BACKGROUND: There is an unmet need for a safer and more effective treatment for obesity.This study assessed the effects of licogliflozin, a dual inhibitor of sodium-glucose co-transporter (SGLT) 1/2, on body weight, metabolic parameters and incretin hormones in patients with type 2 diabetes mellitus (T2DM) and/or obesity. METHODS:Patients with obesity (BMI, 35-50 kg/m 2 ) were enrolled into a 12-week study (N = 88; licogliflozin 150 mg q.d.). Patients with T2DM were enrolled into a second, two-part study, comprising a single-dose cross-over study (N = 12; 2.5 − 300 mg) and a 14-day dosing study (N = 30; 15 mg q.d). Primary endpoints included effects on body weight, effects on glucose, safety and tolerability. Secondary endpoints included urinary glucose excretion (UGE 24 ) and pharmacokinetics, while exploratory endpoints assessed the effects on incretin hormones (total GLP-1, PYY 3-36 , and GIP), insulin and glucagon.RESULTS: Treatment with licogliflozin 150 mg q.d. for 12 weeks in patients with obesity significantly reduced body weight by 5.7% vs placebo (P < 0.001) and improved metabolic parameters such as significantly reduced postprandial glucose excursion (21%; P < 0.001), reduced insulin levels (80%; P < 0.001) and increased glucagon (59%; P < 0.001). In patients with T2DM, a single dose of licogliflozin 300 mg in the morning prior to an oral glucose tolerance test (OGTT) remarkably reduced glucose excursion by 93% (P < 0.001; incremental AUC 0-4h ) and suppressed insulin by 90% (P < 0.01; incremental AUC 0-4h ). Treatment with licogliflozin 15 mg q.d. for 14 days reduced 24-hour average glucose levels by 26% (41 mg/dL; P < 0.001) and increased UGE 24 to 100 g (P < 0.001) in patients with T2DM. In addition, this treatment regimen significantly increased total GLP-1 by 54% (P < 0.001) and PYY 3-36 by 67% (P < 0.05) post OGTT vs placebo, while significantly reducing GIP levels by 53% (P < 0.001). Treatment with licogliflozin was generally safe and well tolerated. Diarrhea (increased numbers of loose stool) was the most common adverse event in all studies (90% with licogliflozin vs 25% with placebo in the 12-week study), while a lower incidence of flatulence, abdominal pain and abdominal distension (25%-43% with licogliflozin vs 9%-11% with placebo in the 12-week study) were among the other gastrointestinal events reported. CONCLUSION: Licogliflozin treatment (1-84 days) leads to significant weight loss and favourable changes in a variety of metabolic parameters and incretin hormones. Dual inhibition of SGLT1/2 with licogliflozin in the gut and kidneys is an attractive strategy for treating obesity and diabetes. K E Y W O R D S clinical trial, continuous glucose monitoring (CGM), incretins, obesity therapy, phase I-II study, weight control

Salivary levels of the immunosuppressive agent, mycophenolic acid (MPA), may provide a convenient and noninvasive method for drug monitoring. An analytical method was developed and validated for quantification of salivary MPA using liquid chromatography tandem mass spectrometry. Sample preparation included addition of 50 microL internal standard solution [500 microg/L indomethacin in methanol] to 100 microL saliva sample, followed by protein precipitation with 200 microL acetonitrile. Supernatants were dried and reconstituted in 100 microL of 85:15% (vol/vol) mixture of methanol and water containing 0.05% formic acid and 20 microL was injected onto the analytical column. The mobile phase comprised a gradient mixture of methanol and 0.05% formic acid, giving a total run time of 7.5 minutes. Chromatograms were obtained using mass transitions of m/z 319.0-->190.8 for MPA and m/z 355.9-->312.2 for indomethacin. The calibration curve was linear over a concentration range of 2.5 to 800 microg/L (r=0.9999) and the recovery of MPA from saliva was >90%. The inaccuracy was <10% and intra- and interday coefficient of variation ranged from 2.8% to 5.2%. Mean+/-SD of MPA concentrations in saliva (n=100) obtained from 11 kidney transplant recipients was 31.4+/-32.3 microg/L (range: 2.6 to 220.4 microg/L) and correlated well with total (r=0.909) and unbound (r=0.910) MPA concentrations in plasma. In conclusion, a simple, sensitive, and specific method was developed and validated for quantification of MPA in saliva. Additional clinical studies are required to establish the usefulness of this specimen in the clinical management of organ transplant recipients.

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This study indicates that diabetes mellitus significantly affects the concentration of CsA metabolites. Because CsA is eliminated as metabolites via the biliary route, the decrease in the blood concentration of CsA metabolites during postabsorption phase would probably reflect lower hepatic cytochrome P450 3A4 enzyme activity. However, other mechanisms including altered expression of transporters may also play a role. Results of cyclosporine therapeutic drug monitoring in diabetic patients must be interpreted with caution when nonspecific assays are used.

Saliva may offer an alternative specimen for the therapeutic monitoring of cyclosporine (CsA) in children and patients with difficult venous access. For a highly protein-bound drug such as CsA, saliva may also provide a practical approach for measuring the unbound concentration. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is ideally suited for the measurement of drugs in saliva. A solid-phase extraction technique, analytic liquid chromatography over an Aqua Perfect C18 column, maintained at 65 degrees C, and electrospray tandem mass spectrometry were used to quantify CsA in saliva. The method used cyclosporine C (CsC) as the internal standard. Mobile phase comprised of a 97:3 vol/vol mixture of methanol and 30 mmol ammonium acetate at a flow rate of 0.5 mL/min. Chromatograms using mass transitions of m/z 1219.9 --> m/z 1202.9 for CsA and m/z 1235.9 --> m/z 1218.9 for CsC were obtained. The calibration curve was linear from 1 to 300 microg/L with correlation coefficient values ranging from 0.9732 to 0.9968). The lower limit of quantification was 1 microg/L, and limit of detection was 0.6 microg/L with an average extraction recovery of 84.7 +/- 2.6% for CsA and 93.7 +/- 4.4% for CsC from the saliva matrix. The accuracy of the method ranged from 92% to 104.7%, and the intra- and interrun coefficients of variation were 6.9-12.2% and 8.3-12.1%, respectively. The correlation coefficient value between the CsA concentration measurements in 15 paired blood-saliva samples from kidney transplant recipients was 0.695 (P = 0.006). The noninvasive and simple method of saliva collection coupled with the LC-MS/MS quantification technique for CsA analysis would generate novel data that could benefit patients undergoing CsA therapy.