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Int. J. Pharm. Sci. Rev. Res., 33(1), July – August 2015; Article No. 10, Pages: 40-47 ISSN 0976 – 044X
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Harsharan Pal Singh1*, Ishpreet Kaur2, Gunjan Sharma3
1Department of Quality Assurance, AIMIL Pharmaceuticals (India) Limited, New Delhi, India.
2Department of Quality Assurance, Delhi Institute of Pharmaceutical Sciences & Research, Pushp Vihar, New Delhi, India.
3Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh, India.
*Corresponding author’s E-mail: harsharanpal.singh@gmail.com
Accepted on: 05-05-2015; Finalized on: 30-06-2015.
ABSTRACT
SGLT2 Inhibitors are a new class of oral antidiabetic agents which reduce the plasma glucose concentration by preventing the
reabsorption of glucose from the S1 segment of proximal convoluted tubule, thereby increasing urinary glucose excretion. Most
recent understanding about the physiology of renal glucose transport system and increased knowledge about rare genetic
syndromes of renal glucosuria has resulted in the development of drugs that selectively inhibit sodium glucose transporter-2(SGLT2).
Their mechanism of action is independent of beta cell and tissue sensitivity to insulin, but they improve glycemic control while
avoiding hypoglycemia and promoting weight loss. This article discusses the basic physiology of SGLT2 transporter system,
mechanism of action and chemistry of various agents under this class. Dapagliflozin and Canagliflozin are the first agents of this
class, approved from the European Medicine Agency and FDA, respectively.
Keywords: Anti-diabetic agents, Diabetes, Glucosuria, SGLT2 Inhibitor, Weight loss
INTRODUCTION
iabetes Mellitus and its Epidemiology
Diabetes mellitus is a chronic disease that
requires life-long pharmacological and non
pharmacological management to prevent
complications such as cardiovascular disease,
retinopathy, nephropathy, and neuropathy.1,2 People
with diabetes are at risk of developing a number of
disabling and life-threatening health problems.
Consistently high blood glucose levels can lead to serious
diseases affecting the heart and blood vessels, eyes,
kidneys, and nerves. Diabetic patients are also at
increased risk of developing infections. In almost all high
income countries, diabetes is a leading cause of
cardiovascular disease, blindness, kidney failure, and
lower-limb amputation.
While type 2 diabetes mellitus is most common form of
diabetes comprising of 90% to 95% of all diabetes cases2.
An estimated 387 million people worldwide live with
diabetes, resulting in 4.9 million deaths in 2014, with
more than 77% of these deaths occurring in low- and
middle income countries. It is projected that the death
burden from diabetes will double by the year 20353.
According to the 2014 IDF report, the estimated
prevalence of diabetes in 2014 was about 8% for men and
women in low-income countries and 10% for both sexes
in upper-middle-income countries with the highest global
prevalence of diabetes in Eastern Mediterranean Region
and Region of the Americas4. The high prevalence rate is
of concern since diabetes is the leading cause of renal
failure, visual impairment, blindness and increases the
risk of lower limb amputation by at least 10 times3,4.
Additionally, patients living with diabetes may need 2 to 3
three times of the health-care resources compared to
people without diabetes and diabetes care may require
allocation of up to 15% of national health care budgets4.
Introduction
Sodium-dependent glucose co-transporters (SGLT) belong
to the family of glucose transporter found in the intestinal
mucosa of small intestine (SGLT1) and in the proximal
tube of nephron (SGLT2 in PCT and SGLT1 in PST) which
contribute to renal glucose reabsorption. In kidneys,
100% of the filtered glucose in the glomerulus has to be
reabsorbed along the nephron via SGLT25,6. In case of
high plasma glucose concentration (hyperglycemia),
glucose is excreted in urine (glucosuria); because SGLT
are saturated with the filtered monosaccharide7. Diabetes
mellitus is the most common metabolic disorder
characterized by hyperglycaemia which is associated with
long term complications affecting kidney, heart, eyes and
nerves8-10. Insulin regulates carbohydrate metabolism by
aiding the transport of glucose and amino acid from the
blood stream into the storage organs such as liver and
muscles. In diabetes mellitus, hindrance in glucose
transport takes place of such a degree that threatens or
impairs health11.
Management of type 2 diabetes mellitus (T2DM) remains
complex and challenging. A wide range of
pharmacotherapy for T2DM which includes metformin,
insulin secretagogues (predominantly sulfonylureas),
thiazolidinediones, α-glucosidase inhibitors, insulin and
more recently glucagon like peptide-1 agonists and
dipeptidyl-peptidase-IV inhibitors, many patients do not
achieve glycemic targets due to side effects of current
therapies, including weight gain, hypoglycemia, fluid
retention and gastrointestinal side effects. Hence, the
Sodium Glucose Co-Transporter-2 (SGLT2) Inhibitors as a New Class of Anti-diabetic Drugs:
Pharmacokinetics, Efficacy and Clinical significance
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Article
Int. J. Pharm. Sci. Rev. Res., 33(1), July – August 2015; Article No. 10, Pages: 40-47 ISSN 0976 – 044X
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41
search for new treatment strategies is ongoing12. Among
the new therapies on the horizon, sodium-glucose co-
transporter 2 (SGLT2) inhibitors seem to be promising and
there are a number of ongoing phase II and III clinical
trials with a variety of these compounds. SGLT2 is
expressed in the renal proximal tubules and accounts for
90% of the renal glucose reabsorption13,14. SGLT2
inhibitors work independently of insulin leading to
negative energy balance by enhanced urinary glucose
excretion. This makes mechanistically possible for this
class of drugs to reduce glucose levels without causing
hypoglycemia and weight gain. However, the side effect
profile remains to be further elucidated in ongoing phase
III trials and these compounds will need to be proved safe
from a renal and cardiovascular perspective in order to
meet current regulatory requirements for new diabetes
treatment15.
Types of SGLT
The two well known members of SGLT family are SGLT1
and SGLT2 (Tables 1, 2), which are members of the SLC5A
gene family13,14.
Including SGLT1 and SGLT2, there are total seven
isoforms in the human protein family SLC5A, many of
which may also be sodium-glucose transporters15,16.
Table 1: SGLT1 and SGLT2 and their Properties
Gene Protein Acronym Tissue distribution in
proximal tubule Na:Glucose
cotransport ratio Glucose
reabsorption
SLC5A1 Sodium/Glucose co-
transporter 1 SGLT1 S3 segment 2:1 10
SLC5A2 Sodium/Glucose co-
transporter 2 SGLT2 Mainly in the S1 and S2
segments 1:1 90
Table 2: Types of Sodium Glucose Transporters
Gene Protein Substrate Tissue distribution
SLC5A1 SGLT1 Glucose and galactose Small intestine, trachea and kidney
SLC5A2 SGLT2 Glucose Kidney
SLC5A4 SGLT3 Glucose sensor Small intestine, lung, uterus, thyroid and testes
SLC5A9 SGLT4 Mannose, glucose, fructose and 1,5-
Anhydroglucitol Small intestine, kidney, lung and liver
SLC5A10 SGLT5 Glucose and galactose Kidney
SLC5A11 SGLT6 Myo-inositol, xylose and chiro-inositol Spinal cord, kidney, brain and small intestine
Table 3: SGLT2 Inhibitors in Clinical Development
Drug Stage Company
Dapagliflozin Approved in US, UK and Germany Bristol-myerssquibb in partnership with Astra Zeneca.
Canagliflozin Approved in US Marketed under license by Janssen, a division of Johnson & Johnson.
Ipragliflozin Phase III clinical trials Discovered by Astellas and Kotobuki Pharmaceutical Co. Ltd
Tofogliflozin Phase III clinical trials Chugai Pharma in collaboration with Kowa and Sanofi
Empagliflozin Phase III clinical trials Discovered by Boehringer Ingelheim and Eli lily and company
Remogliflozin Phase IIb clinical trals Developed by Chugai Pharma in collaboration with Kowa and Sanofi.
Figure 1: Schematic representation of SGLT2 co-
transporter Inhibition
Mechanism of Action
Glucose reabsorption in renal tubules is largely due to
two key glucose transporters: SGLT2 and SGLT1. The
SGLT2 is a high-capacity and low-affinity glucose
transporter expressed in the proximal renal tubules,
which is responsible for majority of re-absorption into the
blood stream of glucose filtered through the
glomerulus16. SGLT1 is a high affinity low capacity
transporter, which is responsible mainly for absorption of
glucose in the gastrointestinal tract. It is also expressed in
the liver, lungs and kidneys15-17. Transport of each glucose
molecule is coupled to co transport of sodium (Na+) ion in
the kidneys and once inside the cell, glucose diffuses into
blood via facilitated transport. Reabsorption of glucose in
Int. J. Pharm. Sci. Rev. Res., 33(1), July – August 2015; Article No. 10, Pages: 40-47 ISSN 0976 – 044X
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proximal tubule of kidney is an active process requiring
energy, which comes from electrochemical gradient
generated by reabsorption of Na+ across the brush
border and is maintained by continuous transport of Na+
across the basolateral membrane into blood via Na+/K+
ATPase. Therefore, blocking the reabsorption of glucose
in the kidneys serves as a strategy to treat
hyperglycaemia17.
Renal Glucose Transport in Normal Condition
Kidneys play a very important role in glucose
homeostasis. Blood glucose is freely filtered by the
glomeruli and is completely reabsorbed from the
proximal tubules via sodium-coupled transporters in the
brush border membrane. The glomeruli filter about 144 g
of glucose per 24 hours, nearly 100% of which is
reabsorbed in the renal tubules. When blood glucose
level reaches the renal threshold for reabsorption, which
is about 8 to 10 mmol/liter (180 mg/dl), glucosuria starts
to develop. The proximal tubule has been divided into S1,
S2 and S3 segments based on the cell morphologies,
although more recent ultra structural analyses of
computer-assisted three-dimensional reconstruction of
mouse proximal tubules revealed no obvious
morphological segmentation of the proximal tubule18,19.
There is evidence for heterogeneity of sodium-dependent
glucose transport along the proximal tubule. The S1 and
S2 segments of the proximal convoluted tubules show
low affinity and high capacity for sodium-dependent
glucose absorption, whereas the distal parts show higher
affinity and low capacity for the same. SGLT2 is located in
the S1 and S2 segments where the majority of filtered
glucose is absorbed and SGLT1 is located in S3 segments
responsible for reabsorbing the remaining glucose17,20.
Renal Glucose Transport in Diabetic Condition
Renal tubular reabsorption is known to undergo
adaptations in uncontrolled diabetes; particularly
relevant in this context is the up-regulation of renal
glucose transporters (GLUTs). The increase in
extracellular glucose concentration in diabetes lowers its
outwardly directed gradient from the tubular cells into
the interstitium.
Hence, up-regulation of SGLT2 is an important adaptation
in diabetes to maintain renal tubular glucose
reabsorption19,20. SGLT2 mRNA expression is up-regulated
in diabetic rat kidneys and this up-regulation is reversed
by lowering blood glucose levels.
Human exfoliated proximal tubular epithelial cells from
fresh urine of diabetic patients express significantly more
SGLT2 and GLUT2 than cells from healthy individuals21.
There is also evidence for up-regulation of GLUT2 gene
expression in renal proximal tubules in diabetic rat
models. Uncontrolled diabetes leading to increased
expression of SGLT2 has practical significance as the
inhibitors are likely to produce greater degrees of
glucosuria in the presence of higher prevailing plasma
glucose levels. This has been shown in preclinical studies
with the nonspecific SGLT inhibitor, T-109522-24.
Interestingly, this up-regulation of SGLT2 receptors is also
seen in renovascular hypertensive rat models. The
authors speculated that angiotensin II-induced SGLT2
over expression probably contributes to increased
absorption of Na+ and thereby leading to development or
maintenance of hypertension. Rats treated with either
Ramipril or Losartan showed significant reduction in the
intensity of immunostaining and levels of SGLT2 protein
and mRNA. This may have relevance in diabetes, given
the high prevalence of hypertension in diabetes25-27.
Initial Discovery of Therapeutic Potential of SLGTs to
Produce Glucosuria
Phlorizin is a glucoside consisting of a glucose moiety and
two aromatic rings (a glycone moiety) joined by an alkyl
spacer28. In the 19th century, French chemists isolated it
from the bark of apple tree to be used in treatment of
fever and infectious diseases, particularly malaria. Von
Mering observed in 1886 that Phlorizin produces
glucosuria and has been used as a tool for physiological
research for more than 150 years. In 1975, a study
showed that infusion of Phlorizin in dogs increased
fractional excretion of glucose by 60%, whereas
glomerular filtration rate and renal plasma flow remained
unchanged29.
Phlorizin is a high-affinity competitive inhibitor of sodium-
dependent glucose transport in renal and intestinal
epithelia. Hence, it causes mal-absorption of glucose and
galactose from the small intestine and of glucose from
the renal tubules30. Phlorizin causes heavy glucosuria and
marks inhibition of glucose uptake in the small intestine
during enteric perfusion in normal rats. It also
significantly reduces blood glucose on oral glucose
tolerance test in mice and lowers blood glucose in
streptozotocin-induced diabetic rats. It improves counter-
regulatory responses reducing the risk of hypoglycemia in
animal models31. In 1986, Unger’s group reported that i.v.
glucose failed to suppress the marked hyperglucagonemia
found in insulin-deprived alloxan-induced diabetic dogs;
however, when hyperglycemia was corrected by
phlorizin, the hyperglucagonemia became readily
suppressible. Phlorizin treatment of partially
pancreatectomized rats completely normalized insulin
sensitivity but had no effect on insulin action in controls,
suggesting that the effect on insulin sensitivity was by
reversal of glucotoxicity, rather than by a direct effect on
insulin sensitivity32. Animal studies with Phlorizin have
shown that its effect of changing the ambient glucose
independent of insulin levels can up-regulate the glucose
transport response to insulin in adipose cells, which may
be as a result of changes in GLUT functional activity33.
These findings provided important proof of concept data,
that Phlorizin itself is unsuitable for development as a
drug for the treatment of diabetes because of its non-
selectivity and low oral bioavailability. T-1095 is a
Int. J. Pharm. Sci. Rev. Res., 33(1), July – August 2015; Article No. 10, Pages: 40-47 ISSN 0976 – 044X
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synthetic Phlorizin derivative, which unlike Phlorizin is
absorbed into the circulation on oral administration and
is metabolized to its active form T-1095A. It suppresses
the activity of SGLT1 and SGLT2 in the kidney and
increases urinary glucose excretion in diabetic animals,
thereby decreasing blood glucose levels. With long-term
T-1095 treatment, both blood glucose and glycosylated
hemoglobin (HbA1c) levels were reduced in
streptozotocin-induced diabetic rats and the obese
insulin resistant yellow KK rat models. Chronic
administration of T-1095 lowered blood glucose and
HbA1c levels, partially improved glucose intolerance and
insulin resistance and prevented the development of
diabetic neuropathy in the diabetic insulin-resistant GK
rat models. There were no adverse side effects reported
at the end of the study. This drug, however, did not
proceed to clinical development, presumably because it
also inhibits SGLT1.26,34
SGLT2 Inhibitor Drugs
Dapagliflozin
IUPAC name
(2S,3R,4R,5S,6R)-2-[4-chloro-3-(4-ethoxybenzyl)phenyl]-6
(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol
Dapagliflozin (Trade name Farxiga in the US and Forxiga
in the EU) is a drug used to treat type 2 diabetes. It was
developed by Bristol-Myers Squibb in partnership with
AstraZeneca. The FDA approved dapagliflozin on January
8, 2014 for glycemic control, along with diet and exercise,
in adults with type 2 diabetes. It is now marketed in a
number of European countries including UK and
Germany35. Dapagliflozin has been associated with
modest reductions in body weight (2–3 kg), when used as
monotherapy or dual therapy with metformin,
dapagliflozin is not associated with an increased risk of
hypoglycaemia. Dapagliflozin has been associated with a
modest reduction in systolic blood pressure (1–2
mmHg)35,36.
Pharmacokinetics
Dapagliflozin is a C-aryl glucoside-derived SGLT2 Inhibitor
resistant to gastrointestinal glucosidase enzymes and can
be administered orally in an unmodified form.
Dapagliflozin is rapidly and extensively absorbed after
oral administration. The oral bioavailability of a 10 mg
dose is ≥75%36. Dapagliflozin is extensively metabolised
into inactive conjugates, predominantly dapagliflozin 3-O-
glucuronide, and then eliminated by the kidneys. The
glucosuric efficacy of dapagliflozin is dependent on renal
function, because its efficacy is reduced in patients with
renal impairment36,37.
Canagliflozin
IUPAC name
(2S,3R,4R,5S,6R)-2-{3-[5-[4-Fluoro-phenyl)-thiophen-2-
ylmethyl]-4-methyl-phenyl}-6-hydroxymethyl-tetrahydro-
pyran-3,4,5-triol
Canagliflozin (trade name Invokana) is a drug for the
treatment of type 2 diabetes. It was developed by
Mitsubishi Tanabe Pharma and is marketed under license
by Janssen, a division of Johnson & Johnson. In March
2013, Canagliflozin became the first SGLT2 inhibitor to be
approved in the United States.38,39
Canagliflozin is indicated as an adjunct to diet and
exercise to improve glycemic control in adults with Type 2
diabetes and is used as a single agent (monotherapy), or
in combination with other glucose-lowering agents. The
Main merit of this drug is that it produces beneficial
effects on HDL cholesterol and systolic blood pressure.38-
40
Pharmacokinetics
Canagliflozin is rapidly absorbed in the gastrointestinal
(GI) tract. Relative oral bioavailability of Canagliflozin is
65% and reaches peak concentrations within 1 to 2 hours.
It is recommended that it has to be taken before the first
meal of the day to allow for the potential to reduce
postprandial plasma glucose excursions resulting from
delayed intestinal glucose absorption. It is highly protein-
bound, mostly to albumin at 99%. UGT enzyme inducers
(e.g., rifampin, phenytoin, ritonavir) may decrease the
plasma levels and efficacy of canagliflozin. No Appearance
of significant interactions between canagliflozin and
CYP450 enzymes 1A2, 2A6, 3A4, 2B6, 2C9, 2C19, 2D6, and
2E41. The drug is metabolized primarily into two inactive
metabolites by uridinediphosphateglu-curonosyl
transferase (UGT) enzymes: UGT 1A9 and UGT 2B4 via
glucuronidation. The recommended starting dose of
canagliflozin is 100 mg once daily before the first meal
which can be increased to 300 mg41,42.
Ipragliflozin
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IUPAC name
(1S)-1,5-Anhydro-1-C-[3-[(1-benzothiophen-2-yl)methyl]-
4-fluorophenyl]-D-glucitol.
Ipragliflozin (trade name-Suglat) is a selective SGLT2
inhibitor discovered through research collaboration
between Astellas and Kotobuki Pharmaceutical Co., Ltd.
Astellas has been granted approval in Japan for this drug,
in order to bring a new drug in this class to the market43.
Astellas has conducted six Phase III studies to investigate
the safety and efficacy of ipragliflozin used in
combination with other hypoglycemic agents for a long
term period demonstrating significant decrease of HbA1c,
an index of glycemic control, in change from baseline
compared to placebo. It is an SGLT-2 inhibitor in Phase III
clinical development.43,44
Pharmacokinetics
The recommended dose is 50 mg once daily, in the
morning which may be increased up to 100 mg once a
day. It is absorbed rapidly, taking approximately 1 h to
reach the maximum concentration44. It significantly
reduces glycosylated hemoglobin, fasting plasma glucose,
and mean amplitude of glucose excursions. Ipragliflozin is
primarily eliminated via conjugation by the liver as five
pharmacologically inactive metabolites (M1, M2, M3, M4
and M6). Significant dose-dependent increases in urinary
glucose excretion are observed in all ipragliflozin
groups43-45.
Tofogliflozin
IUPAC name
(1S,3'R,4'S,5'S,6'R)-6-(4-Ethylbenzyl)-6'-(hydroxymethyl)-
3',4',5',6'-tetrahydro-3H-spiro[2-benzofuran-1,2'-pyran]-
3',4',5'-triol hydrate (1:1)
Tofogliflozin (USAN, codenamed CSG452) is an
experimental drug for the treatment of diabetes mellitus
and is being developed by Chugai Pharma in collaboration
with Kowa and Sanofi. As of 2013, the drug is in Phase III
clinical trials. Currently, Chugai is conducting phase III
clinical trial in Japan to evaluate its efficacy and safety for
the target indication of type 2 diabetes.46
Pharmacokinetics
It is a novel C-arylglucoside with an O-spiroketal ring
system46. The results of the Phase II study in the US
indicated that tofogliflozin 5, 10, 20, and 40 mg daily
resulted in significant dose-dependent reductions in
HbA1c compared to placebo along with an increase in
urinary glucose excretion (UGE) as expected.46,47
Empagliflozin
IUPAC name
(2S,3R,4R,5S,6R)-2-[4-chloro-3-[[4-[(3S)-oxolan-
3yl]oxyphenyl]methyl]phenyl]-6-(hydroxymethyl)oxane-
3,4,5-triol.
Empagliflozin (BI-10773) is a sodium glucose co-
transporter Type 2 (SGLT-2) inhibitor. It is discovered
through collaboration between BoehringerIngelheim
Pharmaceuticals, Inc. and Eli Lilly and Company.
Currently, in the phase III clinical trial, it is administered
orally at 10mg or 25mg once daily.48
Pharmacokinetics
It demonstrates a dose proportional increase in drug
exposure and supports once daily dosing. It is rapidly
absorbed, reaching peak levels in 1.5–3.0 h after dosing
and shows a biphasic decline. Elevated urinary glucose
excretion is observed with all the doses. Multiple once
daily oral doses of empagliflozin (2.5-100 mg) reduced
plasma glucose and is well tolerated in type 2
patients.48,49
Remogliflozin etabonate
IUPAC Name
5-methyl-4-[4-(1-methylethoxy)benzyl]-1-(1-methylethyl)-
1H-pyrazol-3-yl 6-O-(ethoxycarbonyl)-β-D-
glucopyranoside.
Remogliflozin etabonate (INN/USAN) is a proposed drug
for the treatment of type 2 diabetes being investigated by
GlaxoSmithKline50,51. Remogliflozin is now being
developed by BHV Pharma. Remogliflozin etabonate (RE)
is prodrug of remogliflozin, the active entity that inhibits
SGLT2. An inhibitor of this pathway enhances urinary
glucose excretion (UGE), and potentially improves plasma
glucose concentrations in diabetic patients. It is currently
in phase IIb trials.50
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Pharmacokinetics
Remogliflozin ebonite salt is metabolized to remogliflozin
in body. It is a benzylpyrazole glucoside. Remogliflozin is
further metabolized to GSK279782, which is an equally
potent inhibitor of SGLT2 but circulates at approximately
20% of the plasma concentrations of remogliflozin. Single
oral doses of remogliflozin etabonate up to 1000 mg in
healthy subjects and repeated dosing in subjects with
T2DM (up to 1000 mg BID for 2 weeks) have been safe
and well tolerated. It is intended for use in the treatment
of T2DM as monotherapy orin combination with
metformin and other antidiabetic therapies as well.50,51
Merits and De-merits of SGLT2 Inhibitors
Merits
Weight maintenance is a key target for any type 2
diabetes treatment. No hypoglycemia as SGLT2 inhibitors
do not induce insulin secretion or inhibit hepatic glucose
production. Improve insulin sensitivity and indirectly
preserve β-cells by depletion of toxic glucose
concentration in blood. SGLT2 inhibitors produce osmotic
diuretic effect which may be advantageous in patients
with hypertension and Cardiac Heart Failure.
Demerits
There may be a risk of negative effect of glucosuria on the
kidneys, polyuria and increased thirst, but there is no
strong evidence about it. Another problem in relation to
the genitourinary tract is increased risk for bacterial or
fungal infection, but only long term clinical trial can result
in this risk.
CONCLUSION
Renal SGLT-2 inhibition is a clinically useful strategy for
control of diabetes. A number of agents having glucoside
moiety are being developed and are in various stages of
clinical testing. SGLT2 inhibitors are referred to as a
chemical inducer of familial renal glucosuria and as an
energy controller acting in the negative direction,
alongside lifestyle interventions. On the basis of this
principle, SGLT2 inhibitors are expected to achieve long-
term glycemic control, improve insulin resistance, and
preserve pancreatic β-cell function without inducing
bodyweight gain or increasing hypoglycemic risk. The
therapeutic potency, safety, and tolerability of SGLT2 may
be beneficial for the treatment of diabetes, and they may
be expected to display synergistic effects when used in
combination with multiple anti diabetic drugs.
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Source of Support: Nil, Conflict of Interest: None.
