The Cardioprotective and Anticancer Effects of SGLT2 Inhibitors: JACC: CardioOncology State-of-the-Art Review

Sodium-glucose cotransporter-2 (SGLT2) inhibitors, originally approved for type 2 diabetes mellitus, have demonstrated efficacy in reducing cardiovascular events, particularly heart failure, in patients with and without diabetes. An intriguing research area involves exploring the potential application of SGLT2 inhibitors in cardio-oncology, aiming to mitigate the cardiovascular adverse events associated with anticancer treatments. These inhibitors present a unique dual nature, offering both cardioprotective effects and anticancer properties, conferring a double benefit for cardio-oncology patients. In this review, the authors first examine the established cardioprotective effects of SGLT2 inhibitors in heart failure and subsequently explore the existing body of evidence, including both preclinical and clinical studies, that supports the use of SGLT2 inhibitors in the context of cardio-oncology. The authors further discuss the mechanisms through which SGLT2 inhibitors protect against cardiovascular toxicity secondary to cancer treatment. Finally, they explore the potential anticancer effects of SGLT2 inhibitors along with their proposed mechanisms.

Canagliflozin mitigates carfilzomib-induced endothelial apoptosis via an AMPK-dependent pathway

Carfilzomib (CFZ) is a proteasome inhibitor approved for relapsed/refractory multiple myeloma (MM) but its clinical use is limited by cardiovascular toxicity. The mechanisms of CFZ-induced cardiovascular toxicity are not fully understood but endothelial dysfunction may be a common denominator. Here, we first characterized the direct toxic effects of CFZ on endothelial cells (HUVECs and EA.hy926 cells) and tested whether SGLT2 inhibitors, known to have cardioprotective effects, can protect against CFZ-induced toxicity. To determine the chemotherapeutic effect of CFZ in the presence of SGLT2 inhibitors, MM and lymphoma cells were treated with CFZ with or without canagliflozin. CFZ decreased cell viability and induced apoptotic cell death in endothelial cells in a concentration-dependent manner. CFZ also upregulated ICAM-1 and VCAM-1 and downregulated VEGFR-2. These effects were associated with the activation of Akt and MAPK pathways, inhibition of p70s6k, and downregulation of AMPK. Canagliflozin, but not empagliflozin or dapagliflozin, protected endothelial cells from CFZ-induced apoptosis. Mechanistically, canagliflozin abrogated CFZ-induced JNK activation and AMPK inhibition. AICAR (an AMPK activator) protected from CFZ-induced apoptosis, and compound C (an AMPK inhibitor) abrogated the protective effect of canagliflozin, strongly suggesting that AMPK mediates these effects. Canagliflozin did not interfere with the anticancer effect of CFZ in cancer cells. In conclusion, our findings demonstrate for the first time the direct toxic effects of CFZ in endothelial cells and the associated signaling changes. Canagliflozin abrogated the apoptotic effects of CFZ in endothelial cells in an AMPK-dependent mechanism, without interfering with its cytotoxicity in cancer cells.

Abstract P3115: The Protective Effect Of Canagliflozin Against Carfilzomib-induced Endothelial Toxicity

Introduction: The anti-cancer agent carfilzomib (CFZ) is associated with serious cardiovascular side effects. There is anecdotal clinical evidence that endothelial dysfunction contributes to CFZ-induced cardiovascular complications; however, the toxic effects of CFZ have not been reported in endothelial cells (ECs). The anti-diabetic Sodium glucose cotransporter 2 (SGLT 2 ) inhibitors have newly emerged as cardio-protective agents in heart failure, myocardial infarction, stroke, and diabetic cardiomyopathy. The objectives of the current work are to characterize the toxic effects of CFZ in two human-derived endothelial cell lines, human umbilical vein endothelial cells (HUVECs) and EA.hy926, determine the molecular signaling changes associated with these toxic effects, and investigate the protective effects of SGLT 2 inhibitors (Empagliflozin, Dapagliflozin, Canagliflozin) on CFZ-induced endothelial toxicity.

Methods: Both ECs were treated with clinically relevant concentrations of CFZ (0.05, 0.1, 0.2, 0.5, and 1 μM) for 24 hours. EA.hy926 cells were treated with 0.5 μM CFZ with or without SGLT 2 inhibitor (0.1, 1, 10, 50, 100 μM). Cell viability was determined by the MTT assay and protein expressions of apoptotic markers, mitogen-activated protein kinases (MAPKs), and the p70S6K pathway were determined by western blotting.

Results: CFZ reduces cell viability and induces apoptotic cell death in the two cell lines in a concentration-dependent manner. CFZ-induced apoptosis is also associated with activation of the p38 and JNK MAPK pathways and a remarkable inhibition of the p70S6K pathway. In EA.hy926, Canagliflozin prevents reduction in cell viability caused by CFZ, while empagliflozin and dapagliflozin have not shown any protective effects in vitro. Mechanistically, canagliflozin abrogates CFZ-induced endothelial cell apoptosis, and prevents CFZ-induced JNK activation.

Conclusion: This is the first study to report the endothelial toxicity of CFZ. CFZ induces endothelial cell apoptosis which may contribute to CFZ-induced cardiovascular complications and canagliflozin protects against CFZ endothelial toxicity. Future research is warranted to identify the protective effects of SGLT 2 inhibitors against CFZ in vivo.

Molecular mechanisms and cardiovascular implications of cancer therapy-induced senescence

Cancer treatment has been associated with accelerated aging that can lead to early-onset health complications typically experienced by older populations. In particular, cancer survivors have an increased risk of developing premature cardiovascular complications. In the last two decades, cellular senescence has been proposed as an important mechanism of premature cardiovascular diseases. Cancer treatments, specifically anthracyclines and radiation, have been shown to induce senescence in different types of cardiovascular cells. Additionally, clinical studies identified increased systemic markers of senescence in cancer survivors. Preclinical research has demonstrated the potential of several approaches to mitigate cancer therapy-induced senescence. However, strategies to prevent and/or treat therapy-induced cardiovascular senescence have not yet been translated to the clinic. In this review, we will discuss how therapy-induced senescence can contribute to cardiovascular complications. Thereafter, we will summarize the current in vitro, in vivo, and clinical evidence regarding cancer therapy-induced cardiovascular senescence. Then, we will discuss interventional strategies that have the potential to protect against therapy-induced cardiovascular senescence. To conclude, we will highlight challenges and future research directions to mitigate therapy-induced cardiovascular senescence in cancer survivors.