"The pharmacological profile of SGLT2 inhibitors: Focus on mechanistic aspects and pharmacogenomics".

Diabetes, characterized by high glucose levels, has been listed to be one of the world's major causes of death. Around 1.6 million deaths are attributed to this disease each year. Persistent hyperglycemic conditions in diabetic patients affect various organs of the body leading to diabetic complications and worsen the disease condition. Current treatment strategies for diabetes include biguanides, sulfonylureas, alpha-glucosidase inhibitors, thiazolidinediones, insulin and its analogs, DPP-4(dipeptidyl peptidase-4) and GLP-1 (glucagon-like peptide) analogs. However, many side effects contributing to the devastation of the disease are associated with them. Sodium glucose co-transporter-2 (SGLT2) inhibition has been reported to be new insulin-independent approach to diabetes therapy. It blocks glucose uptake in the kidneys by inhibiting SGLT2 transporters, thereby promoting glycosuria. Dapagliflozin, empagliflozin and canagliflozin are the most widely used SGLT2 inhibitors. They are effective in controlling blood glucose and HbA1c levels with few side effects including hypoglycemia or weight gain which makes them preferable to other anti-diabetic drugs. However, treatment is found to be associated with inter-individual drug response to SGLT2 inhibitors and adverse drug reactions which are also affected by genetic variations. There have been very few pharmacogenetics trials of these drugs. This review discusses the various SGLT2 inhibitors, their pharmacokinetics, pharmacodynamics and genetic variation influencing the inter-individual drug response.

Glucose Metabolism in the Kidney: Neurohormonal Activation and Heart Failure Development.

The liver is not the exclusive site of glucose production in humans in the postabsorptive state. Robust data support that the kidney is capable of gluconeogenesis and studies have demonstrated that renal glucose production can increase systemic glucose production. The kidney has a role in maintaining glucose body balance, not only as an organ for gluconeogenesis but by using glucose as a metabolic substrate. The kidneys reabsorb filtered glucose through the sodium-glucose cotransporters sodium-glucose cotransporter (SGLT) 1 and SGLT2, which are localized on the brush border membrane of the early proximal tubule with immune detection of their expression in the tubularized Bowman capsule. In patients with diabetes mellitus, the renal maximum glucose reabsorptive capacity, and the threshold for glucose passage into the urine, are higher and contribute to the hyperglycemic state. The administration of SGLT2 inhibitors to patients with diabetes mellitus enhances sodium and glucose excretion, leading to a reduction of the glycosuria threshold and tubular maximal transport of glucose. The net effects of SGLT2 inhibition are to drive a reduction in plasma glucose levels, improving insulin secretion and sensitivity. The benefit of SGLT2 inhibitors goes beyond glycemic control, since inhibition of renal glucose reabsorption affects blood pressure and improves the hemodynamic profile and the tubule glomerular feedback. This action acts to rebalance the dense macula response by restoring adenosine production and restraining renin-angiotensin-aldosterone activation. By improving renal and cardiovascular function, we explain the impressive reduction in adverse outcomes associated with heart failure supporting the current clinical perspective.

Does 2-FDG PET Accurately Reflect Quantitative In Vivo Glucose Utilization?

2-Deoxy-2-18F-fluoro-d-glucose (2-FDG) with PET is undeniably useful in the clinic, being able, among other uses, to monitor change over time using the 2-FDG SUV metric. This report suggests some potentially serious caveats for this and related roles for 2-FDG PET. Most critical is the assumption that there is an exact proportionality between glucose metabolism and 2-FDG metabolism, called the lumped constant, or LC. This report describes that LC is not constant for a specific tissue and may be variable before and after disease treatment. The purpose of this work is not to deny the clinical value of 2-FDG PET; it is a reminder that when one extends the use of an appropriately qualified imaging method, new observations may arise and further validation would be necessary. The current understanding of glucose-based energetics in vivo is based on the quantification of glucose metabolic rates with 2-FDG PET, a method that permits the noninvasive assessment of various human disorders. However, 2-FDG is a good substrate only for facilitated-glucose transporters (GLUTs), not for sodium-dependent glucose cotransporters (SGLTs), which have recently been shown to be distributed in multiple human tissues. Thus, the GLUT-mediated in vivo glucose utilization measured by 2-FDG PET would be masked to the potentially substantial role of functional SGLTs in glucose transport and use. Therefore, under these circumstances, the 2-FDG LC used to quantify in vivo glucose utilization should not be expected to remain constant. 2-FDG LC variations have been especially significant in tumors, particularly at different stages of cancer development, affecting the accuracy of quantitative glucose measures and potentially limiting the prognostic value of 2-FDG, as well as its accuracy in monitoring treatments. SGLT-mediated glucose transport can be estimated using α-methyl-4-deoxy-4-18F-fluoro-d-glucopyranoside (Me-4FDG). Using both 2-FDG and Me-4FDG should provide a more complete picture of glucose utilization via both GLUT and SGLT transporters in health and disease states. Given the widespread use of 2-FDG PET to infer glucose metabolism, it is relevant to appreciate the potential limitations of 2-FDG as a surrogate for glucose metabolic rate and the potential reasons for variability in LC. Even when the readout for the 2-FDG PET study is only an SUV parameter, variability in LC is important, particularly if it changes over the course of disease progression (e.g., an evolving tumor).

Immediate and delayed effects of nutrient-sensing in fruit fly Drosophila melanogaster.

Starting in late 1980's, Bill Timberlake and associates conducted a series of experiments on anticipatory contrast which showed that rats' feeding decisions were regulated by the nutritive value of currently ingested and anticipated food. The effects of nutrient sensing on feeding regulation have been studied intensively in rodents, and recently, in the fruit fly Drosophila melanogaster. In this study, we developed a new behavioral test to study rapid feeding decisions of tethered flies within 6-8 s of ingestion. Using a two-phase experimental design, we presented individual flies one of four serial combinations of a non-nutritive sugar, arabinose, or a nutritive sugar, sucrose. Feeding decisions of wildtype (Canton-S) flies are altered both by immediate effects of nutrient sensing and 1-hour delayed effects of nutrient-feeding, and the two effects act additively to yield a signature pattern of behavioral contrast based on nutritive contrast. Feeding phenotype of flies that carry a mutation of the dSLC5A11 (cupcake) gene varied with the mutant allele and genetic background. Fasted dSLC5A11 mutants showed an overeating phenotype and a defect in short-term feeding regulation irrespective of the nutritive value of sugar. Flies that carried the dSLC5A111 allele showed differential feeding for arabinose and sucrose. However, dSLC5A112 allele yielded a conspicuous deficit in delayed effects of nutrient ingestion, but only when it was expressed on a Canton-S background. Our results suggest that dSLC5A11 might function to integrate external stimulus properties and internal state for feeding regulation and action selection.

[Potential of the Cerebral Sodium-Glucose Transporter as a Novel Therapeutic Target in Cerebral Ischemia].

　Cerebral ischemic stress often induces a hyperglycemic condition. This postischemic hyperglycemia exacerbates the development of cerebral ischemic neuronal damage, although the mechanism of this exacerbation remains to be clarified. We previously discovered that the cerebral sodium-glucose transporter (SGLT) was closely involved in the development of cerebral ischemic neuronal damage. SGLT is a member of the glucose transporter family and moves glucose together with sodium ions. SGLT-1, -3, -4, and -6 are distributed in the brain. We conducted further experiments to elucidate the detailed mechanism of the exacerbation of cerebral ischemia by cerebral SGLT. The results clarified: 1) the relationship between cerebral SGLT and postischemic hyperglycemia; 2) the involvement of cerebral SGLT-1 (a cerebral SGLT isoform) in cerebral ischemic neuronal damage; and 3) the effects of sodium influx through cerebral SGLT on the development of cerebral ischemic neuronal damage. This paper presents our data on the involvement of cerebral SGLT in the exacerbation of cerebral ischemic neuronal damage.

[The roles of sodium-glucose transporters in tumor cell energy metabolism].

Glucose is a major metabolic substrate required for cancer cell survival and growth.Instead, the entry of glucose molecules into the cells is effected by a large family of structurally related transport proteins known as glucose transporters. Two main types of glucose transporters have been identified, namely, the passive facilitative glucose transporters(GLUTs) and the secondary active sodium-coupled glucose transporters(SGLTs).However, tumor cells may adapt to an ischemic microenvironment by upregulation of SGLTs in the plasma membrane which supplies the tumor cell with glucose even at very low extracellular glucose concentration.Therefore, SGLTs is essential for ischemic and hypoxic tumor cells to uptake glucose.Current research indicates that SGLTs may become a promising biomarker for cancer therapy.

Sodium glucose transport modulation in type 2 diabetes and gastric bypass surgery.

Active sodium-glucose transporters play a role to glucose homeostasis and represent novels targets for the management of type 2 diabetes (T2D). Sodium-glucose cotransporter 1 (SGLT1) is essential for intestinal glucose absorption from the lumen into enterocytes, whereas glucose reabsorption by the kidney is mainly mediated by sodium-glucose cotransporter 2 (SGLT2). SGLT2 inhibitors were developed to occlude SGLT2 glucose reabsorption pathway and cause glycosuria, thereby reducing plasma glucose concentrations. This new class of antidiabetic drugs has been shown to be effective in reducing cardiovascular morbidity and mortality in patients with T2D. Initial clinical studies also suggest that SGLT1 inhibition increases glucagon-like peptide 1 (GLP-1) secretion and decreases postchallenge blood glucose excursion, resulting in a dose-dependent improvement of glucose control. In parallel, we recently identified a previously unknown effect of bile diversion in gastric bypass on sodium glucose transport and postprandial glucose homeostasis, through the modulation of intestinal trafficking of endogenous sodium. This mechanism is consistent with available clinical evidence, and opens up new perspectives in metabolic surgery. More generally, the modulation of intestinal sodium-glucose cotransport appears to be a promising avenue to prevent or treat T2D.

Diabetic nephropathy: where are we on the journey from pathophysiology to treatment?

Diabetic nephropathy affects 30-40% of people with diabetes, and is the leading cause of end-stage kidney disease. The current treatment paradigm relies on early detection, glycaemic control and tight blood pressure management with preferential use of renin-angiotensin system blockade. This strategy has transformed outcomes in diabetic kidney disease over the last 20 years. Over the last two decades we have also witnessed significant advances in the understanding of the pathophysiology of diabetic nephropathy; however, despite this new knowledge, we have yet to develop new treatments of proven efficacy. Whilst a continued emphasis on preclinical and clinical research is clearly needed, clinicians treating people with diabetes should not forget that, in the short term, the greatest gains are likely to be realised by more consistent deployment of existing therapies.

A quantitative feeding assay in adult Drosophila reveals rapid modulation of food ingestion by its nutritional value.

BACKGROUND: Food intake of the adult fruit fly Drosophila melanogaster, an intermittent feeder, is attributed to several behavioral elements including foraging, feeding initiation and termination, and food ingestion. Despite the development of various feeding assays in fruit flies, how each of these behavioral elements, particularly food ingestion, is regulated remains largely uncharacterized. RESULTS: To this end, we have developed a manual feeding (MAFE) assay that specifically measures food ingestion of an individual fly completely independent of the other behavioral elements. This assay reliably recapitulates the effects of known feeding modulators, and offers temporal resolution in the scale of seconds. Using this assay, we find that fruit flies can rapidly assess the nutritional value of sugars within 20-30 s, and increase the ingestion of nutritive sugars after prolonged periods of starvation. Two candidate nutrient sensors, SLC5A11 and Gr43a, are required for discriminating the nutritive sugars, D-glucose and D-fructose, from their non-nutritive enantiomers, respectively. This suggests that differential sensing mechanisms play a key role in determining food nutritional value. CONCLUSIONS: Taken together, our MAFE assay offers a platform to specifically examine the regulation of food ingestion with excellent temporal resolution, and identifies a fast-acting neural mechanism that assesses food nutritional value and modulates food intake.

[Nutrient sensing by the gastro-intestinal nervous system and control of energy homeostasis]. / Détection des nutriments par le système nerveux gastro-intestinal et contrôle de l'homéostasie énergétique.

The gastrointestinal nerves are crucial in the sensing of nutrients and hormones and its translation in terms of control of food intake. Major macronutrients like glucose and proteins are sensed by the extrinsic nerves located around the portal vein walls, which signal to the brain and account for the satiety phenomenon they promote. Glucose is sensed in the portal vein by neurons expressing the glucose receptor SGLT3, which activates the main regions of the brain involved in the control of food intake. Proteins indirectly act on food intake by inducing intestinal gluconeogenesis and its sensing by the portal glucose sensor. The mechanism involves a prior antagonism by peptides of the µ-opioid receptors present in the portal vein nervous system and a reflex arc with the brain inducing intestinal gluconeogenesis. In a comparable manner, short chain fatty acids produced from soluble fibers act via intestinal gluconeogenesis to exert anti-obesity and anti-diabetic effects. In the case of propionate, the mechanism involves a prior activation of the free fatty acid receptor FFAR3 present in the portal nerves and a reflex arc initiating intestinal gluconeogenesis.

Glucose transport families SLC5 and SLC50.

There are three families of glucose transporters in the human genome, SLC2, SLC5 and SLC50. Here I review the structure and function of the SLC5 and SLC50 genes. The human sodium glucose cotransporter family (SLC5) has 12 human genes expressed in tissues ranging from epithelia to the central nervous system. The functions of all are known based on studies using heterologous expression systems: 10 are tightly coupled plasma membrane Na(+)/substrate cotransporters for solutes such as glucose, myoinositol, and anions; 1 is a Na(+)/Cl(-)/Choline cotransporter; and another is a glucose activated ion channel. The exon organization of most of the genes is similar in that they contain 14-15 exons. However, the choline transporter CHT is encoded in by the 8 exon SLC5A7 gene and the myoinositol SMIT transporter by the 1 exon SLC5A3 gene. Mutations in 3 SLC5 genes produce genetic phenotypes (glucose-galactose-malabsorption, renal glucosuria and hypothyroidism). Members of the SLC5 family are multifunctional membrane proteins in that they also behave as uniporters, urea and water channels, and urea and water cotransporters. The atomic structure of a closely related bacterial homolog has been solved and the structural core is common to six unrelated transporters, e.g. members of the SLC6 family of neurotransporters, and this leads to the conclusion that these work by a similar mechanism. The new SWEET class of glucose uniporters, SLC50, only has only one member in the human genome, SLC50A1. The SWEETs are found mostly in plants where they appear to be responsible for sugar efflux and are targeted by pathogens and symbionts for nutrition.

Functional role of sodium glucose transporter in high glucose-mediated angiotensin type 1 receptor downregulation in human proximal tubule cells.

Previously, we have demonstrated human angiotensin type 1 receptor (hAT(1)R) promoter architecture with regard to the effect of high glucose (25 mM)-mediated transcriptional repression in human proximal tubule epithelial cells (hPTEC; Thomas BE, Thekkumkara TJ. Mol Biol Cell 15: 4347-4355, 2004). In the present study, we investigated the role of glucose transporters in high glucose-mediated hAT(1)R repression in primary hPTEC. Cells were exposed to normal glucose (5.5 mM) and high glucose (25 mM), followed by determination of hyperglycemia-mediated changes in receptor expression and glucose transporter activity. Exposure of cells to high glucose resulted in downregulation of ANG II binding (4,034 ± 163.3 to 1,360 ± 154.3 dpm/mg protein) and hAT(1)R mRNA expression (reduced 60.6 ± 4.643%) at 48 h. Under similar conditions, we observed a significant increase in glucose uptake (influx) in cells exposed to hyperglycemia. Our data indicated that the magnitude of glucose influx is concentration and time dependent. In euglycemic cells, inhibiting sodium-glucose cotransporters (SGLTs) with phlorizin and facilitative glucose transporters (GLUTs) with phloretin decreased glucose influx by 28.57 ± 0.9123 and 54.33 ± 1.202%, respectively. However, inhibiting SGLTs in cells under hyperglycemic conditions decreased glucose influx by 53.67 ± 2.906%, while GLUT-mediated glucose uptake remained unaltered (57.67 ± 3.180%). Furthermore, pretreating cells with an SGLT inhibitor reversed high glucose-mediated downregulation of the hAT(1)R, suggesting an involvement of SGLT in high glucose-mediated hAT(1)R repression. Our results suggest that in hPTEC, hyperglycemia-induced hAT(1)R downregulation is largely mediated through SGLT-dependent glucose influx. As ANG II is an important modulator of hPTEC transcellular sodium reabsorption and function, glucose-mediated changes in hAT(1)R gene expression may participate in the pathogenesis of diabetic renal disease.

Biology of human sodium glucose transporters.

There are two classes of glucose transporters involved in glucose homeostasis in the body, the facilitated transporters or uniporters (GLUTs) and the active transporters or symporters (SGLTs). The energy for active glucose transport is provided by the sodium gradient across the cell membrane, the Na(+) glucose cotransport hypothesis first proposed in 1960 by Crane. Since the cloning of SGLT1 in 1987, there have been advances in the genetics, molecular biology, biochemistry, biophysics, and structure of SGLTs. There are 12 members of the human SGLT (SLC5) gene family, including cotransporters for sugars, anions, vitamins, and short-chain fatty acids. Here we give a personal review of these advances. The SGLTs belong to a structural class of membrane proteins from unrelated gene families of antiporters and Na(+) and H(+) symporters. This class shares a common atomic architecture and a common transport mechanism. SGLTs also function as water and urea channels, glucose sensors, and coupled-water and urea transporters. We also discuss the physiology and pathophysiology of SGLTs, e.g., glucose galactose malabsorption and familial renal glycosuria, and briefly report on targeting of SGLTs for new therapies for diabetes.

Intestinal glucose-induced calcium-calmodulin kinase signaling in the gut-brain axis in awake rats.

BACKGROUND: Lumenal glucose initiates changes in gastrointestinal (GI) function, including inhibition of gastric emptying, stimulation of pancreatic exocrine and endocrine secretion, and intestinal fluid secretion. Glucose stimulates the release of GI hormones and 5-hydroxytryptamine (5-HT), and activates intrinsic and extrinsic neuronal pathways to initiate changes in GI function. The precise mechanisms involved in luminal glucose-sensing are not clear; studying gut endocrine cells is difficult due to their sparse and irregular localization within the epithelium. METHODS: Here we show a technique to determine activation of gut epithelial cells and the gut-brain pathway in vivo in rats using immunohistochemical detection of the activated, phosphorylated, form of calcium-calmodulin kinase II (pCaMKII). KEY RESULTS: Perfusion of the gut with glucose (60 mg) increased pCaMKII immunoreactivity in 5-HT-expressing enterochromaffin (EC) cells, cytokeratin-18 immunopositive brush cells, but not in enterocytes or cholecystokinin-expressing cells. Lumenal glucose increased pCaMKII in neurons in the myenteric plexus and nodose ganglion, nucleus of the solitary tract, dorsal motor nucleus of the vagus and the arcuate nucleus. pCaMKII expression in neurons, but not in EC cells, was significantly attenuated by pretreatment with the 5-HT(3) R antagonist ondansetron. Deoxynojirimycin, a selective agonist for the putative glucose sensor, sodium-glucose cotransporter-3 (SGLT-3), mimicked the effects of glucose with increased pCaMKII in ECs and neurons; galactose had no effect. CONCLUSIONS & INFERENCES: The data suggest that native EC cells in situ respond to glucose, possibly via SGLT-3, to activate intrinsic and extrinsic neurons and thereby regulate GI function.

A single amino acid change converts the sugar sensor SGLT3 into a sugar transporter.

BACKGROUND: Sodium-glucose cotransporter proteins (SGLT) belong to the SLC5A family, characterized by the cotransport of Na(+) with solute. SGLT1 is responsible for intestinal glucose absorption. Until recently the only role described for SGLT proteins was to transport sugar with Na(+). However, human SGLT3 (hSGLT3) does not transport sugar but causes depolarization of the plasma membrane when expressed in Xenopus oocytes. For this reason SGLT3 was suggested to be a sugar sensor rather than a transporter. Despite 70% amino acid identity between hSGLT3 and hSGLT1, their sugar transport, apparent sugar affinities, and sugar specificity differ greatly. Residue 457 is important for the function of SGLT1 and mutation at this position in hSGLT1 causes glucose-galactose malabsorption. Moreover, the crystal structure of vibrio SGLT reveals that the residue corresponding to 457 interacts directly with the sugar molecule. We thus wondered if this residue could account for some of the functional differences between SGLT1 and SGLT3. METHODOLOGY/PRINCIPAL FINDINGS: We mutated the glutamate at position 457 in hSGLT3 to glutamine, the amino acid present in all SGLT1 proteins, and characterized the mutant. Surprisingly, we found that E457Q-hSGLT3 transported sugar, had the same stoichiometry as SGLT1, and that the sugar specificity and apparent affinities for most sugars were similar to hSGLT1. We also show that SGLT3 functions as a sugar sensor in a living organism. We expressed hSGLT3 and E457Q-hSGLT3 in C. elegans sensory neurons and found that animals sensed glucose in an hSGLT3-dependent manner. CONCLUSIONS/SIGNIFICANCE: In summary, we demonstrate that hSGLT3 functions as a sugar sensor in vivo and that mutating a single amino acid converts this sugar sensor into a sugar transporter similar to SGLT1.

Reassessment of models of facilitated transport and cotransport.

Most membrane transport models are determinate, requiring the transported ligand(s) to bind initially to a vacant site, which undergoes translation and releases ligand to the alternate side. The carrier reverts to its initial position to complete the net transport cycle. Ligand affinity may change during translation, but this must be compensated by an equivalent energy change(s) within the transport cycle. However, any asymmetric cyclic equilibrium deduced on this basis is thermodynamically fallacious. Determinate cotransport models imply lossless stoichiometric relationships between the complexed cotransported ligands. Independent ligand leakage apart from the mobile cotransport complex must occur outside the canonical cotransport pathway. In contrast, stochastic transport models assume independent ligand diffusion through a variably occluded channel(s) containing binding sites where ligands may undergo bimolecular exchanges. Energy dissipation is intrinsic to all stochastic transport models and occurs within the primary transport pathway. Frictional interactions within a shared path generate flow coupling between ligands. The primary driving forces causing transmembrane ligand flows are their electrochemical potential differences between the external solutions. Demonstrations that ligand exchanges in CLC and neurotransmitter transporters can be multimodal, encompassing both "channel"-like high and "transporter"-like lower conductance states and have independently regulated import and export exchange fluxes are major challenges to determinate models but are explicable by transient widening of a close-encounter region within the channel, leading to decreased coupling and enhanced efflux.

Troglitazone ameliorates high glucose-induced EMT and dysfunction of SGLTs through PI3K/Akt, GSK-3ß, Snail1, and ß-catenin in renal proximal tubule cells.

Peroxisome proliferator-activated receptor-γ (PPARγ) agonists ameliorate renal fibrotic lesions in diabetic nephropathy. However, the effects of the agonists on the epithelial-mesenchymal transition (EMT) linked to membrane transport dysfunction are unknown. The present study aimed to verify the effects of the PPARγ agonist troglitazone on high glucose (HG)-induced EMT in primary cultured renal proximal tubular epithelial cells (PTCs). HG (25 mM) as well as hydrogen peroxide (H(2)O(2)) and transforming growth factor-ß1 (TGF-ß1) decreased expression of epithelial cell marker E-cadherin and increased the expression of the mesenchymal markers vimentin and α-smooth muscle actin (α-SMA). HG, H(2)O(2), and TGF-ß1 decreased Na(+)/H(+) exchangers (NHEs) or Na(+)-glucose cotransporters (SGLTs) and glucose uptake, showing membrane transport dysfunction. HG stimulated the production of cellular reactive oxygen species (ROS), and antioxidants blocked the HG-induced increase in phosphatidylinositol 3-kinase (PI3K)/Akt activation. Antioxidants and inhibitors of PI3K/Akt reversed HG-induced EMT protein expression. Inhibition of PI3K/Akt also blocked HG-induced glycogen synthase kinase-3ß (GSK-3ß) phosphorylation. HG and lithium chloride (GSK-3ß inhibitor) blocked Snail1 and ß-catenin activation. Moreover, transfection with Snail1 or ß-catenin small interfering RNA (siRNA) reversed HG-induced EMT protein expression. Importantly, HG decreased PPARγ activation and troglitazone reversed HG-induced expression of PI3K/Akt, GSK-3ß, Snail1, and ß-catenin as well as EMT proteins. Finally, inhibitors of PI3K/Akt, Snail1/ß-catenin siRNA, and troglitazone blocking the HG-induced EMT restored glucose uptake in PTCs. In conclusion, HG induces EMT through ROS, PI3K/Akt, GSK-3ß, Snail, and ß-catenin. Subsequently, HG-induced EMT may result in SGLT dysfunction that is restored by the PPARγ agonist troglitazone in primary cultured PTCs.