Gliflozins are a class of drugs in the treatment of type 2 diabetes (T2D). They act by inhibiting sodium/glucose cotransporter 2 (SGLT-2), and are therefore also called SGLT-2 inhibitors. The efficacy of the drug is dependent on renal excretion and prevents glucose from going into blood circulation by promoting glucosuria. The mechanism of action is insulin independent.
Three drugs have been accepted by the Food and Drug Administration (FDA) in the United States; dapagliflozin, canagliflozin and empagliflozin. Canagliflozin was the first SGLT-2 inhibitor that was approved by the FDA, being accepted in March 2013. Dapagliflozin and empagliflozin were accepted in 2014.
Introduction
Role of kidneys in glucose homeostasis
There are at least four members of SLC-5 gene family, which are secondary active glucose transporters. The sodium glucose transporters proteins SGLT-1 and SGLT-2 are the two premier members of the family. These two members are found in the kidneys, among other transporters, and are the main co-transporters there related to the blood sugar. They play a role in renal glucose reabsorption and in intestinal glucose absorption.
Blood glucose is freely filtered by the glomeruli and SGLT-1 and SGLT-2 reabsorb glucose in the kidneys and put it back into the circulation cells. SGLT-2 is responsible for 90% of the reabsorption and SGLT-1 for the other 10%.
SGLT-2 protein
Sodium/glucose co-transporter (SGLT) proteins are bound to the cell membrane and have the role of transporting glucose through the membrane into the cells, against the concentration gradient of glucose. This is done by using the sodium gradient, produced by sodium/potassium ATPase pumps, so at the same time glucose is transported into the cells, the sodium is too. Since it is against the gradient, it requires energy to work. SGLT proteins cause the glucose reabsorption from the glomerular filtrate, independent of insulin.
SGLT-2 is a member of the glucose transporter family and is a low-affinity, high-capacity glucose transporter. SGLT-2 is mainly expressed in the S-1 and S-2 segments of the proximal renal tubules where the majority of filtered glucose is absorbed. SGLT-2 has a role in regulation of glucose and is responsible for most glucose reabsorption in the kidneys.
In diabetes, extracellular glucose concentration increases and this high glucose level leads to upregulation of SGLT-2, leading in turn to more absorption of glucose in the kidneys. These effects cause maintenance of hyperglycemia. Because sodium is absorbed at the same time as glucose via SGLT-2, the upregulation of SGLT-2 probably leads to development or maintenance of hypertension. In study where rats were given either ramipril or losartan, levels of SGLT-2 protein and mRNA were significantly reduced. In patients with diabetes, hypertension is a common problem so this may have relevance in this disease.
Drugs that inhibit sodium/glucose cotransporter 2 inhibit renal glucose reabsorption which leads to enhanced urinary glucose excretion and lower glucose in blood. They work independently of insulin and can reduce glucose levels without causing hypoglycemia or weight gain.
Discovery
Medieval physicians routinely tasted urine and wrote discourses on their observations. Which physician originally thought that diabetes mellitus was a renal disorder because of glucose discharged in urine is apparently now lost to history. The discovery of insulin eventually led to a diabetes management focus on the pancreas. Traditional foci of therapeutic strategies for diabetes have been on enhancing endogenous insulin secretion and on improving insulin sensitivity.
In the previous decade the role of the kidney in the development and maintenance of high glucose levels has been examined. The role of the kidney led to the development of drugs that inhibit the sodium/glucose transporter 2 protein. Every day approximately 180 grams of glucose are filtered through the glomeruli and lost into the primary urine in healthy adults, but more than 90% of the glucose that is initially filtered is reabsorbed by a high capacity system controlled by SGLT-2 in the early convoluted segment of the proximal tubules. Almost all remaining filtered glucose is reabsorbed by sodium/glucose transporter 1 so under normal circumstances almost all filtered glucose will be reabsorbed and less than 100 mg of glucose finds its way into the urine of non-diabetic individuals.