Canagliflozin, a sodium glucose co-transporter 2 inhibitor, reduces post-meal glucose excursion in patients with type 2 diabetes by a non-renal mechanism: results of a randomized trial

Stein, Peter; Berg, Jolene Kay; Morrow, Linda; Polidori, David; Artis, Eunice; Rusch, Sarah; Vaccaro, Nicole; Devineni, Damayanthi

doi:10.1016/j.metabol.2014.07.003

Cited by 49 publications

(43 citation statements)

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“…7) [36]; similar results were observed in other phase I, [11], phase II [39], and phase III studies [40,41]. An additional non-renal effect contributing to postprandial glucose lowering in patients with T2DM (as observed in healthy participants) treated with canagliflozin 300-mg dose before a meal was observed; this effect was not observed with a 150-mg dose [42].…”

Section: Plasma Glucose In Patients With T2dmsupporting

confidence: 80%

Clinical Pharmacokinetic, Pharmacodynamic, and Drug–Drug Interaction Profile of Canagliflozin, a Sodium-Glucose Co-transporter 2 Inhibitor

Devineni

Polidori

2015

Clin Pharmacokinet

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The sodium-glucose co-transporter 2 (SGLT2) inhibitors represent novel therapeutic approaches in the management of type 2 diabetes mellitus; they act on kidneys to decrease the renal threshold for glucose (RTG) and increase urinary glucose excretion (UGE). Canagliflozin is an orally active, reversible, selective SGLT2 inhibitor. Orally administered canagliflozin is rapidly absorbed achieving peak plasma concentrations in 1-2 h. Dose-proportional systemic exposure to canagliflozin has been observed over a wide dose range (50-1600 mg) with an oral bioavailability of 65 %. Canagliflozin is glucuronidated into two inactive metabolites, M7 and M5 by uridine diphosphate-glucuronosyltransferase (UGT) 1A9 and UGT2B4, respectively. Canagliflozin reaches steady state in 4 days, and there is minimal accumulation observed after multiple dosing. Approximately 60 % and 33 % of the administered dose is excreted in the feces and urine, respectively. The half-life of orally administered canagliflozin 100 or 300 mg in healthy participants is 10.6 and 13.1 h, respectively. No clinically relevant differences are observed in canagliflozin exposure with respect to age, race, sex, and body weight. The pharmacokinetics of canagliflozin remains unaffected by mild or moderate hepatic impairment. Systemic exposure to canagliflozin is increased in patients with renal impairment relative to those with normal renal function; however, the efficacy is reduced in patients with renal impairment owing to the reduced filtered glucose load. Canagliflozin did not show clinically relevant drug interactions with metformin, glyburide, simvastatin, warfarin, hydrochlorothiazide, oral contraceptives, probenecid, and cyclosporine, while co-administration with rifampin modestly reduced canagliflozin plasma concentrations and thus may necessitate an appropriate monitoring of glycemic control. Canagliflozin increases UGE and suppresses RTG in a dose-dependent manner, thereby lowering the plasma glucose levels and reducing the glycosylated hemoglobin levels through an insulin-independent mechanism of action. The 300-mg dose provides near-maximal effects on RTG throughout the full 24-h dosing interval, whereas the effect of the 100-mg dose on RTG is near-maximal for approximately 12 h and is modestly attenuated during the overnight period. The observed pharmacokinetic/pharmacodynamic profile of canagliflozin in patients with type 2 diabetes mellitus supports a once-daily dosing regimen.

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Section: Plasma Glucose In Patients With T2dmsupporting

confidence: 80%

Clinical Pharmacokinetic, Pharmacodynamic, and Drug–Drug Interaction Profile of Canagliflozin, a Sodium-Glucose Co-transporter 2 Inhibitor

Devineni

Polidori

2015

Clin Pharmacokinet

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“…This was reported first in healthy volunteers 53 but has since been reported in a study of people with type 2 diabetes. 54 Because these drugs act through an insulin-independent mechanism, they can be effective when other drugs that depend entirely (sulfonylureas and meglitinides) or in part (gliptins and GLP-1 analogues) on stimulating insulin release have lost effectiveness. In type 2 diabetes, the capacity of the pancreatic beta cells to produce insulin often falls over time.…”

Section: Sodium-glucose Co-transporter 2 Inhibitorsmentioning

confidence: 99%

“…A study by Stein et al 54 from Janssen Research and Development looked at the SGLT1 effect in people with type 2 diabetes and found that canagliflozin 300 mg, but not 150 mg, reduced postprandial PG, by about 0.5 mmol/l (from graph) for about 2 hours after administration, as it depends on an intestinal drug action not a systemic one. Hence this reduction would occur only after the single daily dose.…”

Section: Clinical Effectivenessmentioning

confidence: 99%

Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation

Johnston

Uthman

Cummins

et al. 2017

Health Technol Assess

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Background Most people with type 2 diabetes are overweight, so initial treatment is aimed at reducing weight and increasing physical activity. Even modest weight loss can improve control of blood glucose. If drug treatment is necessary, the drug of first choice is metformin. However, some people cannot tolerate metformin, which causes diarrhoea in about 10%, and it cannot be used in people with renal impairment. This review appraises three of the newest class of drugs for monotherapy when metformin cannot be used, the sodium–glucose co-transporter 2 (SGLT2) inhibitors. Objective To review the clinical effectiveness and cost-effectiveness of dapagliflozin (Farxiga, Bristol-Myers Squibb, Luton, UK), canagliflozin (Invokana, Janssen, High Wycombe, UK) and empagliflozin (Jardiance, Boehringer Ingelheim, Ingelheim, Germany/Eli Lilly and Company, Indianapolis, IN, USA), in monotherapy in people who cannot take metformin. Sources MEDLINE (1946 to February 2015) and EMBASE (1974 to February 2015) for randomised controlled trials lasting 24 weeks or more. For adverse events, a wider range of studies was used. Three manufacturers provided submissions. Methods Systematic review and economic evaluation. A network meta-analysis was carried out involving the three SGLT2 inhibitors and key comparators. Critical appraisal of submissions from three manufacturers. Results We included three trials of dapagliflozin and two each for canagliflozin and empagliflozin. The trials were of good quality. The canagliflozin and dapagliflozin trials compared them with placebo, but the two empagliflozin trials included active comparators. All three drugs were shown to be effective in improving glycaemic control, promoting weight loss and lowering blood pressure (BP). Limitations There were no head-to-head trials of the different flozins, and no long-term data on cardiovascular outcomes in this group of patients. Most trials were against placebo. The trials were done in patient groups that were not always comparable, for example in baseline glycated haemoglobin or body mass index. Data on elderly patients were lacking. Conclusions Dapagliflozin, canagliflozin and empagliflozin are effective in improving glycaemic control, with added benefits of some reductions in BP and weight. Adverse effects are urinary and genital tract infections in a small proportion of users. In monotherapy, the three drugs do not appear cost-effective compared with gliclazide or pioglitazone, but may be competitive against sitagliptin (Januvia, Merck Sharp & Dohme Limited, Kenilworth, NJ, USA). Funding The National Institute for Health Research Health Technology Assessment programme.

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“…Notably, in the current study, we used 100 mg of canagliflozin once a day unlike the previous clinical study in healthy subjects in which 300 mg once a day was used [9] because only this dose is approved in Japan. Stein et al reported that a dose above 150 mg is needed to reduce plasma postprandial glucose via a non-renal mechanism (probably via inhibiting glucose absorption in the small intestine) in patients with type 2 diabetes [20]. We speculate that the reason for our positive results with this dose of canagliflozin is based, at first, on the difference in the background of patients such as race, BMI, and state of glycemic control as reflected by baseline HbA1c levels.…”

Section: Discussionmentioning

confidence: 73%

Effect of canagliflozin on circulating active GLP-1 levels in patients with type 2 diabetes: a randomized trial

et al. 2017

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SODIUM GLUCOSE COTRANSPORTER 2 (SGLT2) inhibitors are a new class of anti-diabetic drugs that improve glycemic control by inhibiting reabsorption of glucose filtered through the renal glomerulus. SGLT2 is expressed in the S1 segment of the proximal renal tubules, and inhibition of this molecule results in a remarkable increase in urinary glucose excretion [1][2][3][4] Abstract. Canagliflozin has a robust inhibitory effect on sodium glucose transporter (SGLT)-2 and a mild inhibitory effect on SGLT1. The main purpose of this study was to investigate the effect of canagliflozin on circulating active glucagon-like peptide 1 (GLP-1) levels in patients with type 2 diabetes. Patients were randomly divided into a control group (n =15) and a canagliflozin-treated group (n =15). After hospitalization, the canagliflozin-treated group took 100 mg/day canagliflozin for the entire study, and after 3 days both groups took 20 mg/day teneligliptin for an additional 3 days. In a meal test, canagliflozin significantly decreased the area under curve (AUC) (0-120 min) for plasma glucose (PG) after 3 days when compared with that at baseline, and addition of teneligliptin to the canagliflozin-treated group further decreased it. A significant decrease in the AUC (0-120 min) for serum insulin by canagliflozin was obtained, but the addition of teneligliptin elevated the AUC, and thus abolished the significant difference from baseline. A significant increase in the AUC (0-120 min) of plasma active GLP-1 by canagliflozin-treatment compared with that at baseline was observed, and the addition of teneligliptin resulted in a further increase. However, canagliflozin-treatment did not change the AUC (0-120 min) of plasma active glucose-dependent insulinotropic peptide (GIP). In conclusions, canagliflozin-administration before meals decreased PG and serum insulin, and increased plasma active GLP-1 levels in patients with type 2 diabetes. Canagliflozin did not greatly influence plasma active GIP levels. Key words: Canagliflozin, GLP-1, GIP, SGLT1is located in a more distal region from the glomerulus compared with the location of S1. SGLT1 is responsible for approximately 10% of the glucose absorption in the kidney [2]. Among the SGLT2 inhibitors, canagliflozin also possesses a mild SGLT1 inhibitory effect [5,6]. Because SGLT1 is also expressed in the small intestine [7,8], inhibition of SGLT1 appears to cause the inhibition of glucose absorption in this location as well. In fact, it is reported that administration of canagliflozin can transiently repress the increase of postprandial plasma glucose (PG) levels probably via SGLT1 inhibition in the small intestine by a maximum of 30 % in healthy subjects [9].Interestingly, recent animal studies showed that administration of canagliflozin not only caused an increase in the glucose concentration in the lower small intestinal lumen probably by SGLT1 inhibition, but also resulted in a tendency toward an increase in the levels of plasma glucagon-like peptide (GLP)-1 (a hormone that increases insulin secr...

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Canagliflozin, a sodium glucose co-transporter 2 inhibitor, reduces post-meal glucose excursion in patients with type 2 diabetes by a non-renal mechanism: results of a randomized trial

Abstract: These findings suggest that a non-renal mechanism (ie, beyond UGE) contributes to glucose lowering for canagliflozin 300 mg, but not 150 mg.

Cited by 49 publications

References 16 publications

Clinical Pharmacokinetic, Pharmacodynamic, and Drug–Drug Interaction Profile of Canagliflozin, a Sodium-Glucose Co-transporter 2 Inhibitor

Clinical Pharmacokinetic, Pharmacodynamic, and Drug–Drug Interaction Profile of Canagliflozin, a Sodium-Glucose Co-transporter 2 Inhibitor

Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation

Effect of canagliflozin on circulating active GLP-1 levels in patients with type 2 diabetes: a randomized trial

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