The potential role of sodium glucose co-transporter 2 inhibitors in combination therapy for type 2 diabetes mellitus

The Impact of SGLT2 Inhibitors on Dementia Onset in Patients with Type 2 Diabetes: A Meta-Analysis of Cohort Studies

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated neuroprotective effects and hold potential advantages in enhancing cognitive function. This study aimed to clarify the association between SGLT2 inhibitors and the risk of dementia among individuals diagnosed with type 2 diabetes (T2D).

METHODS

All cohort studies concerning the impact of SGLT2 inhibitors on dementia onset in patients with T2D were identified. The literature search encompassed PubMed, Embase, Cochrane Library, and Web of Science from establishment to March 2024, with no language restriction. The quality of the literature was evaluated using the Newcastle-Ottawa Scale (NOS). Meta-analysis was conducted using RevMan 5.4 software, calculating pooled risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous outcomes.

RESULTS

Five cohort studies encompassing a total of 331,908 patients were included in the analysis. The findings showed that individuals receiving SGLT2 inhibitors had a lower risk of dementia (I2 = 42%, p = 0.14; RR: 0.77; 95% CI: 0.71-0.84) compared to the control group. Subgroup analyses confirmed the consistent beneficial effects of SGLT2 inhibitors across different study regions (I2 = 0%, p = 0.60) and genders (I2 = 0%, p = 0.50).

CONCLUSIONS

SGLT2 inhibitors may reduce the dementia risk in T2D patients. Given the limitations of the study, further investigations were warranted to confirm the benefits.

HPLC-DAD technique for the quantification of a recently approved anti-diabetic triple combination along with two toxic official impurities: Toxicity confirmation aided by molecular docking application

BACKGROUND

Gliflozins and gliptins are two distinct groups of pharmacological drugs that reduce blood glucose levels in individuals with type II diabetes in various ways that may perform their functions harmoniously. Trijardy^® tablet, which contains empagliflozin, linagliptin, and metformin, was recently approved. The scientific database does not yet have a method that is sensitive enough to quantify the aforementioned medications in the presence of metformin official toxic impurities melamine and cyanoguanidine. Molecular docking modeling was utilized in this work to further prove the toxicity of melamine.

METHODS

The five analytes listed before were quantified using RP-HPLC-diode array detector and a Zorbax^® C8 column (4.6 × 250 mm, 5 μm) with isocratic mobile phase composed of acetonitrile and 0.05 M potassium dihydrogen phosphate buffer, which had been treated by ?-phosphoric acid to restore a pH of 4.0 (90:10, v/v) at a flow rate of 1.2 mL/min and the eluted peaks were scanned at 250 nm.

CONCLUSION

The utilization of the simplest isocratic elution mode give the current technique a significant time-and cost-saving benefit. The current method can quantify the triple therapy agents in the presence of each other as well as with two official toxic impurities of metformin in one short analytical run.

Safe use of sodium glucose co-transporter 2 inhibitors in the management of type 2 diabetes

One class of oral medicines used in the management of type 2 diabetes is sodium glucose co-transporter 2 (SGLT2) inhibitors. Their mode of action is unique and is not dependent on beta-cell function or the degree of a person's insulin resistance. This article reviews the use of SGLT2 inhibitors in managing type 2 diabetes, explaining the potential benefits and side effects of these medicines. It also explains the role of healthcare professionals, including nurses, in ensuring these medicines are used safely and appropriately.

Simple TLC-spectrodensitometric method for studying lipophilicity and quantitative analysis of hypoglycemic drugs in their binary mixture

A selective and simple salting-out-assisted thin-layer chromatographic methodology was developed for the simultaneous determination of two oral hypoglycemic drugs, dapagliflozin (DAPA) and metformin (MET) in their pure forms, tablets and spiked human plasma samples. Silica gel 60 F₂₅₄ plates were used in the separation of the two drugs using a mobile phase consisting of 0.5 m (NH₄ )₂ SO₄ and methanol (3:7, v/v). The plates were scanned in the reflectance mode at λ_max  = 237 nm. The obtained retardation factor (R_f ) values for DAPA and MET were 0.77 ± 0.02 and 0.25 ± 0.02, respectively. The thin-layer chromatography method was validated according to International Conference on Harmonization guidelines. The peak areas were linearly increased with the increases in concentrations of 45-1,000 and 50-1,500 ng/band for DAPA and MET, respectively. Moreover, the method was applied to estimate the molecular lipophilicity parameters of DAPA and MET via retention data. The suggested method was efficiently utilized for the analysis of DAPA and MET in pharmaceutical tablets and plasma samples with recoveries 98.4-100.4 and RSDs in the ranges of 1.4-2.6 and 2.2-3.0% for DAPA and MET, respectively.

Enhancing the Poor Flow and Tableting Problems of High Drug-Loading Formulation of Canagliflozin Using Continuous Green Granulation Process and Design-of-Experiment Approach

Maximization of drug-loading can significantly reduce the size of dosage form and consequently decrease the cost of manufacture. In this research, two challenges were addressed: poor flow and tableting problems of high-drug loading (>70%) formulation of canagliflozin (CNG), by adopting the moisture-activated dry granulation (MADG) process. In this method, heating and drying steps were omitted so, called green granulation process. A 3² full-factorial design was performed for optimization of key process variables, namely the granulation fluid level (X₁) and the wet massing time (X₂). Granulation of CNG was carried out in the presence of polyvinylpyrrolidone, and the prepared granules were compressed into tablets. Regression analysis demonstrated the significant (p ≤ 0.05) effect of X₁ and X₂ on properties of granules and corresponding tablets, with pronounced impact of X₁. Additionally, marked improvement of granules’ properties and tableting of CNG were observed. Furthermore, the optimized process conditions that produced good flow properties of granules and acceptable tablets were high level of granulation fluid (3.41% w/w) and short wet massing time (1.0 min). Finally, the MADG process gives the opportunity to ameliorate the poor flow and tableting problems of CNG with lower amounts of excipients, which are important for successful development of uniform dosage unit.

SGLT2 inhibitors, an accomplished development in field of medicinal chemistry: an extensive review

Diabetes is a chronic progressive metabolic disease caused by insulin deficiency or insulin resistance. In spite of the availability of several antihyperglycaemics, there is a need for the development of safer antidiabetic drugs due to their undesirable effects. Sodium-glucose cotransporter-2 inhibitors are a class of antidiabetics, which hinder the reabsorption of glucose in the kidneys, causing excretion of glucose via urine. Sodium-glucose cotransporter-2 inhibitors are a well-tolerated class with no significant adverse effects and are found to be favorable in certain conditions, which may be rudimentary to cardiovascular and renal diseases. The current advancements in their design and development, their mechanism of action, structure–activity relationship, synthesis and in silico development along with their auxiliary roles have been extensively reviewed.

Nephrolithiasis and sodium-glucose co-transporter-2 (SGLT-2) inhibitors: A meta-analysis of randomized controlled trials

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) decreased serum uric acid in type 2 diabetes. Hyperuricemia is associated with an increased risk of nephrolithiasis. The present meta-analysis, performed on trials with duration ≥52 weeks in comparison with placebo or active comparators, suggests no effects of SGLT-2i on the risk of nephrolithiasis.

Novel LC-MS/MS method for analysis of metformin and canagliflozin in human plasma: application to a pharmacokinetic study

Highly sensitive and selective liquid chromatography/tandem mass spectrometry (LC-MS/MS) method was developed and validated for the simultaneous estimation of the recently approved oral hypoglycemic mixture; metformin (MET) and canagliflozin (CFZ) in human plasma using propranolol HCl (PPL) and tadalafil (TDF) as internal standards (IS), respectively. Analytes were extracted using protein precipitation induced by acetonitrile then liquid-liquid extraction was performed using ethyl acetate. Reversed phase HPLC was carried out using C18 analytical column (50 mm × 4.6 mm i.d., 5 µm) with a simple isocratic mobile phase composed of 0.1% formic acid and acetonitrile (60:40, v/v). Detection was performed on a triple quadrupole mass spectrometer employing electrospray ionization technique, operating in multiple reaction monitoring (MRM), with the transitions of m/z 130.2 → 60.1, m/z 462.3 → 191.0, m/z 260.2 → 183.0 and m/z 390.2 → 268.2 for MET, CFZ, PPL and TDF, respectively, in the positive ion mode. The analysis was carried out within 5 min over a linear concentration range of 50-5000 ng/mL for MET and 10-1000 ng/mL for CFZ. The method was validated in accordance with the FDA guidelines for bioanalytical method. All obtained recoveries were higher than 90.0% while the accuracy was in the range of 88.14-113.05% and the relative standard deviation was below 10.0% for all investigated drugs by the proposed method. The achieved promising results has allowed for the successful application of the developed LC-MS/MS method to a pharmacokinetic study of the target drugs after their oral administration to Egyptian healthy volunteers. The pharmacokinetic study was accomplished after the agreement of the ethics committee.

Basal glucosuria in cats

Objective of this study was to demonstrate the ubiquitous presence of glucose in urine of euglycemic cats by a highly sensitive glucose assay. The local electronic database was searched for results of quantitative urine glucose measurements in cats. A total of 325 feline urine glucose measurements were identified, of which 303 (93%) had been submitted by one of the co-authors working in a near-by small animal practice. After the exclusion of patients with kidney disease (n = 60), hyperthyroidism (n = 15), diabetes mellitus (n = 11), multiple diseases (n = 9) or steroid treatment (n = 3), as well as serial measurements (n = 87) and outliers (n = 8), the final study population consisted of 132 cats. Urine creatinine concentration was unavailable in five patients. Whereas all but one cat had glucose concentrations above the detection limit of the assay (0.11 mmol/L, Gluco-quant Enzyme Kit/Roche Diagnostics), no positive glucose dipstick test result (Combur 9-Test, Roche Diagnostics) was observed. The median (range) of urinary glucose concentration and the glucose-to-creatinine ratio (UGCR) was 0.389 (<0.11-1.665) mmol/L and 0.0258 (0.007-0.517) respectively. The UGCR was not affected by age, gender, breed or leukocyturia, whereas cats with hematuria had slightly higher values. Data show that so-called "basal glucosuria" is present in the majority of cats and by no means diagnostic for diabetes mellitus or renal glucosuria. This has to be considered when using bio-analytical methods with a low limit of quantification.

Beneficial Effect of the SGLT2 Inhibitor Empagliflozin on Glucose Homeostasis and Cardiovascular Parameters in the Cohen Rosenthal Diabetic Hypertensive (CRDH) Rat

The effectiveness of empagliflozin (EMPA), a sodium glucose cotransporter type 2 inhibitor, on the kidney, pancreas, and heart was investigated in the Cohen Rosenthal diabetic hypertensive rat model (CRDH rat). Six-week-old CRDH male rats were fed a sugar diet (SD) and treated with the compound EMPA (group Drug/SD) or respective comparator with vehicle (group Veh/SD). A control group was fed a regular diet without treatment (group Veh/P). Preventive treatment with EMPA was measured during 4 months of follow-up. The treatment effect was evaluated according to results observed after 4 months in group Drug/SD when compared to those in group Veh/SD. Significant effect resulted in the following parameters: enhancement of urinary glucose excretion in association with diuresis; amelioration of postprandial hyperglycemia and fasting blood glucose levels; and decrease in calculated Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) as well as lower systolic and diastolic blood pressures. At the end of treatment, EMPA preserved nephrin integrity in the kidney, reduced proteinuria, and prevented diabetes-induced damage to glomerular diaphragm structure. In the pancreas, EMPA demonstrated an impressive decrease in fatty infiltration and atrophy. Blood pressure was significantly reduced in the EMPA-treated group (15 ± 5.1 mm Hg, P < .05) in contrast to the vehicle and control groups. Finally, compared to controls, EMPA significantly reduced left ventricle (LV) mass and LV systolic dilatation, according to 2-dimensional echocardiography. The importance of the study lies in demonstrating the efficacy of an antidiabetic drug with beneficial effects on blood pressure, weight, kidney, and pancreas and a positive effect on the heart.

Different mathematical processing of absorption, ratio and derivative spectra for quantification of mixtures containing minor component: An application to the analysis of the recently co-formulated antidiabetic drugs; canagliflozin and metformin

In the presented work several spectrophotometric methods were performed for the quantification of canagliflozin (CGZ) and metformin hydrochloride (MTF) simultaneously in their binary mixture. Two of these methods; response correlation (RC) and advanced balance point-spectrum subtraction (ABP-SS) were developed and introduced for the first time in this work, where the latter method (ABP-SS) was performed on both the zero order and the first derivative spectra of the drugs. Besides, two recently established methods; advanced amplitude modulation (AAM) and advanced absorbance subtraction (AAS) were also accomplished. All the proposed methods were validated in accordance to the ICH guidelines, where all methods were proved to be accurate and precise. Additionally, the linearity range, limit of detection and limit of quantification were determined and the selectivity was examined through the analysis of laboratory prepared mixtures and the combined dosage form of the drugs. The proposed methods were capable of determining the two drugs in the ratio present in the pharmaceutical formulation CGZ:MTF (1:17) without the requirement of any preliminary separation, further dilution or standard spiking. The results obtained by the proposed methods were in compliance with the reported chromatographic method when compared statistically, proving the absence of any significant difference in accuracy and precision between the proposed and reported methods.

Treatment of type 2 diabetes mellitus in the elderly

The prevalence of type 2 diabetes is expected to increase gradually with the prolongation of population aging and life expectancy. In addition to macrovascular and microvascular complications of elderly patients of diabetes mellitus, geriatric syndromes such as cognitive impairment, depression, urinary incontinence, falling and polypharmacy are also accompanied by aging. Individual functional status in the elderly shows heterogeneity so that in these patients, there are many unanswered questions about the management of diabetes treatment. The goals of diabetes treatment in elderly patients include hyperglycemia and risk factors, as in younger patients. comorbid diseases and functional limitations of individuals should be taken into consideration when setting treatment targets. Thus, treatment should be individualized. In the treatment of diabetes in vulnerable elderly patients, hypoglycemia, hypotension, and drug interactions due to multiple drug use should be avoided. Since it also affects the ability to self-care in these patients, management of other concurrent medical conditions is also important.

Pharmacotherapy of 'treatment resistant' type 2 diabetes

INTRODUCTION

Despite type 2 diabetes (T2D) management offers a variety of pharmacological interventions targeting different defects, numerous patients remain with persistent hyperglycaemia responsible for severe complications. Unlike resistant hypertension, treatment resistant T2D is not a classical concept although it is a rather common observation in clinical practice. Areas covered: This article proposes a definition for 'treatment resistant diabetes', analyses the causes of poor glucose control despite standard therapy, briefly considers the alternative approaches to glucose-lowering pharmacotherapy and finally describes how to overcome poor glycaemic control, using innovative oral or injectable combination therapies. Expert opinion: Before considering intensifying the pharmacotherapy of a patient with poorly controlled T2D, it is important to verify treatment adherence, target obesity and consider various non pharmacological improvement quality interventions. If treatment resistant diabetes is defined as not achieving glycated haemoglobin target despite oral triple therapy with a third glucose-lowering agent added to metformin-sulfonylurea dual treatment, the combination of a dipeptidyl peptidase-4 (DPP-4) inhibitor and a sodium glucose cotransporter type 2 (SGLT2) inhibitor may offer new opportunities before considering injectable therapies. Insulin basal therapy (± metformin) may be optimized by the addition of a SGLT2 inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist.

Treatment Approach to Patients With Severe Insulin Resistance

In Brief Patients with severe insulin resistance require >2 units/kg of body weight or 200 units/day of insulin. Yet, many patients do not achieve glycemic targets despite using very high doses of insulin. Insulin can cause weight gain, which further contributes to worsening insulin resistance. This article describes the pharmacological options for managing patients with severe insulin resistance, including the use of U-500 insulin and newer agents in combination with insulin.

Single-pill combination therapy for type 2 diabetes mellitus: linagliptin plus empagliflozin

BACKGROUND

Treatment of type 2 diabetes mellitus invariably requires the use of multiple daily medications which can impact negatively on patient adherence. As a result, there is growing interest in the use of single-pill combinations that can reduce the pill burden. Many such formulations incorporate metformin, although this agent is not suitable for all patients. The single-pill combination of the dipeptidyl peptidase-4 inhibitor linagliptin with the sodium glucose co-transporter 2 inhibitor empagliflozin offers a new and attractive option, given their complementary mechanisms of action.

SCOPE

Publications with titles containing the keywords 'linagliptin' or 'empagliflozin' were identified from a non-systematic search of PubMed without date restrictions, together with abstracts presented at the annual meetings of the American Diabetes Association and the European Association for the Study of Diabetes 2012-2014. ClinicalTrials.gov was searched for entries containing these two keywords. Additional references known to the author were included.

FINDINGS

The efficacy and safety of linagliptin and empagliflozin as monotherapy or in combination with other oral antidiabetic drugs has been established through extensive clinical trial programs. Studies specifically evaluating the efficacy/safety of a dipeptidyl peptidase-4 inhibitor/sodium glucose co-transporter 2 inhibitor in combination are limited, but do include two studies of linagliptin/empagliflozin of up to 52 weeks in duration. These studies show that the single-pill combination of linagliptin and empagliflozin produced clinical improvements in glycemic control that were generally superior to the improvements seen with linagliptin and empagliflozin alone, but with a safety profile comparable to that of the individual constituents.

CONCLUSIONS

The single-pill combination of linagliptin and empagliflozin, with their complementary mechanisms of action, is a promising treatment option for patients with type 2 diabetes mellitus. It would reduce the daily pill burden in this population, potentially improving adherence to, and optimizing the benefits of, treatment of diabetes mellitus.