TheSGLT-2 inhibitor dapagliflozin ehnanced the anticancer activities and exerts cardioprotective effects during exposure to ipilimumab through NLRP3 inflammasome and pro-fibrotic cytokines

Abstract

Background The clinical trial “DECLARE-TIMI 58” (Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58), demonstrated that dapagliflozin, a Sodium glucose cotransporter 2 inhibitor, reduces the composite end point of cardiovascular death/hospitalization for heart failure in a broad population of patients with type 2 diabetes mellitus. Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, achieving unprecedented efficacy in multiple malignancies. However, ICIs are associated with immune-related adverse events involving cardiotoxicity. Purpose We aimed to study if dapagliflozin could affect ipilimumab-induced anticancer efficacy in human breast cancer cells and reduces its cardiotoxicity. Methods Co-culture of hPBMCs and human cardiomyocytes or estrogen-responsive and triple-negative breast cancer cells (MCF-7 and MDA-MB-231 cell lines) were exposed to ipilimumab (200 nM) alone or combined to SGLT-2 inhibitor (dapagliflozin) for 72h. After the incubation period, we performed the following tests: determination of cell viability, through analysis of mitochondrial dehydrogenase activity, study of lipid peroxidation (quantifying cellular Malondialdehyde and 4-hydroxynonenal), intracellular Ca2+ homeostasis. Moreover, pro-inflammatory studied were also performed (activation of NLRP3 inflammasome; expression of TLR4/MyD88; transcriptional activation of p65/NF-κB and secretion of cytokines involved in cardiotoxicity (Interleukins 1β, 8, 6). Results Dapagliflozin increases significantly the cardiomyocytes viability during exposure to Ipilimumab. Indeed, in human breast cancer cells, dapagloflozin showed an opposite behavior with a significant increase in cell mortality and apoptosis (p<0.001 vs only ipilimumab). Cardioprotective properties of dapagliflozin are explainable by the reduction of intracellular Ca2+ overload (−56,8% vs only ipilimumab; p<0,001), of the lipid peroxidation (mean reduction of 42,1–48,6% compared to cells exposed only to ipilimumab; p<0,05). Moreover, cells exposed to dapagliflozin during ipilimumab reduced the protein expression of pro-inflammatory cytokines involved in cardiotoxicity and resistance to anticancer effects of ICIs (−47,2% for Interleukin-1β; −48,7 for Interleukin 6; −32,1% for Interleukin 8; p<0,001 for all vs only ipilimumab groups). Notably, dapagliflozin reduces p65-NF-κB activation (−46,3 and −49,3% vs only ipilimumab, p<0.05) and inhibits of 43,2–53,7% the expression of NLRP3 inflammasome, p<0.05 for all). No significant effects were seen on TLR4/MYD88 expression in all groups. Conclusion Dapagliflozin demonstrated cardioprotective properties during Ipilimumab exposure in co-culture model of hPBMCs and cardiomyocytes. Dapagliflozin improves Ca2+ homeostasis and inhibits the pro-inflammatory “NLRP3–NF-κB–cytokines” pathways in cardiac cells. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ricerca corrente grant of Italian Ministry of Health

The Cardioprotective and Anticancer Effects of SGLT2 Inhibitors

“…Subsequent to landmark studies demonstrating the cardioprotective effects of SGLT2 inhibitors in HF, numerous in vivo ( Table 2 ) and in vitro ( Table 3 ) studies, starting in 2019, have underscored the cardioprotective roles of SGLT2 inhibitors in mitigating cardiotoxicity induced by various cancer treatments, including DOX, 17 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 sunitinib, 20 trastuzumab, 21 cisplatin, 19 ipilmumab, 54 , 55 ponatinib, 56 and carfilzomib. 57 DOX has received particular attention because of its status as the most cardiotoxic cancer treatment and its widespread use.…”

“… 32 Researchers have investigated several models of DOX cardiotoxicity, including acute 39 , 42 , 43 , 48 , 51 and chronic 17 , 39 , 41 , 46 , 47 , 48 cardiotoxicity, cardiorenal syndrome, 40 and conditions involving diabetic 44 and nondiabetic rodents. Empagliflozin 17 , 20 , 21 , 39 , 40 , 41 , 42 , 43 , 49 , 55 , 56 and dapagliflozin 44 , 45 , 46 , 48 , 50 , 51 , 52 , 53 , 54 , 56 have emerged as the most commonly used SGLT2 inhibitors, followed by canagliflozin. 19 , 57 Notably, no in vivo studies have reported the protective effects of canagliflozin against DOX, with only 1 in vivo study reporting the cardioprotective effects of canagliflozin against cisplatin 19 and an in vitro study demonstrating its efficacy against carfilzomib.…”

“… 55 Dapagliflozin showed similar attenuation in vitro in response to trastuzumab and ipilimumab cardiotoxicity. 54 Recently, canagliflozin counteracted cisplatin-induced cardiotoxicity by reducing levels of nuclear factor κB, myeloperoxidase, inducible nitric oxide synthase, tumor necrosis factor-α, and interleukin-1β. 19 …”

“… 55 Furthermore, dapagliflozin protected human cardiomyocytes from ipilimumab cytotoxicity by reducing lipid peroxidation and intracellular calcium overload. 54 Canagliflozin exhibited a cardioprotective effect against cisplatin-induced acute cardiotoxicity through the regulation of nuclear factor erythroid 2–related factor 2 expression. 19 …”