Sodium-Glucose Co

Transport Inhibitors

Presented by:
Arooj Anwer(06)
Presented to:
Dr.Hassan
* Sodium-glucose co transporter

 Relatively a new class of drugs that work by

increasing urinary glucose excretion.

 SGLT1 and SGLT2 are a family of glucose

transporter found in the intestinal mucosa (enterocytes) of
the small intestine and the proximal tubule of the nephron
(functional unit of the kidney)
* SGTL1 inhibitors

 SGLT1 inhibitor is currently being studied and pending Food

and Drug Administration (FDA) approval for adults with
type 1 diabetes mellitus(T1DM) in combination
with insulin therapy

T1DM
  T1DM is a condition in which the body does not produce
insulin and therefore cannot control the amount of sugar in
the blood.
 Mechanism of action
 SGLT1 inhibitor plays a crucial role in the
intestinal absorption of glucose and the renal reabsorption of
glucose, particularly in patients with
uncontrolled diabetes and those receiving SGLT2 inhibitors.

 The inhibition of SGLT1 lowers serum glucose levels , thus

improving post-meal glycemic control.
 Example

 "Sotagliflozin" is the first oral SGLT1 inhibitor

developed to treat adult patients with T1DM in
combination with insulin, which is to be reviewed
by the FDA.

 Zynquista (pending FDA approval)

 * SGTL2 Inhibitors
Physiology
 Three glucose transporters have been found to be
responsible for the reabsorption of glucose at the
proximal tubule: SGLT1 ,SGLT2,GLUT2 respect to
location.

 SGLT2 is found almost exclusively in the kidney

 SGLT2 is a low-capacity, high-affinity glucose transporter

 accounts for 90% of the glucose reabsorption

 Mechanism Of Action

 Reduce blood glucose though glycosuria and natriuresis initiated

by the inhibition of glucose reabsorption at the proximal tubule
of the kidney.
 Pharmacodynamics studies have revealed that SGLT2 inhibitors
are filtered from the blood through the glomerulus and exhibit
their inhibitory effects exclusively on the extracellular side of
the plasma membrane
Novel study
 Recent work determining the differences between SGLT2 and
SGLT1 has identified an additional Na+ binding site in SGLT1 that
is not present in SGLT2.
 Current SGLT2 Inhibitors

 Four SGLT2 inhibitors approved by the Food and Drug

Administration since 2013

1. canagliflozin,
2. Empagliflozin
3. Dapagliflozin,
4. Ertugliflozin
 Clinical uses

1.Use In The Treatment Of Type 2 Diabetes:

  American Diabetes Association (ADA) recently published their

2019 guidelines in which;
 SGLT2 inhibitors are a preferred adjunct medication in
patients with the atherosclerotic cardiovascular disease
(ASCVD), congestive heart failure (CHF) or chronic kidney
disease (CKD)
 ADA guidelines also recommend SGLT2 inhibitors when there is
a compelling need to promote weight loss.
 2.Cardiovascular Effects
Congestive Heart Failure;

 Empagliflozin use resulted in a 35% risk reduction in

hospitalizations for congestive heart failure and a 38% risk
reduction in death from cardiovascular causes.

 reduction in the strain and stress on the heart walls and by

protective metabolic and anti-inflammatory effects.
 3.Blood Pressure

  SGLT2 inhibitors are associated with both a systolic and

diastolic blood pressure reduction.

Novel uses
 Non-Alcoholic Fatty Liver Disease
 Weight Loss/Obesity
(SGLT2 inhibitors cause weight loss in a dose
dependent manner. Meta analyses estimate the weight loss effect
to be approximately 1.5–2.5 kg)
 Early Stage Lung Adenocarcinoma
 contraindication
 Empagliflozin, dapagliflozin and canagliflozin should not be
initiated in patients with an eGFR persistently less than 45
mL/min/1.73m2
Side effects
 Genital Tract Infections
Increased risk of genital tract infections of
mycotic origin in those with type 2 diabetes. Glycosuria,
impaired immunity, and the hyperglycemia combined with a
warm, moist environment all are contributing factors.
 Amputations
A retrospective cohort study of 953,906 diabetic
patients found an association between the initiation of SGLT2
inhibitors with an increased risk of amputation when compared
to metformin, sulfonylureas and thiazolidinedione.
  Bone Fractures
canagliflozin adversely affects bone
microarchitecture, bone strength and bone mineral density
 Electrolyte Imbalance
 Diabetic Ketoacidosis
SGLT2 inhibitors lower the insulin to glucagon
ratio and enhance lipolysis, which stimulates the production of
ketones in the liver
 Lipids
SGLT2 inhibitors may cause a slight increase in both HDL
and LDL cholesterols levels in a dose dependent
manner( dapagliflozin, empagliflozin )
 Uric Acid/Chronic Kidney Disease
As an adjunct antihyperglycemic
medication, they lower serum uric acid levels by
approximately 0.60 to 0.75 mg/dL

 Renal Effects
 Inhibition of SGLT2 corrects the increased
intraglomerular pressure observed in type II diabetics. The
SGLT2 mediated inhibition of sodium transport in the proximal
tubule results in increased delivery of sodium to the distal
nephron.
  Risk Of Cancer
Dapagliflozin originally applied for FDA
approval, it was denied in 2011 due to concerns about the
increased risk of bladder and breast cancer.
 Posology
 Dapagliflozin = 10mg OD as monotherapy + with
metformin,sulfonylurea,DPP-4 inhibitors or insulin
 Dapagliflozin = 5mg in hepatic insuffiency
 Canagliflozin = 100mg OD to 300mg
 Empagliflozin =10 and 25mg
 Drug interactions

 No clinical drug interactions with other anti diabetic

drugs.
 Concomitant prescription of loop diuretic and SGLT2
should be avoided because of potential risk for volume
depletion.
 Canagliflozin with phenytoin,rifampicin,ritonavir require
increase in dose from 100 to 300mg,
 UGT enzyme-inducing agents increase metabolism of
canagliflozin thus leading to decrease in peak plasma
level and reduce efficacy,
 References

• sodium-dependent D-glucose transport system in the

kidney. Am J Physiol Renal Physiol. 1987;253:1.
doi:10.1152/ajprenal.1987.253.1.f1
• Heterogeneity of sodium-dependent D-glucose
transport sites along the proximal tubule: evidence
from vesicle studies. Am J Physiol Renal Physiol.
1982;242:4. doi:10.1152/ajprenal.1982.242.4.f406
• Molecular analysis of the SGLT2 gene in patients with
renal glucosuria. J Am Soc Nephrol. 2003;14(11):2873–
2882. doi:10.1097/01.asn.0000092790.89332.d2
• SGLT2 mediates glucose reabsorption in the early
proximal tubule. J Am Soc Nephrol. 2010;22(1):104–
112. doi:10.1681/asn.2010030246