Clinical Care/Education/Nutrition/Psychosocial Research ORIGINAL ARTICLE Canagliflozin Lowers Postprandial Glucose and Insulin by Delaying Intestinal Glucose Absorption in Addition to Increasing Urinary Glucose Excretion Results of a randomized, placebo-controlled study 1 2 DAVID POLIDORI, PHD NICOLE VACCARO, BS low-capacity, high-affinity transporter ex- 2 2 SUE SHA, MD, PHD KRISTIN FARRELL, BS 3 2 pressed in the distal segment of the prox- SUNDER MUDALIAR, MD PAUL ROTHENBERG, MD, PHD 3 3 imal tubule (1), in the intestinal mucosa THEODORE P. CIARALDI, PHD ROBERT R. HENRY, MD 2 of the small intestine (2), and in other tis- ATALANTA GHOSH, PHD sues to a lesser extent (3). Although SGLT1 plays a smaller role in renal glu- cose absorption than SGLT2, SGLT1 is OBJECTIVEdCanagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, is also a low-potency SGLT1 inhibitor. This study tested the hypothesis that intestinal canagliflozin levels the primary pathway involved in intesti- postdose are sufficiently high to transiently inhibit intestinal SGLT1, thereby delaying intestinal nal glucose and galactose absorption glucose absorption. (2,4,5). Pharmacologic inhibition of SGLT2 RESEARCH DESIGN AND METHODSdThis two-period, crossover study evaluated is a novel approach to lowering plasma fl effects of canagli ozin on intestinal glucose absorption in 20 healthy subjects using a dual-tracer glucose in hyperglycemic individuals by method. Placebo or canagliflozin 300 mg was given 20 min before a 600-kcal mixed-meal tolerance test. Plasma glucose, 3H-glucose, 14C-glucose, and insulin were measured frequently blocking renal glucose reabsorption, low- ering the renal threshold for glucose for 6 h to calculate rates of appearance of oral glucose (RaO) in plasma, endogenous glucose production, and glucose disposal. (RTG), and thereby markedly increasing urinary glucose excretion (UGE). Cana- RESULTSdCompared with placebo, canagliflozin treatment reduced postprandial plasma gliflozin, an SGLT2 inhibitor in develop- glucose and insulin excursions (incremental 0- to 2-h area under the curve [AUC0–2h] reductions ment for the treatment of patients with of 35% and 43%, respectively; P , 0.001 for both), increased 0- to 6-h urinary glucose excretion – 6 , P , fl type 2 diabetes (6 10), is also a low-potency (UGE0–6h,18.2 5.6 vs 0.2 g; 0.001), and delayed RaO. Canagli ozin reduced AUC RaO fl by 31% over 0 to 1 h (geometric means, 264 vs. 381 mg/kg; P , 0.001) and by 20% over 0 to 2 h SGLT1 inhibitor. In vitro, canagli ozin in- P fl hibited sodium-dependent 14C-a-methyl- (576 vs. 723 mg/kg; = 0.002). Over 2 to 6 h, canagli ozin increased RaO such that total AUC , P RaO over 0 to 6 h was 6% lower versus placebo (960 vs. 1,018 mg/kg; = 0.003). A modest glucoside uptake in cells expressing (;10%) reduction in acetaminophen absorption was observed over the first 2 h, but this differ- human SGLT2 or SGLT1 with half-maximal fi ence was not suf cient to explain the reduction in RaO. Total glucose disposal over 0 to 6 h was inhibitory concentrations (IC50) of 4.4 6 similar across groups. 1.2 and 684 6 159 nmol/L, respectively (8). Because the maximum plasma con- CONCLUSIONSdCanagliflozin reduces postprandial plasma glucose and insulin by increas- centrations of unbound canagliflozin in ing UGE (via renal SGLT2 inhibition) and delaying RaO, likely due to intestinal SGLT1 inhibition. subjects treated with canagliflozin 300 mg once-daily are ;100 nmol/L (maximum plasma concentrations are ;10 mmol/L ; he sodium glucose cotransporter 2 (1). SGLT2 is a high-capacity, low-affinity (11) and protein binding is 99% [un- (SGLT2) is the major transporter transporter expressed primarily at the lu- published data]), only minimal systemic T inhibition of SGLT1 is expected in sub- responsible for reabsorption of glu- minal membrane of the early segments of fl cose filtered through the renal glomerulus the proximal renal tubules (1). SGLT1 is a jects treated with canagli ozin 300 mg. In clinical studies in healthy subjects and subjects with type 2 diabetes, treat- ccccccccccccccccccccccccccccccccccccccccccccccccc ment with canagliflozin provided dose- 1 2 From Janssen Research & Development, LLC, San Diego, California; Janssen Research & Development, LLC, dependent increases in UGE compared Raritan, New Jersey; and the 3University of California, San Diego, San Diego, California Corresponding author: David Polidori, [email protected]. with placebo (7,9). In healthy subjects Received 15 November 2012 and accepted 07 January 2013. treated with escalating doses of canagliflo- DOI: 10.2337/dc12-2391. Clinical trial reg. no. NCT01173549, clinicaltrials.gov. zin given 10 min before a mixed meal, This article contains Supplementary Data online at http://care.diabetesjournals.org/lookup/suppl/doi:10 doses of canagliflozin higher than 200 .2337/dc12-2391/-/DC1. © 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly mg reduced postprandial plasma glucose cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/ and insulin concentrations to a greater ex- licenses/by-nc-nd/3.0/ for details. tent than lower doses of canagliflozin, care.diabetesjournals.org DIABETES CARE 1 Diabetes Care Publish Ahead of Print, published online February 14, 2013 Canagliflozin delays gut glucose absorption even when compared with doses that pro- Safety analyses 180, 210, 240, 270, 300, and 360 min for vided similar UGE during the postpran- Vital sign measurements, 12-lead electro- measurements of plasma glucose (labeled dial period (7). These pronounced cardiograms, physical examinations, and and unlabeled) and insulin. Additional reductions in postprandial glucose and clinical laboratory tests were performed at blood samples were drawn at predefined insulin excursions observed with canagli- predefined time points throughout the time points for determination of canagli- flozin doses higher than 200 mg were study. Adverse events (AEs) were moni- flozin and acetaminophen concentrations only observed for the first meal after dos- tored from the signing of informed consent and for analysis of other pharmacody- ing; similar reductions beyond that ex- until completion of the last study-related namic markers, including concentrations pected on the basis of increased UGE procedure. of glucose-dependent insulinotropic pep- were not observed after later meals (lunch tide (GIP), glucagon-like peptide-1 (GLP- and dinner) given on the same day (7). On Study design 1), and peptide YY (PYY). the basis of these observations, it was hy- This was a randomized, double-blind, pothesized that after dosing and during placebo-controlled, two-period crossover Bioanalytical analyses drug absorption, canagliflozin concentra- study consisting of a screening phase, a Plasma and urine glucose concentrations tions within the lumen of the intestinal 25-day double-blind treatment phase (in- were measured using a hexokinase en- tract could be sufficiently high to provide cluding two 1-day treatment periods zymatic assay, and plasma insulin con- transient inhibition of intestinal SGLT1- and a washout period of 7–21 days be- centration was determined using an mediated glucose absorption, thereby tween periods 1 and 2), and a follow-up electrochemiluminescent sandwich im- lowering postprandial plasma glucose phase of up to 10 days after period 2. munoassay (Roche Diagnostics, Indian- and insulin concentrations. Subjects were randomized to one of two apolis, IN). 3H-glucose and 14C-glucose The current study investigated the ef- treatment sequences: canagliflozin 300 specific activities were determined using fects of a single 300-mg oral dose of canagli- mg in period 1, followed by matching pla- the assays described by Mudaliar et al. flozin on intestinal glucose absorption cebo in period 2, or vice versa. On days –3 (14) and Kreisberg et al. (15), respec- and metabolism in healthy subjects (Clin- and –2 of each period, subjects were tively. Recycling of 14C-glucose over the icalTrials.gov Identifier: NCT01173549). counseled to adhere to a specified diet course of the procedure was negligible, This study used a dual-tracer method to (;55% carbohydrate, 30% fat, 15% pro- with recycled 14C generally below the test the hypothesis that canagliflozin 300 mg tein, and total caloric intake of ;30 kcal/kg limit of detection, similar to the observa- slows the rate of systemic appearance of body weight). On the morning of day –1 tions of others (16,17). Active and total orally administered glucose (R O) during a of each study period, subjects were admit- a plasma GLP-1 levels were measured using mixed-meal tolerance test (MMTT) com- ted to the clinical research unit in a fasting an electrochemiluminescent sandwich pared with placebo. state for safety analyses, followed by stan- immunoassay (Meso Scale Discovery, dardized meals. Gaithersburg, MD). Total plasma GIP RESEARCH DESIGN AND On the morning of day 1 of each study was measured using an enzyme-linked METHODS period, after an overnight fast of at least 8 h, immunosorbent assay, and total plasma subjects received a primed (25 mCi), PYY was measured using a radioimmuno- Study population continuous intravenous infusion of assay (Millipore, Billerica, MA). Plasma This study was conducted from 22 No- 3H-glucose (0.25 mCi/min) for approxi- acetaminophen concentration was deter- vember 2010 to 29 September 2011 at a mately 9 h. Three hours after starting the mined using a validated high-performance single center in San Diego, California.