Journal Club 2015年6月4日 8:30-8:55 ８階 医局 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 松田 昌文 Alpérovitch A, Kurth T, Bertrand M, Ancelin ML, Helmer C, Debette S, Tzourio C. Primary prevention with lipid lowering drugs and long term risk of vascular events in older people: population based cohort study. BMJ. 2015 May 19;350:h2335. doi: 10.1136/bmj.h2335. Uchida S, Mitani A, Gunji E, Takahashi T, Yamamoto K. In vitro characterization of luseogliflozin, a potent and competitive sodium glucose co-transporter 2 inhibitor: Inhibition kinetics and binding studies. J Pharmacol Sci. 2015 Apr 9. pii: S1347-8613(15)00074-2. doi: 10.1016/j.jphs.2015.04.001. 2015年6月4日　8:30-8:55 ８階　医局 埼玉医科大学　総合医療センター　内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田　昌文　 Matsuda, Masafumi

From: Cost-Effectiveness and Population Impact of Statins for Primary Prevention in Adults Aged 75 Years or Older in the United StatesStatins for Primary Prevention in U.S. Adults Aged 75 Years or Older Ann Intern Med. 2015;162(8):533-541. doi:10.7326/M14-1430 米国の高齢者に対する一次予防目的でのスタチン療法の費用対効果をマルコフモデルで検証。75-94歳の全成人でのスタチン療法実施により、障害調整生命年当たりの増分費用は2万5200ドルで、約11万人の心筋梗塞発症、約7万人の冠動脈心疾患死亡が回避されるが、機能的制限/軽度認知障害のわずかな相対リスク増加で効果は相殺されると推定された。 Figure Legend: The value of the statin-associated DALY reduction at which the lines cross the x-axis is the magnitude needed to offset the cardiovascular benefit and result in no net DALYs gained. DALY = disability-adjusted life-year; LDL-C = low-density lipoprotein cholesterol. Date of download: 5/6/2015 Copyright © American College of Physicians. All rights reserved.

Copyright © 2015 American Medical Association. All rights reserved. From: Evaluation and Treatment of Older Patients With Hypercholesterolemia:  A Clinical Review JAMA. 2014;312(11):1136-1144. doi:10.1001/jama.2014.10924 No randomized clinical trials (RCTs) of statin or any other hypocholesterolemic medication included persons older than 80 years at baseline. Figure Legend: Suggested Treatment Algorithm for Statin Treatment in Patients Older Than 80 Years With Hypercholesterolemia and Without a Condition Seriously Limiting Life ExpectancyThis approach is used by the authors and is based on the best available evidence but does not represent treatments validated in clinical trials, because the clinical features of the patients considered in this article have not been studied in randomized clinical trials. ASCVD indicates atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol. Date of download: 6/3/2015 Copyright © 2015 American Medical Association. All rights reserved.

Copyright © 2015 American Medical Association. All rights reserved. From: Evaluation and Treatment of Older Patients With Hypercholesterolemia:  A Clinical Review JAMA. 2014;312(11):1136-1144. doi:10.1001/jama.2014.10924 Observational Studies and Randomized Clinical Trials of Statins in Older People With or Without ASCVD Table Title: Date of download: 6/3/2015 Copyright © 2015 American Medical Association. All rights reserved.

Copyright © 2015 American Medical Association. All rights reserved. From: Evaluation and Treatment of Older Patients With Hypercholesterolemia:  A Clinical Review JAMA. 2014;312(11):1136-1144. doi:10.1001/jama.2014.10924 Ideally, treatment of hypercholesterolemia for patients at risk of ASCVD should start before they turn 80 years old. No RCT evidence exists to guide statin initiation after age 80 years. Decisions to use statins in older individuals are made individually and are not supported by high-quality evidence. Observational Studies of Statin Therapy and Functioning in Older People Table Title: Date of download: 6/3/2015 Copyright © 2015 American Medical Association. All rights reserved.

Copyright © 2015 American Medical Association. All rights reserved. From: Statins and Physical Activity in Older Men:  The Osteoporotic Fractures in Men Study JAMA Intern Med. 2014;174(8):1263-1270. doi:10.1001/jamainternmed.2014.2266 Figure Legend: Mean Physical Activity Scale in the Elderly (PASE) Scores According to Statin User GroupsPASE scores were estimated by mixed-effects linear regression adjusted for age, site, and baseline total cholesterol (fixed-in-time), myocardial infarction, stroke, hypertension, diabetes, perceived health and body mass index (time-varying). The error bars represent 95% confidence intervals for the estimated mean PASE at each visit (n = 3039). Date of download: 6/3/2015 Copyright © 2015 American Medical Association. All rights reserved.

1INSERM, U897-Epidemiology and Biostatistics, Bordeaux, France 2Université de Bordeaux, Bordeaux, France 3INSERM, U1061, Montpellier, France 4Université de Montpellier I, Montpellier, France BMJ. 2015 May 19;350:h2335. doi: 10.1136/bmj.h2335.

Objective To determine the association between use of lipid lowering drugs (statin or fibrate) in older people with no known history of vascular events and long term risk of coronary heart disease and stroke

Design Ongoing prospective population based cohort study recruited in 1999-2000, with five face-to-face examinations. Setting Random sample of community dwelling population aged 65 years and over, living in three French cities (Bordeaux, Dijon, Montpellier). Participants 7484 men and women (63%) with mean age 73.9 years and no known history of vascular events at entry. Mean follow-up was 9.1 years. Main outcome measures Adjusted hazard ratios of coronary heart disease and stroke in baseline lipid lowering drug users compared with non-users, calculated using multivariable Cox proportional hazard models adjusted for numerous potential confounding factors. Hazard ratios were estimated for use of any lipid lowering drug and for statin and fibrate separately.

mg/dL NO YES T-Chol 231(39) 216(35) 207 239 HDL-C 63(15) 63(15) 54 68 LDL-C 146(35) 131(31) 125 152 TG 101 97 83 178

注意：スタチンを使っていること自体がCHDを起こすリスクのある対象とも考えられるが

mg/dL T-Chol 201 251 LDL-C 152 174 HDL-C 35 42 TG 124 177

Results Lipid lowering drug users were at decreased risk of stroke compared with non-users (hazard ratio 0.66, 95% confidence interval 0.49 to 0.90); hazard ratios for stroke were similar for statin (0.68, 0.45 to1.01) and fibrate (0.66, 0.44 to 0.98). No association was found between lipid lowering drug use and coronary heart disease (hazard ratio 1.12, 0.90 to 1.40). Analyses stratified by age, sex, body mass index, hypertension, systolic blood pressure, triglyceride concentrations, and propensity score did not show any effect modification by these variables, either for stroke or for coronary heart disease.

Conclusion In a population based cohort of older people with no history of vascular events, use of statins or fibrates was associated with a 30% decrease in the incidence of stroke.

Message 血管イベントの既往のない65歳以上の男女7484 人を対象に、脂質降下薬（スタチンまたはフィ ブラート系薬）の使用と冠動脈疾患・脳卒中の 長期リスクの関連を集団ベースのコホート研究 で検証。平均9.1年の追跡の結果、使用者は非使 用者に比べ脳卒中リスクが低かった（ハザード 比0.66）。脂質降下薬の使用と冠動脈疾患に関 連はなかった。 スタチン/フィブラートは心臓でなく脳に効い た！？

Decline of FPG during SGLT-2 inhibitors Data from Phase 2 clinical trials in Japan FPG/HbA1c was decreased to below 20 after the administration of SGLT-2 inhibitors! Masafumi Matsuda: DITN 442:9 January, 2015

ビール330ml (アルコール6%) 低血糖 副作用報告 埼玉医科大学総合医療センター内分泌・糖尿病内科　松田昌文　自験

各種SGLT-2阻害薬の血中ブドウ糖濃度に及ぼす効果 埼玉医科大学総合医療センター内分泌・糖尿病内科　松田昌文　自験

SGLT-2阻害薬は止めても、 空腹時に２~４日間は尿糖はかなり出る！ 埼玉医科大学総合医療センター内分泌・糖尿病内科　松田昌文　自験

SGLT-2蛋白に対する結合及び解離 Uchida S, Mitani A, Gunji E, Takahashi T, Yamamoto K.: In vitro characterization of luseogliflozin, a potent and competitive sodium glucose co-transporter 2 inhibitor: Inhibition kinetics and binding studies. J Pharmacol Sci. 2015 Apr 9. pii: S1347-8613(15)00074-2. doi: 10.1016/j.jphs.2015.04.001.

J Pharmacol Sci. 2015 Apr 9. pii: S1347-8613(15)00074-2. doi: 10 J Pharmacol Sci. 2015 Apr 9. pii: S1347-8613(15)00074-2. doi: 10.1016/j.jphs.2015.04.001.

Abstract In this study, we evaluated an inhibition model of luseogliflozin on sodium glucose co-transporter 2 (SGLT2). We also analyzed the binding kinetics of the drug to SGLT2 protein using [3H]-luseogliflozin. Luseogliflozin competitively inhibited human SGLT2 (hSGLT2)-mediated glucose uptake with a Ki value of 1.10 nM. In the absence of glucose, [3H]-luseogliflozin exhibited a high affinity for hSGLT2 with a Kd value of 1.3 nM. The dissociation half-time was 7 h, suggesting that luseogliflozin dissociates rather slowly from hSGLT2. These profiles of luseogliflozin might contribute to the long duration of action of this drug.

Methods to prepare cells stably expressing hSGLT2 and glucose uptake study were described in a previous study (5). The cells were incubated in 75 μL of sodium buffer (140 mM NaCl, 2 mM KCl, 1 mM CaCl2, 1 mM MgCl2, 10 mM HEPES, 5 mM Tris, pH 7.2–7.4) containing 1, 2, 4, 8 or 16 mM of the methyl-α-d-glucopyranoside (α-MG) mixture ([14C]-α-MG: PerkinElmer, Tokyo and unlabeled α-MG: Sigma–Aldrich, St. Louis, MO, USA) and 1, 2 or 4 nM of luseogliflozin (Taisho Pharmaceutical Co., Ltd., Saitama) or dimethyl sulfoxide vehicle at 37 °C for 60 min; each of the incubations was performed in triplicate. Binding assays were performed using a modification of the method of Grempler (7). For the saturation binding experiments, cell membranes (60 μg/well) were incubated with 1.3–368.8 nM [3H]-luseogliflozin (Quotient Bioresearch Ltd., Cardiff, UK) in assay buffer [10 mM HEPES (pH 7.4), 137 mM NaCl] in the absence and presence of glucose (20 mM, Wako Pure Chemical Industries Ltd., Osaka), respectively, for 6 h at 25 °C in 96-well plates. For the association experiments, membranes were incubated with 5.2 and 19 nM of [3H]-luseogliflozin in the absence and presence of glucose (20 mM), respectively, for 0.25, 1, 3, 6, 9 and 12 h at 25 °C. For the dissociation experiments, 12 h after association, 760 and 1970 nM of unlabeled luseogliflozin, approximately 100 times the amount of [3H]-luseogliflozin, in the absence and presence of glucose, respectively, were added, followed by incubation for 2, 4, 7.67, 18.5 and 30 h at 25 °C. The approximate Kd values calculated from the saturation binding experiments were used as the concentrations for [3H]-luseogliflozin in the presence or absence of glucose. Nonspecific binding was determined with 50 μM of phlorizin (Sigma–Aldrich). The data were analyzed using GraphPad Prism 5.04 (GraphPad Software, Inc., La Jolla, CA, USA).

Fig. 1. Kinetic analysis of the inhibition of hSGLT2 by luseogliflozin Fig. 1. Kinetic analysis of the inhibition of hSGLT2 by luseogliflozin. Cells stably expressing hSGLT2 were incubated in sodium buffer containing various concentrations of an α-MG mixture ([14C]-α-MG and unlabeled α-MG) and luseogliflozin at 37 °C for 60 min. Sodium-dependent α-MG uptake was calculated by subtracting radioactivity (cpm) in the absence of sodium from radioactivity in the presence of sodium. The inhibition pattern was analyzed by Lineweaver–Burk plots. The data points represent the mean of three wells from a single representative experiment.

Fig. 2. Analysis of the binding kinetics of [3H]-luseogliflozin to hSGLT2 protein. A and B) Saturation curve and Scatchard plot of [3H]-luseogliflozin binding to hSGLT2. Membranes of hSGLT2 cells were incubated with [3H]-luseogliflozin in an assay buffer in the absence and presence of glucose (20 mM) for 6 h at 25 °C. The data points represent the mean of two wells from a single representative experiment. C and D) Association and dissociation curves of [3H]-luseogliflozin binding to hSGLT2 in the absence and presence of glucose. For the association time-course experiments, membranes were incubated with [3H]-luseogliflozin [5.2 nM (C) and 19 nM (D)] for 0.25–12 h at 25 °C. For the dissociation time-course experiments, after 12 h incubation with [3H]-luseogliflozin, unlabeled luseogliflozin was added in excess [760 nM (C) or 1970 nM (D)] and incubated for 2–30 h at 25 °C. Data represent the mean ± SEM of three experiments.

Recently, empagliflozin, a novel Cglucoside, was shown as a slow-dissociating SGLT2 inhibitor with a half-time of empagliflozinehSGLT2 binding of approximately 60 min

Figure 1. Potency of empagliflozin for sodium glucose cotransporter (SGLT)-2 and selectivity over SGLT-1, 4, 5 and 6. Inset shows the chemical structure of empagliflozin. Results show inhibition of monosaccharide uptake by hSGLT-2, 1, 4, 5 and 6, respectively, at different concentrations of empagliflozin. [14C]-AMG was used as substrate for hSGLT-1, 2 and 4, mannose was used as substrate for hSGLT-5 and myo-inositol for hSGLT-6. Data are shown from representative experiments and are expressed as mean % of respective control ± standard error of the mean, where the control value was measured at 10−11 M empagliflozin of each individual assay. Grempler R, Thomas L, Eckhardt M, Himmelsbach F, Sauer A, Sharp DE, Bakker RA, Mark M, Klein T, Eickelmann P.: Empagliflozin, a novel selective sodium glucose cotransporter-2 (SGLT-2) inhibitor: characterisation and comparison with other SGLT-2 inhibitors. Diabetes Obes Metab. 2012 Jan;14(1):83-90. doi: 10.1111/j.1463-1326.2011.01517.x.

Table 1. Overview of potency on SGLT-2 and selectivity over SGLT-1, 4, 5 and 6 of structurally known SGLT-2 inhibitors. Luseogliflozin, a structurally novel C-5-thioglucoside, is a potent inhibitor of SGLT2 with an IC50 value of 2.26 nM, and exhibits a 1765-fold selectivity for hSGLT2 as compared to hSGLT1 Grempler R, Thomas L, Eckhardt M, Himmelsbach F, Sauer A, Sharp DE, Bakker RA, Mark M, Klein T, Eickelmann P.: Empagliflozin, a novel selective sodium glucose cotransporter-2 (SGLT-2) inhibitor: characterisation and comparison with other SGLT-2 inhibitors. Diabetes Obes Metab. 2012 Jan;14(1):83-90. doi: 10.1111/j.1463-1326.2011.01517.x.

Conclusions: In conclusion, luseogliflozin is a highly potent and competitive inhibitor of SGLT2, and specifically binds to SGLT2. Furthermore, the results of the present study indicated that the dissociation of luseogliflozin from SGLT2 occurs very slowly. The results suggest that the binding kinetics of luseogliflozin to SGLT2 localized in the S1 and S2 segments of the renal proximal tubules may contribute to the sustained pharmacological effect of this drug.

Message Luseogliflozin はEmpagliflozin の7倍くっつ いているらしい。