Sodium-glucose co-transporter 2 inhibitors and Sarcopenia: A controversy that must be solved

[Hepatogenic diabetes: three cases report and literature review]

Hepatogenic diabetes (HepD) is a form of diabetes where the primary pathogenesis is a liver disease, usually cirrhosis, complicated by the development of portal hypertension with the formation of porto-caval shunts. In the development of HepD, in addition to traditional risk factors for carbohydrate metabolism disorders, the pathogenetic features of liver diseases play a significant role. However, the exact mechanism of HepD development remains unclear, and several questions are still open for discussion. Despite having distinct pathophysiological and clinical features, hepatogenic diabetes is currently not considered as an independent disease. This is likely due to the difficulties in differentiating between types of diabetes due to the bidirectional relationship between glucose metabolism disorders and chronic liver diseases. It is known that diabetes negatively affects the development and progression of chronic liver diseases of various etiologies, and their combination is associated with worse clinical outcomes in terms of mortality, the occurrence of liver decompensation, and the development of hepatocellular carcinoma (HCC). Unfortunately, early diagnosis and the selection of optimal therapeutic strategies for diabetes may be challenging due to the lack of established clinical guidelines and the presence of comorbidities in patients with HepD.

Aerobic, resistance, and specialized exercise training in heart failure with preserved ejection fraction: A state-of-the-art review

Heart failure with preserved ejection fraction (HFpEF) is a growing public health burden, contributing to significant morbidity, mortality, and healthcare costs. Exercise intolerance, a hallmark of HFpEF, stems from central (cardiac and pulmonary) and peripheral (vascular and skeletal muscle) factors that result in reduced oxygen delivery and utilization by active muscles. With relatively few effective therapies, exercise training has emerged as a reliable and proven therapeutic intervention to improve exercise capacity and physical function in HFpEF. This review synthesizes evidence from the existing literature to describe and evaluate various exercise modalities in HFpEF. Moderate-intensity continuous training significantly improves peak oxygen consumption and symptom burden and is supported by a large evidence base in patients with HFpEF. High-intensity interval training has shown potential as an alternative regimen with particular benefit in highly selected populations. Multi-modality regimens and low-intensity training approaches are potentially suitable for patients with limited exercise tolerance or those who are more vulnerable or frail. The addition of resistance training may further improve muscle strength and functional capacity. Integrating exercise interventions with complementary dietary approaches has also shown potential for enhancing exercise capacity response. Lastly, emerging modalities, such as inspiratory muscle training and functional electrical stimulation, offer additional unique options. Despite robust evidence, challenges in the long-term durability of benefits, poor responder rates (~ 1/3 of participants), and implementation persist. Ongoing and future efforts can focus on evaluating long-term clinical outcomes (i.e., mortality and hospitalizations), developing more personalized exercise protocols, and applying sustainable implementation strategies in clinical practice.

Age different effects of SGLT2 inhibitors on body composition in individuals with type 2 diabetes: A retrospective cohort study

PURPOSE

This study investigates the long-term impact of sodium-glucose cotransporter 2 inhibitors (SGLT2i)on body composition in individuals with type 2 diabetes (T2D), with a focus on age-related differences. We evaluated changes in body mass index (BMI), body fat percentage, skeletal muscle mass and skeletal muscle mass index (SMI) over 4.4 years on average.

METHODS

This retrospective, single-center clinical cohort study utilized electronic medical records from the University of Tokyo Hospital. 70 people with T2D treated with SGLT2i for more than two years were included. Body compositions were assessed using bioelectrical impedance analysis (BIA) at three time points: before SGLT2i therapy, 1 year after SGLT2 therapy initiation and the latest along with SGLT2i therapy.

RESULTS

During the 4.4-year average treatment period, significant reductions were observed in BMI (30.5 to 29.1, p < 0.0001) and skeletal muscle mass (30.3 kg to 29.0 kg, p < 0.0001). ΔBMI was positively correlated with ΔBody fat percentage and ΔSkeletal muscle mass (all p < 0.0001). Age-stratified analysis showed that in younger individuals, ΔSkeletal muscle mass was significantly associated with both treatment duration and ΔBMI. In contrast, older individuals showed a weaker correlation between ΔSkeletal muscle mass and ΔBMI, and experienced significant muscle mass decline at an earlier point.

CONCLUSION

SGLT2i are effective in managing T2D and reducing BMI and body fat. However, careful monitoring of body composition is crucial, especially in older individuals, to mitigate the risk of sarcopenia and maintain overall health.

Renin angiotensin system-induced muscle wasting: putative mechanisms and implications for clinicians

Renin angiotensin system (RAS) alters various mechanisms related to muscle wasting. The RAS system consists of classical and non-classical pathways, which mostly function differently. Classical RAS pathway, operates through angiotensin II (AngII) and angiotensin type 1 receptors, is associated with muscle wasting and sarcopenia. On the other hand, the non-classical RAS pathway, which operates through angiotensin 1-7 and Mas receptor, is protective against sarcopenia. The classical RAS pathway might induce muscle wasting by variety of mechanisms. AngII reduces body weight, via reduction in food intake, possibly by decreasing hypothalamic expression of orexin and neuropeptide Y, insulin like growth factor-1 (IGF-1) and mammalian target of rapamycin (mTOR), signaling, AngII increases skeletal muscle proteolysis by forkhead box transcription factors (FOXO), caspase activation and muscle RING-finger protein-1 transcription. Furthermore, AngII infusion in skeletal muscle reduces phospho-Bad (Ser136) expression and induces apoptosis through increased cytochrome c release and DNA fragmentation. Additionally, Renin angiotensin system activation through AT1R and AngII stimulates tumor necrosis factor-α, and interleukin-6 which induces muscle wasting, Last but not least classical RAS pathway, induce oxidative stress, disturb mitochondrial energy metabolism, and muscle satellite cells which all lead to muscle wasting and decrease muscle regeneration. On the contrary, the non-classical RAS pathway functions oppositely to mitigate these mechanisms and protects against muscle wasting. In this review, we summarize the mechanisms of RAS-induced muscle wasting and putative implications for clinical practice. We also emphasize the areas of uncertainties and suggest potential research areas.

Impact of SGLT2 inhibitors on survival in gastrointestinal cancer patients undergoing chemotherapy and/or radiotherapy: a real-world data retrospective cohort study

BACKGROUND

The role of sodium-glucose co-transporter 2 inhibitor (SGLT2i) drugs in the management of diabetes and cardiovascular disease is well-established, but emerging evidence suggests potential effects on cancer outcomes, including gastrointestinal (GI) cancers. We conducted an extensive, sex-oriented, real-world data analysis to investigate whether SGLT2i can enhance GI cancer outcomes when used alongside standard therapies such as chemotherapy and radiotherapy.

METHODS

The study applied a retrospective cohort design with data from the TriNetX research database ( https://trinetx.com ), examining GI cancer patients treated with chemotherapy and/or radiotherapy between 2013 and 2023. The intervention cohort consisted of Gl cancer patients who received SGLT2i, while the control cohort did not. A 5-year follow-up period was used, and baseline characteristics were balanced using a 1:1 propensity score matching technique. Cox proportional-hazards and logistic regression models assessed mortality and morbidity risks between the cohorts.

RESULTS

The study included 6,389 male and 3,457 female patients with GI cancer (ICD-10: C15-C25). The use of SGLT2i was significantly associated with improved survival for both male (HR 0.568; 95% CI 0.534-0.605) and female (HR 0.561; 95% CI 0.513-0.614) patients undergoing chemotherapy and/or radiotherapy. SGLT2i use also correlated significantly with lower hospitalisation rates both in male (OR 0.684; 95% CI 0.637-0.734) and female (OR, 0.590; 95% CI 0.536-0.650) patients. The analysis of GI cancer subtypes also demonstrated similar benefits, without significant adverse effects.

CONCLUSIONS

Repurposing SGLT2 inhibitors for cancer treatment could potentially improve outcomes for GI cancer patients without causing significant side effects. Further clinical trials are needed to confirm these findings and establish the optimal condition for its application in GI cancer treatment.

Mitochondrial DNA variants in the pathogenesis and metabolic alterations of diabetes mellitus

Mitochondrial DNA (mtDNA) variants considerably affect diabetes mellitus by disturbing mitochondrial function, energy metabolism, oxidative stress response, and even insulin secretion. The m.3243 A > G variants is associated with maternally inherited diabetes and deafness (MIDD), where early onset diabetes and hearing loss are prominent features. Other types of mtDNA variants involve genes ND4 and tRNA Ala genes that increase susceptibility to type 2 diabetes. Understanding these variants will provide a basis for developing targeted therapy to improve mitochondrial function and metabolic health. This article reviews the impact of mtDNA variants in diabetes, specifically with regards to the m.3243 A > G variant effects on mitochondrial function and insulin secretion and other mtDNA variants that contribute to diabetes susceptibility, particularly ND4 and tRNA Ala gene variants. Data from extant literature were synthesised to obtain an understanding of how mtDNA variants affect diabetes pathogenesis. The main defect for MIDD is the m.3243 A > G variant, which comprises enhanced susceptibility to metabolic syndrome and type 2 diabetes, followed by mitochondrial dysfunction, insulin resistance, and beta-cell dysfunction. Other mtDNA variants have also been reported to enhance diabetes susceptibility through mitochondrial dysfunction and insulin resistance. Increased production of reactive oxygen species (ROS) resulting from mitochondrial malfunction adds to metabolic and tissue damage. This happens in tissues crucial to glucose homeostasis, and it represents an important contribution of mitochondrial dysfunction to metabolic disturbances in diabetes. These mechanisms would underlie the rationale for developing targeted therapies to preserve mitochondrial function and, hence improve the metabolic health of diabetic patients.

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Comprehensive treatment with dapagliflozin in elderly chronic kidney disease patients: Clinical efficacy and impact on body composition

BACKGROUND

Dapagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, is widely used for treating heart failure and chronic kidney disease (CKD). While its renoprotective effects are well established, concerns remain regarding its impact on muscle mass and function, especially in elderly patients.

OBJECTIVE

To assess the effects of dapagliflozin on renal function, body composition, and muscle strength in elderly CKD patients.

METHODS

Twelve elderly CKD patients (75.6 ± 1.4 years) were treated with dapagliflozin for 12 months. Body composition, serum parameters, and muscle function were evaluated at baseline, 6 months, and 12 months. Measurements included changes in eGFR, liver function, HbA1c, and muscle strength.

RESULTS

Dapagliflozin treatment stabilized eGFR without significant improvement, but proteinuria was notably reduced in most patients, indicating a positive renal effect. AST and ALT levels showed significant reduction after 12 months, suggesting improved liver function. No significant changes were observed in body weight, BMI, or muscle mass. Muscle function, as measured by the 5-sit-to-stand test, improved significantly, while grip strength remained stable. No serious adverse events were reported.

CONCLUSION

Dapagliflozin is a safe and effective treatment for CKD in elderly patients, demonstrating renal protection and improved liver function without adversely affecting muscle mass or strength. The study supports the use of dapagliflozin as part of a comprehensive approach, combining pharmacotherapy, lifestyle modification, and exercise to optimize patient outcomes in CKD management.

Sodium-Glucose Cotransporter 2 Inhibitors Improve Body Composition by Increasing the Skeletal Muscle Mass/Fat Mass Ratio in Patients with Type 2 Diabetes: A 52-Week Prospective Real-Life Study

BACKGROUND

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) induce body weight loss, but their effect on skeletal muscle mass (SMM) and strength needs to be better elucidated.

OBJECTIVES

This study aimed to evaluate the effects of SGLT2i on SMM in a real-life population setting of patients with type 2 diabetes (T2D). Secondary outcomes included changes in liver steatosis and in anthropometric and glucometabolic parameters.

METHODS

Seventy-one patients were treated with SGLT2is as an add-on to metformin for 52 consecutive weeks. Visits were scheduled at baseline (T0) and after 6 (T6) and 12 months of therapy (T12) and included the checking of laboratory tests, measurement of anthropometric parameters, bioimpedance analysis of body composition, and abdominal ultrasound (US).

RESULTS

Fat mass (FM) and visceral adipose tissue (VAT) progressively decreased compared to the baseline (FM: -2.9 ± 0.6 kg at T6; -2.8 ± 0.6 kg at T12; VAT: -0.3 ± 0.1 L at T6; -0.4 ± 0.1 L at T12; all p < 0.01). Changes in SMM were less pronounced (-0.4 ± 0.3 kg at T6, ns; -0.7 ± 0.4 kg at T12, p < 0.05), yielding a beneficial increase in the SMM/FM ratio (+0.3 ± 0.05 at T6 and +0.2 ± 0.05 at T12, all p < 0.01). No significant changes in sarcopenia, sarcopenic obesity, fat-free mass, muscle strength, and water compartments were observed at the end of the follow-up period. Anthropometric and glucometabolic parameters, insulin resistance, liver enzymes, and biometric indices and US grading of hepatic steatosis improved throughout this study.

CONCLUSIONS

In a real-life setting, SGLT2i therapy is associated with weight loss attributable to FM rather than SMM loss without any relevant deterioration in muscle strength. In addition, SGLT2is proved to have beneficial effects on steatotic liver disease.

Aging-Related Sarcopenia: Metabolic Characteristics and Therapeutic Strategies

The proportion of the elderly population is gradually increasing as a result of medical care advances, leading to a subsequent surge in geriatric diseases that significantly impact quality of life and pose a substantial healthcare burden. Sarcopenia, characterized by age-related decline in skeletal muscle mass and quality, affects a considerable portion of older adults, particularly the elderly, and can result in adverse outcomes such as frailty, fractures, bedridden, hospitalization, and even mortality. Skeletal muscle aging is accompanied by underlying metabolic changes. Therefore, elucidating these metabolic profiles and specific mechanisms holds promise for informing prevention and treatment strategies for sarcopenia. This review provides a comprehensive overview of the key metabolites identified in current clinical studies on sarcopenia and their potential pathophysiological alterations in metabolic activity. Besides, we examine potential therapeutic strategies for sarcopenia from a perspective focused on metabolic regulation.