 165.0 ng/mL (10 mg dose) 1200 fold
Empagliflozin 90–97% (mice); 89% (dogs); 31% (rats) 86.20% 1.5 13.2 (10 mg dose); 13.3h (25 mg dose) 259nmol/L (10 mg dose); 687nmol/L (25 mg dose) 2500 fold
Ertugliflozin 70-90% 95% 0.5-1.5 11-17 268 ng/mL (15 mg dose) 2000 fold
Ipragliflozin (50 mg) 90% 96.30% 1 15–16 (50 mg dose) 975 ng/mL 360 fold
Luseogliflozin 35.3% (male rats); 58.2% (female rats); 92.7% (male dogs) 96.0–96.3% 0.625±0.354 9.24±0.928 119±27.0 ng/mL 1650 fold
Tofogliflozin (10 mg) 97.50% 83% 0.75 6.8 489 ng/mL 2900 fold

In studies that were made on healthy people and people with type 2 diabetes, who were given dapagliflozin in either single ascending dose (SAD) or multiple ascending dose (MAD) showed results that confirmed a

excretion by the kidney.[49]

Dapagliflozin disposition is not evidently affected by BMI or

dose-dependent increases excretions in urinary glucose, up to 47g/d following single-dose administration, which can be expected from its mechanism of action, dapagliflozin.[50]

Some studies found that dapagliflozin is associated with a decrease in body weight which is statistically superior compared to placebo or other active comparators.[50][44] It is primarily associated with caloric rather than fluid loss.[50][44]

In contrast with other

FGF21), they are more cardioprotective than the other medications used to treat diabetes.[51]

Structure-activity relationship

The

structure-activity relationship
(SAR) of gliflozins is not fully understood.

The most common gliflozins are dapagliflozin, empagliflozin and canagliflozin. The differences in the structures is relatively small. The general structure includes a glucose sugar with an

anomeric carbon. In addition to the glucose sugar moiety and the β-isomeric aryl substituent the aryl group is composed of a diarylmethylene
structure.

The synthesis of Gliflozins involves three general steps. The first one is the construction of the aryl substituent, the next one is the introduction of the aryl moiety onto the sugar or glucosylation of the aryl substituent and the last one the deprotection and modification of the arylated anomeric center of the sugar.[52]

Phlorizin was the first type of gliflozin and it was non-selective against SGLT2/SGLT1. It is a natural O-aryl glycoside composed of a d-glucose and an aromatic ketone.[53] However Phlorizin is very unstable, it is rapidly degraded by glucosidases in the small intestines, so it can not be used as an oral administration medication to treat diabetes. Structural modifications have been made to overcome this instability problem. The most efficient way was to conjugate aryl moiety with glucose moiety since C-glucosides are more stable in the small intestines than O-glucoside derivatives (C-C bond instead of C-O-C bond).[54]

Phlorizin

In the sugar analogues of dapagliflozin, the β-C series are more active than α-C series so it is critical that the β-configuration is at C-1 for the inhibitory activity.[55] Both dapagliflozin and empagliflozin contain a chlorine (Cl) atom in their chemical structure. Cl is a halogen and it has a high electronegativity. This electronegativity withdraws electrons off the bonds and therefore it reduces the metabolism. The Cl atom also reduces the IC50 value of the medication so the medication has better activity. The carbon-fluorine bond (C-F) has also has a very low electron density.[55]

Dapagliflozin
Empagliflozin

For example, in the chemical structure of canagliflozin a fluorine atom is connected to an aromatic ring then the compound is more stable and the metabolism of the compound is reduced. Empagliflozin contains a tetrahydrofuran ring but not canagliflozin nor dapagliflozin.[56]

Canagliflozin

In the development of gliflozins the distal ring contains a thiophene ring instead of an aromatic ring. However the final chemical structures of the marketing gliflozins does not contain this thiophene ring.[57]

History

Main article: Discovery and development of gliflozins

Research

SGLT2 inhibitors increase circulating ketone body concentrations.[58] The cardioprotective effects of SGLT2 inhibitors have been attributed to the elevated ketone levels.[59]

Gliflozins have been posited to exhibit protective effects on the heart, liver, kidneys, anti‐hyperlipidemic, anti‐atherosclerotic, anti‐obesity, anti‐neoplastic effects in in vitro, pre‐clinical, and clinical studies. Pleiotropic effects of this class have been attributed to a variety of its pharmacodynamic actions such as natriuresis, hemoconcentration, deactivation of renin-angiotensin-aldosterone system, ketone body formation, alterations in energy homeostasis, glycosuria, lipolysis, anti‐inflammatory, and antioxidative actions.[60][3]

SGLT2 inhibitors have shown beneficial effects on liver function in clinical trials on individuals with

NAFLD and type 2 diabetes, and also on those without type 2 diabetes.[61][62]

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External links
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