SGLT2抑制剂治疗糖尿病研究进展

近年来,钠-葡萄糖协同转运蛋白2(type 2 sodium glucose co-transporters,SGLT2)抑制剂作为一种新型的治疗糖尿病药物成为研究热点。SGLT2在肾近端小管葡萄糖重吸收中起着非常重要的作用;抑制肾脏SGLT2可以促进Ⅱ型糖尿病人尿糖的排泄,使其血糖恢复正常而不会有低血糖的风险。临床实验表明,SGLT2抑制剂对Ⅱ型糖尿病的治疗效果明显,且具有降低体重、无低血糖风险等优点,目前,许多SGLT2抑制剂已经进入临床评价后期。     

Exploring newer target sodium glucose transporter 2 for the treatment of diabetes mellitus

Diabetes mellitus is an independent risk factor for the development of coronary artery disease, myocardial infarction, hypertension, and dyslipidemia. The treatment of diabetes has been mainly focused on maintaining normal blood glucose concentrations. Insulin and hypoglycemic agents have been used as standard therapeutic strategies. However, these are characterized by limited efficacy and adverse side effects, making the development of new therapeutic alternatives mandatory. Inhibition of glucose reabsorption in the kidney, mediated by Sodium Glucose Transporters (SGLT's), represents a promising therapeutic approach. The high-affinity sodium glucose cotransporter (SGLT1) is expressed to some extent in the kidney and contributes to glucose reabsorption, However Genetic mutations in the SGLT1 gene leading to a functional defect are responsible for glucose/galactose malabsorption. The low-affinity sodium glucose cotransporter (SGLT2), which is expressed specifically in the kidney, plays a major role in renal glucose reabsorption in the proximal tubule. We focused on SGLT2 as a molecular target for this review because it plays a major role in renal glucose reabsorption, and its tissue distribution is limited in the kidney to reduce the likelihood for mechanism-based side effects. Phlorizin, a natural phenolic O-glucoside has been known to induce glucosuria for more than 100 years. As it is not a specific SGLT inhibitor, later on o-glucoside is replaced by c-glycoside as it is resistant to hydrolysis by β-glucosidases. The present review summarizes the concept of SGLT2 selective target based therapy for diabetes mellitus and the current clinical and preclinical development of SGLT2 inhibitors.     

Sodium-glucose cotransporter inhibitors for diabetes

In the search for potential new drug targets for the treatment of diabetes, sodium-glucose cotransporters (SGLTs), in particular SGLT2, have been the subject of particular attention. SGLT2 plays an important role in glucose reabsorption in the kidney, and SGLT2 inhibitors enhance renal glucose excretion and consequently lower plasma glucose levels. Thus, SGLT2 inhibitors can control energy balance in a negative direction. The principle behind SGLT2 inhibition involves the improvement of diabetic conditions without increasing body weight or the risk of hypoglycemia. A number of pharmaceutical companies are evaluating SGLT2 inhibitors, and studies have confirmed the therapeutic potency and safety of these drugs for the potential treatment of diabetes.     

SGLT2抑制剂研究进展

钠-葡萄糖协同转运蛋白（SGLTs）主要存在于小肠黏膜（SGLTl）和肾近曲小管（SGLT1和SGLT2）的转运基因家族,其表达的膜蛋白负责将葡萄糖、氨基酸、维生素、离子和渗透溶质转运至肾近曲小管的刷状缘细胞及小肠上皮细胞。而SGLT2是一种主要在肾脏特异性表达的高效能．低亲和力转运体。葡萄糖在肾近曲小管的重吸收约有90％由SGLT2完成,因此选择性地阻断SGLT2、减少重吸收、增加尿糖排出这一治疗策略已成为糖尿病领域的又一创新性研究,为糖尿病治疗药物提供了新作用靶点。本文对SGLT2抑制剂在治疗2型糖尿病方面的最新研究进展进行介绍,主要阐述其作用机制、疗效（部分在研SGTL2抑制剂的临床试验结果）和安全性。     

钠-葡萄糖共转运蛋白2抑制剂治疗2型糖尿病的临床研究进展

2 型糖尿病是一种以胰岛素分泌缺陷、胰岛素抵抗或者两者并存所致的高血糖为特征的慢性代谢性疾病。早期血糖控制不佳可以促进微血管并发症的进展,以及大血管风险的发生。虽然有众多的降糖药物在临床使用,但只有约50%的患者能实现血糖控制,传统药物仍存在某些不足,因此,需要开发具有新机制的治疗药物。钠-葡萄糖共转运蛋白2（SGLT2）是近年来发现的具有全新作用机制的一个糖尿病治疗靶点。SGLT2 抑制剂通过抑制肾脏近端小管对葡萄糖的重吸收来增加尿中葡萄糖的排泄而达到控制血糖的目的,其独立于葡萄糖依赖的胰岛素途径,能使低血糖发生风险降低。临床试验数据表明,SGLT2 抑制剂单药治疗和与传统降糖药物联合治疗均可以有效地控制血糖,并改善胰岛素抵抗,同时也有降血压和减少体质量作用。尽管后续的研究显示了SGLT2 抑制剂具有良好的耐受性,该类药物在临床上报道的意想不到的风险仍需要大量和长期的临床数据证实。     

Clinical implication of SGLT2 inhibitors in type 2 diabetes

Treatment of type 2 diabetes mellitus (T2DM) continues to present challenges, with many patients failing to achieve glycemic targets. Despite the availability of many oral and injectable anti-diabetic agents, therapeutic efficacy is often offset by undesirable side effects such as hypoglycemia, weight gain and cardiovascular complications. Therefore, the search for new therapeutic agents with an improved benefit–risk profile continues. Recent research has focused on the kidney as a potential therapeutic target, especially because maximal renal glucose reabsorption is increased in T2DM. Under normal physiological conditions, nearly all filtered glucose is reabsorbed in the proximal tubule of the nephron via the sodium/glucose co-transporter 2 (SGLT2). SGLT2-inhibitors are a new class of oral anti-diabetes, which reduce hyperglycemia by increasing urinary glucose excretion independently of insulin secretion or action. Canagliflozin and dapagliflozin in US market, and ipragliflozin and luseogliflozin in Japan market are now available for glycemic control in type 2 diabetics. There are several phase III clinical ongoing trials involving this new class of medications. This review examines some of the key efficacy and safety data from clinical trials of the SGLT2 inhibitors approved, and their future perspectives in the treatment of T2DM.     

新型SGLT1/2双靶点抑制剂sotagliflozin

钠-葡萄糖共转运蛋白2(SGLT2)抑制剂是一类新兴的治疗糖尿病的药物。近年来,遗传学和药理学研究发现,胃肠道SGLT1蛋白也可能成为一个有治疗前景的药物靶点。SGLT1/SGLT2双靶点抑制剂的开发将为糖尿病的治疗提供另一个非胰岛素依赖的途径。临床研究表明,sotagliflozin可以通过双重抑制SGLT1和SGLT2的作用来降低餐后血糖、升高GLP-1和促进尿糖排出。因此,这些特征使得sotagliflozin在对1型和2型糖尿病的治疗方面具有重要临床意义。     

Differentiating sodium-glucose co-transporter-2 inhibitors in development for the treatment of type 2 diabetes mellitus

Introduction: Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a novel class of agents for the treatment of type 2 diabetes mellitus (T2DM). By inhibiting SGLT2, they prevent renal glucose reabsorption, resulting in glucosuria.

Areas covered: The rationale for development of SGLT2 inhibitors is reviewed, with particular focus on the nine SGLT2 inhibitors currently in development. The authors compare the potency and SGLT2 selectivity of the agents, as well as the results from both animal and clinical studies, considering the potential implications they may have for clinical use.

Expert opinion: Current evidence suggests that SGLT2 inhibitors have similar efficacy in terms of glycemic control and also demonstrate benefits beyond glycemic reductions, including reductions in body weight and modest reductions in blood pressure. Additionally, they appear to preserve beta-cell function and improve insulin sensitivity. Their mechanism of action allows for combination of SGLT2 inhibitors with other antidiabetic drugs and use across the treatment continuum for T2DM. Potential differences in safety and efficacy based on observed differences in potency and selectivity among the SGLT2 inhibitors, particularly versus SGLT1, remain to be seen. Further long-term data, including post-marketing surveillance, are required to fully determine the safety profile of SGLT2 inhibitors in large patient groups.     

Evolution of sodium glucose co-transporter 2 inhibitors as anti-diabetic agents

Background: A critical factor for maintenance of glucose balance is the renal recovery of glucose from the glomerular filtrate mediated primarily by sodium glucose co-transporter 2 (SGLT2). This capacity can be modulated by SGLT2 inhibitors thereby providing a unique insulin independent method of treatment of diabetes. Objective/method: A discussion of the evolution of SGLT inhibitors as inferred from patents published from 2005 to 2009 is prefaced by a brief review of the role of SGLT in glucose transport and the clinical findings illustrating the therapeutic potential of SGLT inhibitors as anti-diabetic agents. These compounds comprise O, C and N-glycosides generated by attachment of an appropriate lipophilic aglycone component to a suitable glucose analogue. Conclusion: The realization that the in vivo potency of O-glucosides was markedly less than that of C-glucosides necessitated a shift in medicinal chemistry focus of the pharmaceutical companies pursuing SGLT2 inhibitors. Particular emphasis is placed on the strategy that each used to circumvent the constraints imposed by prior art while utilizing a common pharmacophore. The role of SGLT2 inhibitors for treatment of diabetes will be established by the outcome of the five compounds in advanced clinical trials.     

Inhibitors of type 2 sodium glucose co-transporters – a new strategy for diabetes treatment

In the last few years, the type 2 sodium glucose co-transporters (SGLT2) have been the subject of particular attention as a new, potent group of anti-diabetic drugs.SGLT2 inhibitors block glucose reabsorption in the kidneys, which prompts urinary excretion of glucose and results in lowering of its plasma levels. Although this group of medications is still under investigation, their efficacy in the treatment of type 2 diabetes mellitus (T2D) is very promising, with some of these inhibitors currently undergoing clinical trials.     

已上市钠-葡萄糖协同转运蛋白2抑制剂临床药动学特点比较

钠-葡萄糖协同转运蛋白2(sodium-glucose cotransporter type 2,SGLT2)参与肾脏对90%葡萄糖滤过液的重吸收,在血糖调节中发挥重要作用。SGLT2抑制剂作为2型糖尿病治疗的新靶点,受到广泛关注。目前,已有卡格列净、达格列净、依帕列净、依格列净、托格列净、鲁格列净6种SGLT2抑制剂在美国和日本上市,本研究对已上市的SGLT2抑制剂临床药动学特点进行了比较和综述。     

钠-葡萄糖协同转运蛋白2抑制剂类抗糖尿病新药的研发概况

目前,钠-葡萄糖协同转运蛋白2(SGLT2)抑制剂通过抑制葡萄糖在肾脏近曲小管的重吸收,从而成为治疗糖尿病的新途径。按其结构,SGLT2抑制剂主要分为C-芳基抑制剂、O-芳基抑制剂、S-糖苷抑制剂和N-糖苷抑制剂,而C-芳基抑制剂和O-芳基抑制剂处于研究热点,其中几个新药(dapagliflozin、canagliflozin、ASP1941、BI10773和LX4211)显示出良好的控制血糖水平和减轻体质量的效果,且不良反应较小。综述两类结构中的主要药物研究概况,并分析其研发前景。     

钠–葡萄糖协同转运蛋白2抑制剂对心肌梗死影响的研究进展

钠–葡萄糖协同转运蛋白2(SGLT2)抑制剂是近年来应用于临床的新型口服抗糖尿病药物,主要通过抑制分布在肾脏肾小管处的SGLT2来阻止多余葡萄糖的重吸收,促进尿糖排泄,从而降低循环血糖水平,同时发挥利钠、利尿作用,对充血性心力衰竭也是一种新的治疗选择。随着越来越多的人群受用,研究发现SGLT2抑制剂还具有降低心血管结局等多种心血管保护作用,不仅可使心衰患者受益,对心肌梗死也呈现出多效性,尽管相关机制目前只是推测。主要对SGLT2抑制剂治疗心肌梗死的相关研究进行综述。     

Dapagliflozin: an emerging treatment option in type 2 diabetes

The global incidence of type 2 diabetes mellitus is increasing. Hyperglycemia contributes to both the complications associated with diabetes mellitus and progression of the underlying disease. New agents that lower blood glucose levels are therefore needed to help slow disease progression and reduce disease complications. The sodium-glucose co-transporter 2 (SGLT2) reabsorbs glucose in the kidney. Inhibition of SGLT2 by new agents, such as dapagliflozin, has the potential to reduce hyperglycemia by inhibiting glucose reabsorption in the kidney. Preclinical trials demonstrated that dapagliflozin is a potent and selective inhibitor of SGLT2. It has shown linear pharmacokinetics over the dose range of 2.5 – 500 mg/day, is not significantly influenced when taken with food and is primarily eliminated via urinary excretion. Clinical trials have shown that dapagliflozin treatment induces glucosuria and improves glycemic parameters in patients with type 2 diabetes. Inhibition of SGLT2 is a new and promising approach to treating type 2 diabetes mellitus. This article reviews the role of dapagliflozin as an emerging treatment option in type 2 diabetes.     

糖尿病治疗的新希望——SGLT2抑制剂

钠依赖的葡萄糖运载体(SGLTs)是一类在小肠黏膜和肾近曲小管中发现的转运基因家族,肾脏重吸收葡萄糖的过程主要由SGLTs介导。其中,SGLT1和SGLT2最为重要,SGLT2起主导作用。选择性地抑制SGLT2能显著降低机体对葡萄糖的重吸收,通过增加尿糖的排出从而降低血糖水平。SGLT2抑制剂是一种创造性的治疗策略,其作用靶点和机制与现有降糖药均不同,成为降糖药物研究的热点。文中介绍了SGLT2在调节血糖平衡中的作用,简单介绍了部分在研SGLT2抑制剂,重点综述了Ⅲ期临床药物dapagliflozin的临床试验结果。     

SGLT2 inhibitors: a new emerging therapeutic class in the treatment of type 2 diabetes mellitus

The incidence of type 2 diabetes mellitus is increasing worldwide. The existing therapeutic classes of antidiabetic drugs are not adequately effective in maintaining long-term glycemic control in most patients, even when used in combination. One emerging novel therapeutic class of antidiabetic drugs is sodium glucose cotransporter 2 (SGLT2) inhibitors. SGLT2 accounts for 90% of the glucose reabsorption in the kidney. The SGLT2 inhibitors increase urinary excretion of glucose and lower plasma glucose levels in an insulin-independent manner. Dapagliflozin, the most prominent molecule in this class, is currently in a phase III clinical trial. Other members of this class (eg, sergliflozin, remogliflozin) are also in different phases of clinical trials. This class of novel agents can effectively control blood sugar level without producing weight gain or hypoglycemia. Results of ongoing phase III clinical trials are crucial to determine whether the risk-benefit ratio will allow approval of this new class of drugs for the management of type 2 diabetes mellitus.     

Empagliflozin for the treatment of Type 2 diabetes

Diabetes and its complications account for a significant healthcare burden. There is increasing prevalence of diabetes and newer drugs are being investigated to improve outcomes. Sodium–glucose cotransporter inhibitors (SGLT2 inhibitors) are a newer class of medications, which prevent renal reabsorption of glucose and hence help in glycaemic control without significant risk of hypoglycaemia. Two drugs, namely dapagliflozin and canagliflozin have gained approval and empagliflozin is one of the advanced agents of this class. Early trials with empagliflozin have shown a stable pharmacokinetic profile and pharmacodynamic effects with significant SGLT2 selectivity. Clinical trials have shown improvement in glycaemic control and other benefits including weight loss and lowering of blood pressure. Ongoing trials and surveillance will provide answers about cardiovascular benefits, risk of osteoporosis and cancer.     

钠-葡萄糖协同转运蛋白2（SGLT2）抑制剂的研究进展

钠-葡萄糖协同转运蛋白2(SGLT2)是最近新发现的糖尿病治疗新靶点,其作用机制是特异性地抑制肾脏对葡萄糖的再吸收,且不依赖于β细胞的功能异常或胰岛素抵抗的程度。其效果也不会随着β细胞功能的衰竭或严重胰岛素抵抗而下降,不会产生传统药物带来的不良反应,是糖尿病治疗的新途径。本文介绍SGLT2在调节体内糖平衡中的作用,总结SGLT2抑制剂在2型糖尿病治疗方面的最新进展,并对已报道的抑制剂化学结构进行总结。     

Luseogliflozin and other sodium-glucose cotransporter 2 inhibitors: no enemy but time?

Glycosuria is being increasingly recognised as not only a symptom but also as a novel therapeutic approach in the management of type 2 diabetes mellitus (T2DM). This is accomplished through sodium glucose co-transporter 2 (SGLT2) inhibitors. Consequently, the safety and efficacy of these new agents have been thoroughly studied, both in randomised controlled trials and in systematic reviews and meta-analyses. More recently, a review on the mechanism of action, clinical efficacy and safety of luseogliflozin, a new highly selective SGLT2 inhibitor approved and launched in Japan for T2DM, has documented that this drug lowers plasma glucose concentration and body weight, and that it exhibits benefits in other metabolic parameters with a good safety profile. Despite the promising characteristics of this drug, important issues await consideration. These include the question as to when and to whom early use of SGLT2 inhibitors would be most suitable, as well as instructions on reduction of sulfonylurea dosage during add-on treatment. Further important questions are long-term safety concerns and cost-effectiveness of this new therapeutic class. Finally, we need to know more about the potential differences between the various SGLT2 inhibitors, as such differences might prove clinically useful in selection of hypoglycaemic agents.     

SGLT inhibitors as new therapeutic tools in the treatment of diabetes

Recently, the idea has been developed to lower blood glucose blood glucose levels in diabetes by inhibiting sugar reabsorption sugar reabsorption in the kidney kidney . The main target is thereby the early proximal tubule proximal tubule where secondary active transport secondary active transport of the sugar is mediated by the sodium-D: -glucose D-glucose cotransporter SGLT2 SGLT2 . A model substance for the inhibitors inhibitors is the O-glucoside O-glucoside phlorizin phlorizin which inhibits transport transport competitively. Its binding to the transporter involves at least two different domains: an aglucone binding aglucone binding site at the transporter surface, involving extramembranous loops extramembraneous loops , and the sugar binding sugar binding /translocation site buried in a hydrophilic pocket of the transporter. The properties of these binding sites differ between SGLT2 and SGLT1 SGLT1 , which mediates sugar absorption sugar absorption in the intestine intestine . Various O-, C-, N- and S-glucosides have been synthesized with high affinity affinity and high specificity specificity for SGLT2 SGLT2 . Some of these glucosides are in clinical trials clinical trials and have been proven to successfully increase urinary glucose excretion urinary glucose excretion and to decrease blood sugar blood sugar levels without the danger of hypoglycaemia hypoglycaemia during fasting fasting in type 2 diabetes type 2 diabetes .