Evolution of sodium-glucose co-transporter 2 inhibitors from a glucose-lowering drug to a pivotal therapeutic agent for cardio-renal-metabolic syndrome

Cost-Effectiveness Analysis of SGLT2 Inhibitors for Cardio-Renal-Metabolic Disease Based on Data from Japanese Studies

INTRODUCTION

Cardiovascular, renal, and metabolic diseases, collectively known as cardio-renal-metabolic (CRM) disease, interact and exacerbate each other, creating serious clinical and economic burdens. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are important therapeutic agents in managing CRM disease. Despite proven clinical benefits, the economic benefits of SGLT2i in the management of CRM diseases remain unclear.

METHODS

We developed Markov models representing the natural progression of disease for two populations: a type 2 diabetes mellitus (T2DM) population and non-diabetic chronic kidney disease (non-DM CKD) population. These models incorporated key complications, including heart failure, myocardial infarction, stroke, CKD (for the T2DM population), and end-stage renal disease. A systematic literature search was conducted to determine input parameters. For each model, we estimated the 10-year medical costs, quality-adjusted life years (QALY), and incremental cost-effectiveness ratio (ICER) for SGLT2i treatment compared with conventional treatment. A probabilistic sensitivity analysis (PSA) and scenario analyses with conservative assumptions were performed.

RESULTS

In the base-case analysis, SGLT2i treatment was estimated to increase QALY by 0.177 (7.090 vs 6.913 QALY; T2DM population) and 0.457 (6.980 vs 6.523 QALY; non-DM CKD population), and increase total medical costs by Japanese yen (JPY) 99,060 (JPY 762,524 vs 663,463; T2DM population) and JPY 229,810 (JPY 3,378,873 vs 3,149,063; non-DM CKD population), compared with conventional treatment. The ICER was JPY 559,175/QALY in the T2DM population and JPY 503,123/QALY in the non-DM CKD population. The PSA revealed that the probability of ICER being below the threshold value of JPY 5,000,000/QALY was 100% in the T2DM population and 98.7% in the non-DM CKD population, and the ICERs were below this threshold in all scenario analyses.

CONCLUSION

SGLT2i treatment was demonstrated to be cost-effective in both the T2DM population and the non-DM CKD population, suggesting the potential of SGLT2i to offer significant clinical and economic benefits in the comprehensive management of CRM diseases.

Cardiorenal protection with dapagliflozin in patients with type 2 diabetes mellitus and chronic coronary syndrome undergoing percutaneous coronary intervention: a registry cross-sectional study

IMPORTANCE

Although sodium‒glucose cotransporter-2 (SGLT2) inhibitors have cardiorenal benefits, their efficacy in patients with type 2 diabetes mellitus (T2DM) and chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI) remains underexplored.

OBJECTIVE

To evaluate the cardiorenal protective effects of the SGLT2 inhibitor dapagliflozin in patients with T2DM and CCS receiving PCI.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional analysis of 1,430 patients from a tertiary hospital database who underwent PCI (January 1, 2018, to March 31, 2022).

MAIN OUTCOMES AND MEASURES

Cardiac outcomes (PMI/4aMI) and renal outcomes (eGFR and CI-AKI).

RESULTS

After 1:1 propensity score matching (PSM) (176 dapagliflozin vs. 176 control), the dapagliflozin group showed significantly lower PMI/4aMI rates pre-PSM (39.78% vs. 66.99%; OR 0.862, 95% CI 0.823-0.904; p < 0.001) and post-PSM (39.77% vs. 60.23%; OR 0.660, 95% CI 0.531-0.821; p < 0.001), with sustained significance after adjustment (adjusted OR 0.436, 95% CI 0.285-0.668; p < 0.001). Subgroup analyses highlighted increased protection in patients aged ≥ 65 years, those with multivessel disease, and those with higher contrast volumes. Renal outcomes (CI-AKIESUR and CI-AKIKDIGOs) were not significantly different before or after PSM or after adjustment (all p > 0.05).

CONCLUSIONS AND RELEVANCE

Dapagliflozin exerted robust cardioprotective effects against PMI/4aMI in patients with T2DM and CCS undergoing PCI, particularly among patients in high-risk subgroups, but it did not significantly reduce the risk of CI-AKI. These findings support the peri-PCI use of dapagliflozin to mitigate cardiac risk while highlighting the need for further research to elucidate its renal effects in this population.

Sodium-glucose transport protein 2 inhibitor use in the management of insulin dysregulation in ponies and horses

Laminitis is a common and painful condition of the equine foot and approximately 90% of cases are associated with insulin dysregulation (ID) that is a central feature of the common endocrine disorder equine metabolic syndrome (EMS) and occurs in a subset of animals with pituitary pars intermedia dysfunction. Additional features of EMS include obesity, altered circulating concentrations of adipokines (particularly adiponectin and leptin) and hypertriglyceridaemia. Obesity, ID, hypoadiponectinaemia, hyperleptinaemia and an altered plasma lipid profile are also features of human metabolic syndrome (HMS) alongside hyperglycaemia. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a novel class of oral hypoglycaemic agents used in combination with lifestyle changes in the management of HMS. SGLT2 receptors are responsible for 90% of the renal glucose reabsorption that occurs in the proximal convoluted tubule. Thus, these drugs increase urinary glucose excretion by suppressing glucose reabsorption from the glomerular filtrate resulting in urinary calorie loss with consequent weight loss and improvements in ID, hyperglycemia, hypoadiponectinaemia and hyperleptinaemia. There are no licenced veterinary drugs available for treating ID and preventing insulin-associated laminitis in horses. Thus, the use of SGLT2i for the control of equine hyperinsulinaemia with the goal of improving recovery from associated active laminitis or preventing future laminitis has recently been advocated. There are a small number of published studies reporting the use of the SGLT2i canagliflozin, ertugliflozin and velagliflozin to aid the management of equine ID. However, the doses used are largely extrapolated from human studies with limited consideration of species-specific variations. In addition, there is limited evaluation of the fundamental differences between ID in horses and humans, particularly the fact that most horses with ID remain hyperinsulinaemic but normoglycaemic such that increased urinary loss of glucose may not explain the beneficial effects of these drugs. Further study of the potential deleterious effects of treatment-associated hypertriglyceridaemia is required together with the effect of SGLT2i therapy on circulating concentrations of adipokines in horses.

Progress of SGLT2 inhibitors in the treatment of common immune-related nephropathies

The immune system can lead to a variety of renal diseases through direct or indirect mechanisms. In immune-mediated nephropathy, though standardized treatment, there are still a small number of patients with further decline in renal function, which may even progress to renal failure; sodium-glucose cotransporter protein 2 (SLC5A2,SGLT2) inhibitors not only can significantly reduce blood glucose, but also have an additional protective effect on the kidneys and the heart; this review concludes the potential mechanism of the renal protective effect of SGLT2i and the new advances in the recent years in common immune-mediated nephropathies, which can provide new theoretical references to optimize the therapeutic strategy of common immune-mediated nephropathies.

Meta-analysis of the efficacy and impact on cardiac function of sodium-glucose cotransporter 2 inhibitor Empagliflozin in heart failure patients

BACKGROUND

Currently, there is no comprehensive systematic review available to comprehensively assess the efficacy and safety of Empagliflozin and other sodium-glucose cotransporter 2 inhibitors in the treatment of heart failure (HF). This study employed a meta-analysis approach to systematically evaluate the therapeutic effects of Empagliflozin in HF patients and its impact on cardiac function.

METHOD

The keywords including "heart failure," "HF," "cardiac failure," "cardiac disease," "Empagliflozin," and "sodium-glucose cotransporter 2 inhibitors" were utilized to search for relevant clinical studies on Empagliflozin in the treatment of HF in various databases, such as China National Knowledge Infrastructure, Wanfang, VIP Chinese Medical Journal Database, PubMed, MEDLINE, Embase, Cochrane Library, Springer, and Science Direct. The studies included patients with HF who received drug treatment. Data on baseline characteristics and posttreatment outcomes, including HF hospitalization (HHF), cardiovascular mortality, all-cause mortality, estimated glomerular filtration rate changes, Kansas City Cardiomyopathy Questionnaire quality of life (QoL) scores, N-terminal pro-B-type natriuretic peptide, left ventricular ejection fraction, hematocrit, and other relevant indicators were collected. Meta-analysis was conducted using RevMan5.3 to analyze the extracted data.

RESULTS

A total of 15 studies were included in the final analysis, comprising 36,917 patients with HF. Among them, 18,486 patients were in Empagliflozin group, and 18,431 patients were in control (Ctrl) group. The results of the meta-analysis demonstrated that, relative to Ctrl group, Empagliflozin group showed a substantially lower HHF rate, a substantial improvement in estimated glomerular filtration rate changes, a reduced cardiovascular mortality rate, a higher Kansas City Cardiomyopathy Questionnaire QoL score, increased hematocrit values, reduced N-terminal pro-B-type natriuretic peptide changes, and enhanced left ventricular ejection fraction changes. These findings suggest that remarkable improvements in various outcomes compared to the Ctrl group.

CONCLUSION

The sodium-glucose cotransporter 2 inhibitor Empagliflozin markedly reduces the HHF rate and cardiovascular mortality in HF patients. It also improves patients' QoL, enhances renal function, and increases cardiac function while reducing both, the preload and afterload.

A novel model of cardiovascular-kidney-metabolic syndrome combining unilateral nephrectomy and high-salt-sugar-fat diet in mice

The aim of this study was to explore biological interaction and pathophysiology mechanisms in a new mouse model of cardiovascular-kidney-metabolic (CKM) syndrome, induced by chronic moderate renal failure in combination with consumption of a customized Western diet rich in carbohydrates, fat and salt. Male C57BL/6J mice were subjected to unilateral nephrectomy, fed a customized Western diet rich not only in sugar and fat but also in salt, and followed for 12 weeks or 20 weeks. Sham-operated mice on a standard chow served as healthy controls. Body composition, weight gain, glucose metabolism, fat distribution, blood pressure, cardiac function, vascular reactivity, renal function, inflammation and mitochondrial function were measured and combined with biochemical and histopathological analyses. The novel triple-hit model of CKM syndrome showed signs and symptoms of metabolic syndrome, disturbed glucose metabolism, impaired adipocyte physiology and fat redistribution, cardiovascular dysfunction, renal damage and dysfunction, systemic inflammation, elevated blood pressure and cardiac remodeling. The pathological changes were more pronounced in mice after prolonged exposure for 20 weeks, but no deaths occurred. In the present mouse model of CKM syndrome, profound and significant metabolic, cardiac, vascular and renal dysfunctions and injuries emerged by using a Western diet rich not only in fat and carbohydrates but also in salt. This multisystem disease model could be used for mechanistic studies and the evaluation of new therapeutic strategies.

Glucose Deprivation Promotes Pseudohypoxia and Dedifferentiation in Lung Adenocarcinoma

Increased utilization of glucose is a hallmark of cancer. Sodium-glucose transporter 2 (SGLT2) is a critical player in glucose uptake in early-stage and well-differentiated lung adenocarcinoma (LUAD). SGLT2 inhibitors, which are FDA approved for diabetes, heart failure, and kidney disease, have been shown to significantly delay LUAD development and prolong survival in murine models and in retrospective studies in diabetic patients, suggesting that they may be repurposed for lung cancer. Despite the antitumor effects of SGLT2 inhibition, tumors eventually escape treatment. Here, we studied the mechanisms of resistance to glucose metabolism-targeting treatments. Glucose restriction in LUAD and other tumors induced cancer cell dedifferentiation, leading to a more aggressive phenotype. Glucose deprivation caused a reduction in alpha-ketoglutarate (αKG), leading to attenuated activity of αKG-dependent histone demethylases and histone hypermethylation. The dedifferentiated phenotype depended on unbalanced EZH2 activity that suppressed prolyl-hydroxylase PHD3 and increased expression of hypoxia-inducible factor 1α (HIF1α), triggering epithelial-to-mesenchymal transition. Finally, a HIF1α-dependent transcriptional signature of genes upregulated by low glucose correlated with prognosis in human LUAD. Overall, this study furthers current knowledge of the relationship between glucose metabolism and cell differentiation in cancer, characterizing the epigenetic adaptation of cancer cells to glucose deprivation and identifying targets to prevent the development of resistance to therapies targeting glucose metabolism.

SIGNIFICANCE

Epigenetic adaptation allows cancer cells to overcome the tumor-suppressive effects of glucose restriction by inducing dedifferentiation and an aggressive phenotype, which could help design better metabolic treatments.

Challenging Clinical Perspectives in Type 2 Diabetes with Tirzepatide, a First-in-Class Twincretin

Tirzepatide is a first-in-class GIP/GLP-1 receptor agonist ('twincretin')-a single molecule that acts as an agonist at both glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptors. In the SURPASS clinical trial program in type 2 diabetes mellitus (T2D), tirzepatide was associated with unprecedented reductions in HbA1c, clinically significant weight loss and other metabolic benefits, combined with low rates of hypoglycaemia across a wide range of patient characteristics. The safety and adverse event rate for tirzepatide appears comparable to that of GLP-1 receptor agonists. Although results from dedicated cardiovascular (CV) and kidney trials are currently not available, information to date suggests that tirzepatide may have CV and kidney benefits in people with T2D. Tirzepatide has been approved for the treatment of T2D in the USA, United Arab Emirates, European Union, Japan and Australia. Here, we review how tirzepatide will fit into the T2D treatment continuum. We also consider future directions with tirzepatide in T2D, including its potential for targeting cardio-renal-metabolic disease in T2D, and discuss how tirzepatide-and other co-agonists in development-may challenge current approaches for management of T2D.

The lipidomic and inflammatory profiles of visceral and subcutaneous adipose tissues are distinctly regulated by the SGLT2 inhibitor empagliflozin in Zucker diabetic fatty rats

The pharmacological inhibition of sodium-glucose cotransporter 2 (SGLT2) has emerged as a treatment for patients with type 2 diabetes mellitus (T2DM), cardiovascular disease and/or other metabolic disturbances, although some of the mechanisms implicated in their beneficial effects are unknown. The SGLT2 inhibitor (SGLT2i) empagliflozin has been suggested as a regulator of adiposity, energy metabolism, and systemic inflammation in adipose tissue. The aim of our study was to evaluate the impact of a 6-week-empagliflozin treatment on the lipidome of visceral (VAT) and subcutaneous adipose tissue (SAT) from diabetic obese Zucker Diabetic Fatty (ZDF) rats using an untargeted metabolomics approach. We found that empagliflozin increases the content of diglycerides and oxidized fatty acids (FA) in VAT, while in SAT, it decreases the levels of several lysophospholipids and increases 2 phosphatidylcholines. Empagliflozin also reduces the expression of the cytokines interleukin-1 beta (IL-1β), IL-6, tumor necrosis factor-alpha (TNFα), monocyte-chemotactic protein-1 (MCP-1) and IL-10, and of Cd86 and Cd163 M1 and M2 macrophage markers in VAT, with no changes in SAT, except for a decrease in IL-1β. Empagliflozin treatment also shows an effect on lipolysis increasing the expression of hormone-sensitive lipase (HSL) in SAT and VAT and of adipose triglyceride lipase (ATGL) in VAT, together with a decrease in the adipose content of the FA transporter cluster of differentiation 36 (CD36). In conclusion, our data highlighted differences in the VAT and SAT lipidomes, inflammatory profiles and lipolytic function, which suggest a distinct metabolism of these two white adipose tissue depots after the empagliflozin treatment.