Canagliflozin

Canagliflozin
Clinical data
Pronunciation /ˌkænəɡlɪˈfloʊzɪn/ KAN-ə-glif-LOH-zin
Trade names Invokana, Sulisent, Prominad
Synonyms JNJ-28431754; TA-7284; (1S)-1,5-anhydro-1-C-(3-{[5-(4-fluorophenyl)thiophen-2-yl]methyl]}-4-methylphenyl)-D-glucitol
AHFS/Drugs.com invokana
License data
Pregnancy
category
  • US: C (Risk not ruled out)
    Routes of
    administration    		 By mouth (tablets)
    ATC code
    Legal status
    Legal status
    • AU: S4 (Prescription only)
    • UK: POM (Prescription only)
    • US: ℞-only
    • In general: ℞ (Prescription only)
    Pharmacokinetic data
    Bioavailability 65%
    Protein binding 99%
    Metabolism Hepatic glucuronidation
    Elimination half-life 11.8 (10–13) hours
    Excretion Faecal and 33% renal
    Identifiers
    CAS Number
    PubChem CID
    IUPHAR/BPS
    DrugBank
    ChemSpider
    UNII
    ChEBI
    ChEMBL
    ECHA InfoCard 100.223.671 Edit this at Wikidata
    Chemical and physical data
    Formula C24H25FO5S
    Molar mass 444.52 g/mol
    3D model (JSmol)
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    Canagliflozin (trade name Invokana or Sulisent) is a medication used for the treatment of type 2 diabetes.[1][2] It is of the gliflozin class or subtype 2 sodium-glucose transport (SGLT-2) inhibitors class.

    This mechanism is associated with a low risk of hypoglycaemia (too low blood glucose) compared to sulfonylurea derivatives and insulin.[3] In 2017, the FDA concluded that canagliflozin causes an increased risk of leg and foot amputations.[4] The FDA began requiring a Boxed Warning to be added to the canagliflozin drug labels to describe this risk.[5]

    Canagliflozin is an inhibitor of subtype 2 sodium-glucose transport proteins (SGLT2), which is responsible for at least 90% of renal glucose reabsorption (SGLT1 being responsible for the remaining 10%). Blocking this transporter causes up to 119 grams of blood glucose per day to be eliminated through the urine.[6] It was developed by Mitsubishi Tanabe Pharma and is marketed under license by Janssen, a division of Johnson & Johnson.[7]

    Medical use

    Canagliflozin is an anti-diabetic drug used to improve glycemic control in people with type 2 diabetes. In extensive clinical trials, canagliflozin produced a consistent dose-dependent decrease in HbA1c levels of 0.77% to 1.16% when administered either as monotherapy, in combination with metformin, in combination with metformin and a sulfonylurea, in combination with metformin and pioglitazone, or in combination with insulin, from initial HbA1c levels of 7.8% to 8.1%. When added to metformin, canagliflozin daily was shown to be non-inferior to both sitagliptin 100 mg daily and glimepiride in reducing HbA1c levels at one year, whilst canagliflozin 300 mg successfully demonstrated statistical superiority over both sitagliptin and glimiperide in decreasing HbA1c levels. Secondary efficacy endpoints of higher reductions in weight and blood pressure (versus sitagliptin and glimiperide) were also observed in studies. It is unclear whether or not it has any unique cardiovascular benefits beyond lowering blood sugar.[8] Although canagliflozin produces beneficial effects on HDL cholesterol, it has also been shown to increase LDL cholesterol to produce no change in total cholesterol.[9][10]

    Recent evidence shows that apart from positive effects on glycemic levels, canagliflozin also provides significant cardiovascular protection in type 2 diabetics, reducing the risk of heart attacks and heart failures.[11]

    Contraindications

    Canaglifozin is contraindicated in:

    Adverse effects

    As with all SGLT-2 inhibitors, canagliflozin is associated with increased incidence of urinary tract infections, fungal infections of the genital area, thirst,[14] elevations in LDL cholesterol, increased urination and episodes of low blood pressure. There are concerns that it may also increase the risk of diabetic ketoacidosis.[15]

    Possible cardiovascular problems are an ongoing issue with gliflozin drugs.[16] The pre-specified endpoint for cardiovascular safety in the canagliflozin clinical development program was "Major Cardiovascular Events Plus", defined as the occurrence of cardiovascular death, non-fatal myocardial infarctions, non-fatal strokes, or unstable angina leading to hospitalization. This endpoint occurred in more people in the placebo group (20.5%) than in the canagliflozin treated group (18.9%).

    Nonetheless, a United States Food and Drug Administration advisory committee expressed concern regarding the cardiovascular safety of canagliflozin. A greater number of cardiovascular events was observed during the first 30 days in study subjects who received canagliflozin (0.45%) compared those who received placebo (0.07%), suggesting an early period of increased cardiovascular risk. In addition, there was an increased risk of stroke in subjects who received canagliflozin. However, none of these effects were statistically significant. Additional cardiovascular safety data from another ongoing study are expected in 2015.[16]

    On May 15, 2015, the FDA issued a warning that certain SGLT2 diabetes drugs, including canagliflozin, may lead to ketoacidosis, a condition where the body produces higher levels of ketone bodies. The FDA is continuing to investigate the issue, and cautions that patients should not stop taking canagliflozin without first talking to their doctor.[17]

    On September 10, 2015, the FDA issued a drug safety communication for canagliflozin to address risks for bone fracture and decreased bone density. A label warning for fractures was already included in the Adverse Reactions section; however, the FDA made the addition to the Warnings and Precautions section to reflect new information from a placebo study. They advised that health care professionals should consider fracture risk factors before prescribing canagliflozin, and patients should disclose any bone fracture risk factors to their doctors, but that patients should not stop taking the medication without first talking to their doctor.[18]

    On December 4, 2015, the FDA issued another safety communication for SGLT2 inhibitors, indicating that it would require new warnings to be added to the canagliflozin label about elevated blood acid levels and urinary tract infections.[19]

    A June 29, 2016 report on the ongoing cardiovascular outcomes trial for canagliflozin (CANVAS) revealed interim findings of new safety concerns including heightened risk of bone fracture that was found to increase with the duration of treatment.[20]

    On May 16, 2017, the FDA concluded that canagliflozin causes an increased risk of leg and foot amputations.[4] The FDA began requiring a boxed warning to be added to the canagliflozin drug labels to describe this risk.[5]

    Interactions

    The drug may increase the risk of dehydration in combination with diuretic drugs.[21]

    Because it increases renal excretion of glucose, treatment with canagliflozin prevents renal reabsorption of 1,5-anhydroglucitol, leading to artifactual decreases in serum 1,5-anhydroglucitol. Therefore, canagliflozin can interfere with the use of serum 1,5-anhydroglucitol (assay trade name, GlycoMark) as a measure of postprandial glucose levels.[22]

    Mechanism of action

    Canagliflozin is an inhibitor of subtype 2 sodium-glucose transport proteins (SGLT2), which is responsible for at least 90% of renal glucose reabsorption (SGLT1 being responsible for the remaining 10%). Blocking this transporter causes up to 119 grams of blood glucose per day to be eliminated through the urine,[6] corresponding to 476 kilocalories. Additional water is eliminated by osmotic diuresis, resulting in a lowering of blood pressure.

    This mechanism is associated with a low risk of hypoglycaemia (too low blood glucose) compared to other types of anti-diabetic drugs such as sulfonylurea derivatives and insulin.[3]

    History

    On July 4, 2011, the European Medicines Agency approved a paediatric investigation plan and granted both a deferral and a waiver for canagliflozin (EMEA-001030-PIP01-10) in accordance with EC Regulation No.1901/2006 of the European Parliament and of the Council.[23]

    Canagliflozin was approved by the FDA on March 29, 2013, and became the first SGLT2 inhibitor in the United States.[24][25]

    References

    1. ↑ New J&J diabetes drug effective in mid-stage study, Jun 26, 2010
    2. ↑ Edward C. Chao (2011). "Canagliflozin". Drugs of the Future. 36 (5): 351–357. doi:10.1358/dof.2011.036.05.1590789.
    3. 1 2 A. Klement (20 January 2014). "Tubuläre Senkung des Blutzuckers bei Diabetes mellitus: Invokana". Österreichische Apothekerzeitung (in German) (2/2014): 20f.
    4. 1 2 "Press Release: FDA Confirms Increased Risk of Leg and Foot Amputations With Diabetes Medicine Canagliflozin". Fox Business. 2017-05-16. Retrieved 2017-05-16.
    5. 1 2 "FDA Drug Safety Communication: FDA confirms increased risk of leg and foot amputations with the diabetes medicine canagliflozin (Invokana, Invokamet, Invokamet XR)". FDA.gov. 2017-05-16. Retrieved 2017-05-16.
    6. 1 2 Prous Science: Molecule of the Month November 2007
    7. ↑ http://www.investor.jnj.com/releasedetail.cfm?releaseid=710584
    8. ↑ Heston, TF; Olson, AH; Randall, NR (2017). "Canagliflozin lowers blood sugar, but does it also lower cardiovascular risk? Maybe not". Ann Transl Med. 5: 473. doi:10.21037/atm.2017.09.28. PMC 5733311. PMID 29285506.
    9. ↑ "Summary Review" (PDF). fda.gov. March 29, 2013. Retrieved 2014-07-09.
    10. 1 2 "Invokana (canagliflozin) Tablets, for Oral Use. Full Prescribing Information" (PDF). Janssen Pharmaceuticals, Inc. Retrieved 14 November 2016.
    11. ↑ Usman, Muhammad Shariq; Siddiqi, Tariq Jamal; Memon, Muhammad Mustafa; Khan, Muhammad Shahzeb; Rawasia, Wasiq Faraz; Talha Ayub, Muhammad; Sreenivasan, Jayakumar; Golzar, Yasmeen (2018-01-01). "Sodium-glucose co-transporter 2 inhibitors and cardiovascular outcomes: A systematic review and meta-analysis". European Journal of Preventive Cardiology: 2047487318755531. doi:10.1177/2047487318755531. ISSN 2047-4881. PMID 29372664.
    12. ↑ Canagliflozin. Lexi-Drugs. Lexicomp Online [database online]. Hudson, OH: Lexicomp, Inc. http://online.lexi.com. Updated April 8, 2017. Accessed April 13, 2017.
    13. ↑ Canagliflozin. Lexi-Drugs. Lexicomp Online [database online]. Hudson, OH: Lexicomp, Inc. http://online.lexi.com. Updated March 31, 2017. Accessed April 5, 2017.
    14. ↑ Haberfeld, H (ed.). Austria-Codex (in German) (2013/14, supplement 01/14 ed.). Vienna: Österreichischer Apothekerverlag.
    15. ↑ FDA (2015-05-15). "SGLT2 inhibitors: Drug Safety Communication - FDA Warns Medicines May Result in a Serious Condition of Too Much Acid in the Blood". Retrieved 19 May 2015.
    16. 1 2 Tucker, Miriam (10 January 2013). "FDA Advisory Panel Supports Diabetes Drug Canagliflozin". Medscape Family Medicine. Retrieved 3 August 2015. Safety discussions by the panel circled back repeatedly to the cardiovascular risk data
    17. ↑ Research, Center for Drug Evaluation and. "Drug Safety and Availability - FDA Drug Safety Communication: FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood". www.fda.gov. Retrieved 2016-06-07.
    18. ↑ "FDA Drug Safety Communication: FDA revises label of diabetes drug canagliflozin (Invokana, Invokamet) to include updates on bone fracture risk and new information on decreased bone mineral density". FDA. U.S. Food & Drug Administration. Retrieved 10 September 2015.
    19. ↑ "SGLT2 Inhibitors: Drug Safety Communication - Labels to Include Warnings About Too Much Acid in the Blood and Serious Urinary Tract Infections". FDA. Food and Drug Administration. Retrieved 11 March 2016.
    20. ↑ Schroeder, C. "New Report Warns of Increasing SGLT2 & Invokana Risks". DrugNews. Pro Media One. Retrieved 8 August 2016.
    21. ↑ Yamout, H; Perkovic, V; Davies, M; Woo, V; de Zeeuw, D; Mayer, C; Vijapurkar, U; Kline, I; Usiskin, K; Meininger, G; Bakris, G (August 2014). "Efficacy and Safety of Canagliflozin in Patients with Type 2 Diabetes and Stage 3 Nephropathy". American Journal of Nephrology. 40 (1): 64–74. doi:10.1159/000364909. PMID 25059406. Retrieved 31 March 2017.
    22. ↑ Balis, Dainius A; Tong, Cindy; Meininger, Gary (July 2014). "Effect of canagliflozin, a sodium–glucose cotransporter 2 inhibitor, on measurement of serum 1,5-anhydroglucitol". J Diabetes. 6 (4): 378–380. doi:10.1111/1753-0407.12116.
    23. ↑ "EMEA-001030-PIP01-10". EMA European Medicines Agency. Retrieved May 6, 2013.
    24. ↑ "Canagliflozin". www.fda.gov. United States Food and Drug Administration. Retrieved 23 March 2016.
    25. ↑ "U.S. FDA approves Johnson & Johnson diabetes drug, canagliflozin". Reuters. March 29, 2013. U.S. health regulators have approved a new diabetes drug from Johnson & Johnson, making it the first in its class to be approved in the United States.


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