T2DM: SGLT2 inhibitors aid insulin resistance

Researchers of the German Center for Diabetes Research (DZD), the departments of Internal Medicine IV (Director: Prof. Andreas Birkenfeld) and Clinical Chemistry and Pathobiochemistry (Director: Prof. Andreas Peter) of Tübingen University Hospital and the Institute of Diabetes Research and Metabolic Diseases (IDM) at Helmholtz Munich have shown for the first time that the SGLT2 inhibitor empagliflozin can be used to treat insulin resistance in the brain, with positive effects on the metabolism of the entire body. The outcomes were featured in the study, 'Improves Insulin Sensitivity of the Hypothalamus in Humans With Prediabetes: A Randomized, Double-Blind, Placebo-Controlled, Phase 2 Trial’, was published in Diabetes Care.

The brain has a decisive influence on our eating behaviour and thus also on body weight and metabolism. If the brain reacts sensitively to insulin, we eat less, less abdominal fat is stored, and the insulin sensitivity of the entire body improves. However, in people with obesity or type 2 diabetes, the hormone in the brain is no longer effective. This insulin resistance leads to a disturbed metabolism. So far, insulin resistance in the brain cannot be treated with drugs.


The researchers investigated whether a diabetes drug from the SGLT2 inhibitor group can also reverse insulin resistance in the brain. SGLT2 inhibitors reduce elevated blood glucose levels in diabetes by promoting glucose excretion through the urine and have a beneficial effect on the heart, circulation and kidneys. For this purpose, the effect of the SGLT2 inhibitor empagliflozin on the insulin sensitivity of the brain was investigated in study participants with a preliminary stage of diabetes (prediabetes).


In a prospective, randomised, double-blind study, 40 people with prediabetes (age: 60±9 years; BMI: 31.5±3.8kg/m²) received the drug empagliflozin or a placebo for eight weeks. The researchers used functional magnetic resonance imaging (fMRI) to determine the insulin sensitivity of the brain before and after treatment. For this purpose, the subjects were given insulin via a nasal spray. When the hormone is absorbed through the nose, it reaches the brain directly. In addition, whole-body magnetic resonance imaging (MRI) was used to determine fat distribution.


"While placebo administration had no influence on insulin action in the brain, empagliflozin treatment significantly improved the effect of the hormone on brain activity," said lead author, PD Dr Stephanie Kullmann, summarising the results of the study.


Empagliflozin administration also improved fasting glucose levels and decreased liver fat content. Although the SGLT2 inhibitor did not reduce weight, it did reduce body fat content.


"Our studies confirm insulin resistance in the brain in people with prediabetes," said last author, Professor Martin Heni of Tübingen University Hospital, Germany. "Treatment with empagliflozin was able to restore insulin sensitivity. These results position SGLT2 inhibitors as the first potential pharmacological approach to treat insulin resistance in the brain. The increased insulin sensitivity also contributes to improved body metabolism."


As a next step, the researchers plan to investigate whether the improved insulin action in the brain is also involved in the beneficial effects of SGLT2 inhibitors on the heart and kidneys.