This study aims to elucidate the mechanisms whereby the SGLT2i "ertugliflozin" modifies cardiorenal interactions that regulate fluid volume and neurohormonal activation in patients with type 2 diabetes and heart failure (T2D-HF).
Newer agents called sodium glucose co-transporter-2 inhibitors (SGLT2i) have been developed to improve glycemic control and lower hemoglobin A1c by increasing glycosuria. SGLT2i also reduce blood pressure and albuminuria in T2D - possibly through natriuresis. Importantly, a landmark trial "EMPA-REG OUTCOME" demonstrated that the SGLT2i "empagliflozin" is the first anti- hyperglycemic agent to reduce mortality and HF risk, and also to decrease the risk of progressive diabetic nephropathy. Similar benefits were also recently reported in the CANVAS Program trial with canagliflozin. Despite the benefits observed in these two pivotal trials, the mechanisms responsible for beneficial effects of SGLT2i in patients with T2D with respect to the development and/or worsening of HF are not currently known. In light of the results of EMPA-REG OUTCOME, the investigators aim to elucidate the mechanisms whereby the SGLT2i "ertugliflozin" modifies cardiorenal interactions that regulate fluid volume and neurohormonal activation in patients with T2D and HF (T2D-HF). The investigators will test the hypothesis that ertugliflozin increases proximal tubular natriuresis, thereby reducing plasma volume, without inducing significant renal vasoconstriction or activation of the sympathetic nervous system (SNS) (see below, Figure 1). The systematic understanding of the effects of SGLT2i in the setting of HF will enable the design of rational physiology based strategies to decrease the burden of HF, which could have major clinical and research implications internationally.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
34
Ertugliflozin Tablets Total Dose 15mg (10mg + 5 mg) once daily for 12 weeks
Placebo once daily for 12 weeks
Toronto General Hospital
Toronto, Ontario, Canada
Vanderbilt University Medical Centre
Amsterdam, De Boelelaan, Netherlands
University Medical Center Groningen
Groningen, Netherlands
Fractional Excretion of Lithium (FELi)
The difference in fractional excretion of lithium (FELi) with ertugliflozin vs. placebo. This was measured using exogenous lithium administration 12 hours before lithium excretion was measured in urine and blood.
Time frame: Change in outcomes was measured acute (1 week minus baseline values) and chronic (12 weeks minus baseline values)
Fractional Excretion of Sodium (FENa)
The difference in fractional excretion of sodium (FENa) with ertugliflozin vs. placebo. This was measured using exogenous lithium administration 12 hours before sodium excretion was measured in urine and blood.
Time frame: Change in outcomes was measured acute (1 week minus baseline values) and chronic (12 weeks minus baseline values)
Change in Absolute Fractional Distal Sodium Reabsorption From Baseline (FELi-FENa)
The difference in fractional excretion of lithium and fractional excretion of sodium (calculated by the difference between FELi and FENa) with ertugliflozin vs. placebo. This was measured using exogenous lithium administration 12 hours before sodium excretion was measured in urine and blood.
Time frame: Change in outcomes was measured acute (1 week minus baseline values) and chronic (12 weeks minus baseline values)
Glomerular Filtration Rate (GFR)
The difference in iohexol-measured GFR with ertugliflozin vs. placebo. 5ml bolus iohexol (Omnipaque 300mg) was infused intravenously over 2 minutes while participants were supine. Iohexol disappearance curve was used to measure GFR over from 2-4 hours after infusion.
Time frame: Glomerular Filtration Rate (GFR, based on plasma iohexol clearance) will be measured at 12 weeks
Effective Renal Plasma Flow (ERPF)
The difference in ERPF with ertugliflozin vs. placebo. Paraaminohippurate (PAH) was intravenously administered to measured ERPF.
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Time frame: Effective Renal Plasma Flow (ERPF, based on paraaminohippurate plasma clearance) will be measured at 12 weeks
Systolic Blood Pressure (SBP)
The difference in seated SBP with ertugliflozin vs. placebo
Time frame: chronic (12 weeks)
Diastolic Blood Pressure (DBP)
The difference in seated DBP with ertugliflozin vs. placebo
Time frame: chronic (12 weeks)
Heart Rate (HR)
The difference in seated HR with ertugliflozin vs. placebo
Time frame: chronic (12 weeks)
LV Ejection Fraction
Echocardiography for markers of systolic and diastolic function
Time frame: chronic (12 weeks)
Carotid-femoral Pulse Wave Velocity
Arterial Stiffness using SphygmaCor software. Pulse points measured at carotid and femoral arteries.
Time frame: chronic (12 weeks)
Plasma Volume
Plasma volume will be measured using a non-radioactive technique (indocyanine green dilution)
Time frame: chronic (12 weeks)
Extracellular Water
Extracellular water will be measured non-invasively using bioimpedence spectroscopy
Time frame: chronic (12 weeks)
Cardiac Output
Cardiac output will also be measured using non-invasive cardiac monitoring (NICOM)
Time frame: chronic (12 weeks)
Systemic Vascular Resistance
Systemic vascular resistance will also be measured using non-invasive cardiac monitoring (NICOM)
Time frame: chronic (12 weeks)
Blood Angiotensin II
Neurohormones/biomarkers
Time frame: chronic (12 weeks)
BNP
Neurohormones/biomarkers
Time frame: chronic (12 weeks)
Norepinephrine
Neurohormones/biomarkers
Time frame: chronic (12 weeks)
Urinary Adenosine
Neurohormones/biomarkers
Time frame: chronic (12 weeks)