Possibility of pharmacokinetic drug interaction between a DPP-4 inhibitor and a SGLT2 inhibitor

Pharmacokinetics and Safety of a Fixed-Dose Combination of Alogliptin and Extended-Release Metformin Under Fasting and/or Fed Conditions in Healthy Adults

This phase 1, randomized, open-label, 2 × 2 crossover study evaluated the bioequivalence of fixed-dose combination (FDC) formulations of alogliptin (ALO) and metformin extended-release (MET XR) compared to their individual formulations and assessed the effect of food on FDC pharmacokinetics in healthy participants. The study comprised the high-dose bioequivalence study (ALO 25 mg/MET XR 1000 mg) and the low-dose bioequivalence study (ALO 12.5 mg/MET XR 500 mg), both conducted under fasting conditions, and the food effect study (ALO 12.5 mg/MET XR 1000 mg) conducted under both fasting and fed conditions. Among enrolled participants, 46 of 50 completed the high-dose bioequivalence study, 45 of 51 completed the low-dose bioequivalence study, and 22 of 26 completed the food effect study. Plasma concentrations were analyzed using liquid chromatography-tandem mass spectrometry. The geometric mean ratios of AUClast and Cmax for the FDC versus individual formulations were within the bioequivalence range (0.80-1.25) for both ALO and MET XR. ALO's pharmacokinetics were unaffected by food, while MET XR exhibited a significant food effect, with AUClast increasing by a factor of 1.63 and Tmax delayed by 2 hours. Given these findings, the FDC should be administered with food, consistent with MET XR monotherapy recommendations.

Optimizing Cardiovascular Outcomes in Type 2 Diabetes: Early Initiation of Dapagliflozin and Sitagliptin From a Cardiologist's Perspective

INTRODUCTION

Cardiovascular (CV) disease (CVD) risk is greater in patients with diabetes mellitus and is the major contributor to disability and premature mortality compared to those who do not have diabetes. The clinical implications of CVD in people with type 2 diabetes mellitus (T2DM) have increased the emphasis on concurrent treatment to prevent the onset of CVD through personalized management for glycemic control and CVD risk management.

METHODS

Key opinion leaders, comprising 98 cardiologists from across India, participated in seven advisory board meetings held in various cities to explore the challenges and strategies for the early initiation of fixed-dose combinations (FDCs) of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP4i) with a focus on the combination of dapagliflozin and sitagliptin in addressing the CVD risks in patients with T2DM and high risk for CV complications. The expert group discussed the available literature evidence from the clinical trials, systematic reviews, and real-world studies on the benefits of FDC of SGLT2i and DPP4i and FDC of dapagliflozin and sitagliptin to provide rational and practical guidance for its optimal use in addressing the CVD risks in patients with T2DM.

RESULTS

The expert group emphasized the importance of timely glycemic control and early initiation of combination therapy of FDC of SGLT2i + DPP4i in T2DM with CVD risks. Addressing multiple pathophysiological aspects of T2DM is crucial, and considering combination therapy with SGLT2i and DPP4i may be pertinent in this context. Combining dapagliflozin and sitagliptin in FDC to target multiple pathophysiological pathways for T2DM appears to have several glycemic and extra-glycemic benefits.

CONCLUSION

This practical guidance document provides valuable insights from leading cardiologists that would support clinicians in selecting the synergistic combination SGLT2i + DPP4i (dapagliflozin + sitagliptin) FDC as an appropriate treatment choice in early intensive therapy in managing people with T2DM and CVD risk for better patient outcomes. The expert opinion in this guidance builds on the established guideline recommendations on FDC of SGLT2i and DPP4i.

Comparative Analysis of Proximal Tubule Cell Sources for In Vitro Studies of Renal Proximal Tubule Toxicity

Background/Objectives: The kidneys are essential for eliminating drugs and chemicals from the human body and renal epithelial cells are particularly vulnerable to damage caused by xenobiotics and their metabolites. Drug-induced kidney toxicity is a major cause of drug attrition during preclinical and clinical development and the ability to predict renal toxicity remains a pressing challenge, necessitating more predictive in vitro models. However, the abundance of commercially available renal proximal tubule epithelial cell (RPTEC) sources complicates the selection of the most predictive cell types. Methods: This study compared a wide range of RPTEC sources, including primary cells (Lonza) and various RPTEC lines from different vendors, such as ciPTECs (Cell4Pharma), TERT1/RPTECs (ATCC), and HEK293 (GenoMembrane), including OAT1-overexpressing variants. HepG2 cells were included for a comparison of organ specificity. The different cells were cultured in 96- or 384-well plates and exposed to 12 drugs for 72 h at a concentration yielding a response (0.3-300 µM) to evaluate their ability to predict clinical outcomes. The CellTiterGlo® assay was used to measure cell viability, and transcriptome data from unexposed cells was analyzed using the TempO-seq® S1500+ platform. Results: Gene expression data showed that the primary kidney cells most closely matched the transcriptome of the human kidney medulla, followed by the TERT1 and ciPTEC lines, with the HEK lines showing the lowest similarity. The RPTEC sources showed clustering by cell type, with OAT1 overexpression driving changes in metabolic, detoxification, and immune pathways, especially in TERT1 cells. Cell viability data were used to determine points of departure (PODs) which were compared to human serum Cmax values to assess safety margins. The TERT1 and ciPTEC RPTEC lines demonstrated the highest predictive performance for nephrotoxicity, with OAT1 overexpression significantly enhancing sensitivity, accuracy, and overall predictive power (MCC scores: 0.764 and 0.667, respectively). In contrast, HepG2 cells showed the lowest performance across all metrics, highlighting the critical role of cell type and transporter expression in nephrotoxicity prediction. Conclusions: This study highlights important differences among RPTEC sources and their utility in drug safety studies of the renal proximal tubule. We show that while improved cell options for renal proximal tubule are needed, OAT1-overexpressing RPTECs are a superior model to the background cell type.

Dosing Time-Dependent Difference in the Suppressive Effect of Empagliflozin on the Development of Mechanical Pain Hypersensitivity in Diabetic Mice

A problem for patients with diabetes is the rise of complications, such as peripheral neuropathy, nephropathy, and retinopathy. Among them, peripheral neuropathy, characterized by numbness and/or hypersensitivity to pain in the extremities, is likely to develop in the early stages of diabetes. Empagliflozin (EMPA), a sodium-glucose cotransporter-2 inhibitor, exerts hypoglycemic effects by preventing glucose reabsorption in proximal tubular cells. EMPA can improve cardiovascular and renal outcomes in diabetic patients, but its suppressive effect on the development of diabetic neuropathy remains unclear. In this study, we demonstrated that optimizing the dosing schedule of EMPA suppressed the development of pain hypersensitivity in streptozotocin (STZ)-induced diabetic model mice maintained under standardized light/dark cycle conditions. A single intraperitoneal administration of STZ to mice induced hyperglycemia accompanied by pain hypersensitivity. Although EMPA did not exert anti-hypersensitivity effect on STZ-induced diabetic mice after the establishment of neuropathic pain, the development of pain hypersensitivity in the diabetic mice was significantly suppressed by daily oral administration of EMPA at the beginning of the dark phase. On the other hand, the suppressive effect was not observed when EMPA was administered at the beginning of the light phase. The hypoglycemic effect of EMPA and its stimulatory effect on urinary glucose excretion were also enhanced by the administration of the drug at the beginning of the dark phase. Nocturnal mice consumed their food mainly during the dark phase. Our results support the notion that morning administration of EMPA may be effective in suppressing the development of peripheral neuropathy in diabetic patients. SIGNIFICANCE STATEMENT: Empagliflozin, a sodium-glucose cotransporter-2 inhibitor suppressed the development of neuropathic pain hypersensitivity in streptozotocin-induced diabetic model mice in a dosing time-dependent manner.

Case Report: Diabetic ketoacidosis after co-administration of empagliflozin and probenecid

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are filtered and secreted to their primary site of action in the proximal tubule of the kidney. At this site, SGLT2 inhibitors also reduce renal elimination of ketone bodies, a finding implicated in their propensity to cause ketoacidosis. Many commonly used medications have potential to diminish renal elimination of SGLT2 inhibitors and to compound the effects of SGLT2 inhibitors on renal elimination of ketone bodies by inhibiting tubular secretion of the SGLT2 inhibitor itself and/or ketone bodies. We present a case of severe diabetic ketoacidosis (DKA) in a patient with type 2 diabetes occurring several days after co-prescription of empagliflozin and probenecid. Other than the recent introduction of empagliflozin, no cause for the DKA episode was apparent. A pharmacokinetic interaction between probenecid and empagliflozin, involving organic anion transporter 3 (OAT3), reduces proximal tubular secretion of empagliflozin and increases patient exposure to the drug. Whether or not this phenomenon is sufficient to cause severe DKA is discussed. An alternative explanation as to the DKA aetiology is proposed, wherein probenecid may compound effects of empagliflozin on renal elimination of ketone bodies. We suggest that clinicians exercise caution when prescribing SGLT2 inhibitors alongside pharmacologic inhibitors of, or competitors for, proximal tubular organic anion transporters in patients with diabetes mellitus due to the risk of severe DKA.

Sodium-glucose cotransporter 2 inhibitors and cardiorenal outcomes in kidney transplantation

PURPOSE OF REVIEW

This review aims to explore the current evidence regarding cardiovascular and kidney outcomes in patients who undergo treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2i) post kidney transplantation.

RECENT FINDINGS

Summary findings from individual studies included in this review showed largely favorable results in the kidney transplant recipients (KTRs) being treated with SGLT2i.These outcomes included parameters such as allograft function, glycemic control, proteinuria, blood pressure, weight loss and safety profile, among others. Almost all the studies reported an initial 'dip' in eGFR, followed by recovery, after the initiation of SGLT2i treatment. None of the studies reported significant interaction of SGLT2i with immunosuppressive medications. The most common adverse effects noted in these studies were infection-related including UTI and genital mycosis. None of the studies reported acute graft rejection attributable to SGLT2i therapy.

SUMMARY

SGLT2i can play a significant role in improving health outcomes in KTRs. However, clinical trials with larger representation of KTRs longer follow-up period are needed to draw more substantial conclusions.

Pharmacokinetic Comparison Between a Fixed-Dose Combination of Empagliflozin L-Proline/Metformin and Empagliflozin/Metformin in Healthy Korean Subjects

Empagliflozin and metformin are oral antidiabetic drugs commonly used to treat type 2 diabetes mellitus as a combination therapy. This study aimed to compare the pharmacokinetics and safety of a newly developed fixed-dose combination of 5-mg empagliflozin L-proline and 1000-mg metformin with the reference drug. A randomized, open-label, single-dose, 2-period, 2-treatment, crossover study was conducted in healthy Korean subjects. The subjects received a single oral dose of reference drug or test drug at each period. The pharmacokinetic (PK) parameters were calculated using a noncompartmental method. The geometric mean ratios and 90% confidence intervals of the plasma maximum concentration (Cmax ) and area under the concentration-time curve from time zero to the last quantifiable concentration (AUClast ) were calculated. A total of 27 healthy subjects were included in the PK analysis. For empagliflozin, the geometric mean ratios (90% confidence intervals) of the test to reference drug for Cmax and AUClast were 1.03 (0.99-1.08) and 1.03 (1.00-1.06), respectively. For metformin, the corresponding values for Cmax  and AUClast were 0.99 (0.92-1.06) and 1.00 (0.94-1.06), respectively. In conclusion, a fixed-dose combination of empagliflozin L-proline and metformin showed similar PK characteristics to the reference drug, and both drugs were safe in healthy subjects.

Adverse events and drug-drug interactions of sodium glucose co-transporter 2 inhibitors in patients treated for heart failure

INTRODUCTION

Sodium glucose co-transporter 2-inhibitors (SGLT2-I), antihyperglycemic agents, are increasingly prescribed in chronic heart failure (CHF). Their risk for drug-drug interactions (DDI) seems low. Safety-data derive mainly from diabetes-patients. This review aims to summarize adverse-events (AE) and DDI of the SGLT2-I dapagliflozin, empagliflozin and sotagliflozin in patients with CHF.

AREAS COVERED

Literature-search-terms in PubMed were 'adverse event/drug-drug interaction' and 'heart failure AND 'dapagliflozin' OR 'empagliflozin' OR 'sotagliflozin.'AEreported in randomized controlled trials (RCT) comprisegenitaland urinary-tract infections, hypotension, ketoacidosis, renal impairment, hypoglycemia, limb-amputations, Fournier's gangrene, bone-fractures, hepatopathy, pancreatitis, diarrhea, malignancy and venous thromboembolism. Their incidence is largely unknown, since they were not consistently evaluated in RCT of CHF. Further AE from meta-analyses, pharmacovigilance reports, case-series and case-reports include erythrocytosis, hypertriglyceridemia, myopathy, sarcopenia, skin problems, ventricular tachycardia, and urinary retention. The maximal observation period of RCT in CHF was 26 months.DDI were mainly studied in healthy volunteers for 3-8 days. In CHF or diabetes-patients, DDI were reported with interleukin-17-inhibitors, linezolid, lithium, tacrolimus, valproate, angiotensin-receptor-neprilysin-inhibitors and intravenous iron.

EXPERT OPINION

Guidelines recommend treatment with SGLT2-I for CHF but no data on AE during long-term therapy and only little information on DDI are available, which stresses the need for further research. Evidence-based recommendations for ketoacidosis-prevention are desirable.

Fournier's gangrene and diabetic ketoacidosis with lower-than-anticipated glucose levels associated with SGLT-2 inhibitor: A double trouble

Empagliflozin has a demonstrated cardiovascular benefit. It is co-prescribed as a glucose-lowering medication in patients with type II diabetes mellitus. Herein, we discuss dual-emergency side-effects, Fournier's gangrene (FG) and diabetic ketoacidosis with lower-than-anticipated glucose levels in a patient on Empagliflozin, a sodium-glucose transport protein 2 inhibitor (SGLT-2i). The pathophysiologic mechanism of FG in correlation with SGLT-2i is not yet elucidated. SGLT-2i increase predisposition to genital mycotic and urinary infections, a mechanism favouring FG. A patient with type II diabetes mellitus on SGLT-2i presented with acute necrotic infection of the scrotum and simultaneous diabetic ketoacidosis with lower-than-anticipated glucose levels. This dual emergency was managed with debridement and medical treatment on lines of diabetes ketoacidosis, respectively. A re-look at this group of glucose-lowering medications from bedside towards benchtop research may help to prod into any other mechanistic basis of these life-threatening clinical occurrences.

Pharmacokinetics of a Fixed-Dose Combination Product of Dapagliflozin and Linagliptin and Its Comparison with Co-Administration of Individual Tablets in Healthy Humans

Dapagliflozin, a selective sodium–glucose co-transporter-2 inhibitor, and linagliptin, a competitive, reversible dipeptidyl peptidase-4 inhibitor, are commonly prescribed antidiabetic medications in general clinics. Since there are several merits to combining them in a fixed-dose combination product, this study investigated the pharmacokinetic equivalence between the individual component (IC) and fixed-combination drug product (FCDP) forms of dapagliflozin and linagliptin. A randomized, open-label, single-dose crossover study was conducted. All participants (n = 48) were randomly allocated to group A (period 1: ICs, period 2: FCDP) or group B (period 1: FCDP, period 2: ICs), and each group received either a single dose of IN-C009 (FCDP) or single doses of both dapagliflozin and linagliptin. There was no statistically significant difference found between the pharmacokinetic variables of FCDP and IC. The values of estimated geometric mean ratios and the 90% confidence interval for both maximum concentration and area under the plasma drug concentration–time curve were within the range of 0.8–1.25 for both dapagliflozin and linagliptin. The results of the clinical study demonstrated comparable pharmacokinetic characteristics between IC and FCDP forms of dapagliflozin and linagliptin. The combined use of dapagliflozin and linagliptin was safe and tolerable in both formulations.

Mechanism and reversal of drug-induced nephrotoxicity on a chip

The kidney plays a critical role in fluid homeostasis, glucose control, and drug excretion. Loss of kidney function due to drug-induced nephrotoxicity affects over 20% of the adult population. The kidney proximal tubule is a complex vascularized structure that is particularly vulnerable to drug-induced nephrotoxicity. Here, we introduce a model of vascularized human kidney spheroids with integrated tissue-embedded microsensors for oxygen, glucose, lactate, and glutamine, providing real-time assessment of cellular metabolism. Our model shows that both the immunosuppressive drug cyclosporine and the anticancer drug cisplatin disrupt proximal tubule polarity at subtoxic concentrations, leading to glucose accumulation and lipotoxicity. Impeding glucose reabsorption using glucose transport inhibitors blocked cyclosporine and cisplatin toxicity by 1000- to 3-fold, respectively. Retrospective study of 247 patients who were diagnosed with kidney damage receiving cyclosporine or cisplatin in combination with the sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin showed significant (P < 0.001) improvement of kidney function, as well as reduction in creatinine and uric acid, markers of kidney damage. These results demonstrate the potential of sensor-integrated kidney-on-chip platforms to elucidate mechanisms of action and rapidly reformulate effective therapeutic solutions, increasing drug safety and reducing the cost of clinical and commercial failures.

Efficacy and Safety of Tofogliflozin and Ipragliflozin for Patients with Type-2 Diabetes: A Randomized Crossover Study by Flash Glucose Monitoring

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors promote urinary glucose excretion. However, the differences in the effects of various SGLT2 inhibitors are unknown. We used flash glucose monitoring (FGM) to identify the differences between tofogliflozin and ipragliflozin in terms of efficacy in reducing glycemic variability and mitigate hypoglycemia risk.

METHODS

In this crossover study, 24 patients with type-2 diabetes mellitus (T2DM) receiving insulin glargine U300 therapy were randomly allocated to tofogliflozin and ipragliflozin or ipragliflozin and tofogliflozin group. Glycemic variability and hypoglycemia were compared using to the 3-day FGM data per treatment period.

RESULTS

Glucose level 2 h after each meal was significantly lower with tofogliflozin administration than with ipragliflozin administration. Time below the target glucose range after tofogliflozin administration was significantly lower than that after ipragliflozin administration (2.1% ± 4.4% vs. 8.7% ± 11.7%). The 24-h standard deviation of glucose level, mean amplitude of glycemic excursion, and mean percent time with nocturnal hypoglycemia after tofogliflozin administration were significantly lower than those after ipragliflozin administration.

CONCLUSIONS

Tofogliflozin was more effective and safer than ipragliflozin in reducing glycemic variability and mitigating hypoglycemia risk in patients with T2DM treated with insulin glargine U300.

TRIAL REGISTRATION

This trial was registered at the University Hospital Medical Information Network Clinical Trial Registry (no. UMIN000037158).