diabetes research and clinical practice 106 (2014) 50–56

Contents available at ScienceDirect

Diabetes Research
and Clinical Practice
jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es

Pharmacokinetic and pharmacodynamic study of

ipragliflozin in Japanese patients with type 2
diabetes mellitus: A randomized, double-blind,
placebo-controlled study§

Takeshi Kadokura a,*, Noriko Akiyama a, Atsunori Kashiwagi b,

Atsushi Utsuno a, Kenichi Kazuta a, Satoshi Yoshida a,
Itsuro Nagase a, Ronald Smulders c, Shigeru Kageyama d
a
Astellas Pharma Inc. Japan, Tokyo, Japan
b
Shiga University of Medical Science, Shiga, Japan
c
Astellas Pharma Global Development Europe, Leiden, The Netherlands
d
The Jikei University School of Medicine, Tokyo, Japan

article info abstract

Article history: Aims: Ipragliflozin is a novel and highly selective sodium–glucose transporter 2 (SGLT2)
Received 6 September 2013 inhibitor that reduces plasma glucose levels by enhancing urinary glucose excretion in patients
Received in revised form with type 2 diabetes mellitus (T2DM). We examined the pharmacokinetic and pharmacody-
15 May 2014 namic characteristics of two oral doses of ipragliflozin in Japanese patients with T2DM.
Accepted 20 July 2014 Methods: In this randomized, placebo-controlled, double-blind study, patients were treated
Available online 26 July 2014 with placebo, 50 mg or 100 mg ipragliflozin once daily for 14 days. Plasma and urine
pharmacodynamic parameters were measured on Days 1 and 14, and pharmacokinetic
Keywords: parameters on Day 14. Pharmacodynamic characteristics included area under the curve
Ipragliflozin (AUC) for plasma glucose and insulin for 0–3 h (AUC0–3h) and 0–24 h (AUC0–24h). Pharmaco-
Fasting glucose kinetic characteristics included AUC0–24h, maximum ipragliflozin concentration (Cmax), and
Postprandial glucose time to maximum plasma ipragliflozin concentration (tmax).
SGLT2 Results: Thirty patients were enrolled; 28 were included in pharmacokinetic/pharmacodynam-
Type 2 diabetes ic analyses and 30 in safety analyses. Administration of 50 and 100 mg ipragliflozin significantly
reduced fasting plasma glucose, as well as the AUC0–3h and AUC0–24h for plasma glucose relative
to placebo. Both doses of ipragliflozin also reduced AUC0–24h for insulin, body weight, and
glycoalbumin, while urinary glucose excretion increased remarkably. Cmax and AUC0–24h were
1.7- and 1.9-fold higher, respectively, in the 100-mg group than in the 50-mg group.
Conclusions: Ipragliflozin increased urinary glucose excretion and improved fasting and
postprandial glucose, confirming its pharmacokinetic/pharmacodynamic properties in
Japanese patients with T2DM.
# 2014 Elsevier Ireland Ltd. All rights reserved.

§
Results of this study were presented as a poster at the 71st Scientific Sessions of the American Diabetes Association, San Diego, CA,
USA (June 24–28, 2011) and at the 55th Annual Meeting of the Japan Diabetes Society, Yokohama, Japan (May 17–19, 2012).
* Corresponding author. Tel.: +81 3 3244 2579; fax: +81 3 3243 5732.
E-mail address: takeshi.kadokura@astellas.com (T. Kadokura).
http://dx.doi.org/10.1016/j.diabres.2014.07.020
0168-8227/# 2014 Elsevier Ireland Ltd. All rights reserved.
 diabetes research and clinical practice 106 (2014) 50–56
1. Introduction
Sodium–glucose transporter 2 (SGLT2) is a member of the SGLT
family of solute transporters. It is highly expressed in proximal
tubules in the kidney, where it plays a key role in glucose
reabsorption [1]. Inhibition of SGLT2 was demonstrated to
suppress renal glucose reabsorption and therefore enhance
urinary glucose excretion (UGE) in vivo [2]. Consequently,
inhibition of SGLT2 was proposed as an insulin-independent
approach for treating type 2 diabetes mellitus (T2DM) [3].
Several SGLT2 inhibitors, including ipragliflozin, have since
been developed, representing a new class of oral hypoglyce-
mic agents.
Ipragliflozin is a potent and selective inhibitor of SGLT2
in vitro, and increases UGE in a dose-dependent manner
in vivo [4]. Studies in healthy volunteers have confirmed that
ipragliflozin also dose-dependently increases UGE in humans
[5,6]. Subsequent studies have shown that ipragliflozin, by
enhancing UGE, decreases fasting plasma glucose (FPG) and
glycosylated hemoglobin (HbA1c) in patients with T2DM [7,8].
In a phase II study conducted in Japanese patients,
treatment with 50 or 100 mg ipragliflozin for 12 weeks led to
significant reductions in HbA1c, FPG, and body weight [5]. To
date, however, the pharmacodynamic and pharmacokinetic
properties of ipragliflozin in Japanese patients with
T2DM have not been reported. Therefore, we conducted a
14-day, placebo-controlled, pharmacokinetic/pharmacody-
namic study to determine the effects of two doses of
ipragliflozin on daily plasma glucose profiles and urinary
glucose excretion, specifically in Japanese patients with T2DM.
2. Methods
2.1. Patients
Eligible patients were aged 20–74 years, had been diagnosed
with T2DM for 12 weeks, were drug-naive or on mono-
therapy, had a body mass index (BMI) of 20–45 kg/m2, HbA1c
(NGSP units) of 7.4–10.5%, FPG levels of 126 to <240 mg/dL,
and fasting serum C-peptide level of >0.6 ng/mL. Patients
previously using oral hypoglycemic drugs entered a manda-
tory washout period of 13 days before starting the present
study. Patients were excluded from the study if they had
advanced diabetes complications (neuropathy, retinopathy,
nephropathy, and macroangiopathy), had used insulin within
12 weeks of starting the study, had chronic diseases requiring
continuous administration of corticosteroids or immunosup-
pressants, were using diuretics, or had evidence of renal
disease, among other criteria. All patients provided written
informed consent before enrollment.
2.2. Study design and treatments
This was a multicenter, placebo-controlled, double-blind
study that examined the pharmacodynamics, pharmacoki-
netics, and safety profiles of two oral doses of ipragliflozin (50
and 100 mg) administered for 14 days in Japanese patients
with T2DM. Supplementary Fig. 1 shows the design of the
51
study. After providing informed consent, patients entered a 1-
to 2-week screening period, with an additional 13-day
washout for those previously using oral hypoglycemic agents.
All patients received placebo during the run-in period. Upon
confirmation of eligibility, the patients were randomized in a
double-blind manner to receive 50 mg ipragliflozin, 100 mg
ipragliflozin, or placebo, which were to be administered once
daily before breakfast for 2 weeks. Patients were hospitalized
from Days 2 to 1 and from Days 13 to 15 at either Keiyukai
Moriya Keiyu Hospital (Moriya, Ibaraki, Japan) or Kunwakai
Aiwa Clinic (Koshigaya, Saitama, Japan) for pharmacodynam-
ic/pharmacokinetic assessments, urine collection, and clinical
investigations, with a follow-up visit at 1–3 weeks.
Eligible patients were randomly and equally assigned to the
three groups (1:1:1 ratio; block size = 3) in accordance with an
assignment list, which was prepared by an assignment
manager who was independent of the sponsor. The assign-
ment schedule was sealed by the assignment manager until
the code was broken. Patients in the 100-mg group took two
tablets containing 50 mg ipragliflozin. Patients in the 50-mg
group took one 50-mg tablet and one placebo tablet. Patients in
the placebo group took two placebo tablets. The appearances
of the placebo/active tablets and their packaging were
indistinguishable. To maintain blinding, the investigators,
study collaborators, and subjects were to refrain from
measuring urinary glucose levels, unless deemed necessary
for safety reasons. During the study, patients were prohibited
from using oral hypoglycemic drugs from 13 days before the
start of screening, insulin from 12 weeks before the start of
screening, or diuretics from the start of screening until the end
of the treatment period. Continuous use of corticosteroids/
immunosuppressants/glucose/glucagon, changes to diet ther-
apy, and initiation of hospitalization therapies for controlling
plasma glucose were also prohibited from the start of
screening to the end of the treatment period. However,
temporary or topical administration of corticosteroids, immu-
nosuppressants, glucose, or glucagon was permitted.
The study protocol, patient informed consent forms, and
case report forms were approved by institutional review
boards at each participating site. The study was conducted in
accordance with Good Clinical Practice, the International
Conference on Harmonization guidelines, and local laws and
regulations. Compliance with Good Clinical Practice was
evaluated by auditors who were independent to the study
management. This study was registered at ClinicalTrials.gov
(identifier: NCT01023945).
2.3. Pharmacodynamic and pharmacokinetic assessments
Pharmacodynamic and pharmacokinetic assessments were
conducted during hospitalization. During hospitalization,
patients were provided standardized meals at 08:30, 12:30,
and 18:30. The same meals were provided to each patient
during hospitalization and the subjects were asked to eat a
constant amount. Blood samples were collected at 0 (before
breakfast), 0.5, 1, 1.5, 2, 3, 4 (before lunch), 5, 6, 7, 10 (before
dinner), 11,12,13, and 24 h (before study drug administration)
on Days 1 and 14 to determine plasma glucose and serum
insulin levels. Blood samples for FPG, fasting serum insulin
(FSI), and glycoalbumin assessment were collected on Day 1
52 diabetes research and clinical practice 106 (2014) 50–56
(before study drug administration) and Day 15. Urinary
samples were collected over 0–4 h (before lunch, 08:30–
12:30), 4–10 h (before dinner, 12:30–18:30), and 10–24 h (before
study drug administration, 18:30–08:30) periods on Days 1
and 14 to measure urine volume, and urinary glucose and
creatinine concentrations.
Pharmacodynamic parameters included plasma glucose
(daily profile, including area under the concentration–time
curve from 0 to 3 h [AUC0–3h] and 0 to 24 h [AUC0–24h], FPG, and
PPG at 1 and 2 h after breakfast) and serum insulin (daily
profile, FSI, AUC0–24h, and AUC0–3h). The pharmacokinetic
parameters were the maximum concentration (Cmax), AUC0–24h
of ipragliflozin, time to Cmax (tmax), apparent terminal elimina-
tion half-life (t1/2), oral clearance (CL/F), renal clearance (CLR),
amount excreted in urine (Ae), and fraction of drug excreted in
urine (Ae%). Urinary pharmacodynamic parameters were 24-h
UGE and 24-h urine volume.
Other clinically relevant outcomes assessed in the study
were body weight and glycoalbumin. We measured glycoal-
bumin rather than HbA1c as the former reflects glucose
control over a much shorter period (2 weeks) compared with
1–2 months for HbA1c. Clinical laboratory tests, as well as
measurement of plasma and urinary ipragliflozin concentra-
tions, were performed at Mitsubishi Chemical Medience Corp.
(Tokyo, Japan). HbA1c was measured using an enzymatic
assay, insulin by a microparticle enzyme immunoassay, and
glycoalbumin by an enzymatic assay.
To measure plasma ipragliflozin concentrations, blood
samples were collected in heparin-coated tubes and centri-
fuged for 10 min at 2000  g. The plasma samples were then
frozen at 20 8C and sent to Mitsubishi Chemical Medience
Corp. Plasma ipragliflozin concentrations were measured
using a validated liquid chromatography–tandem mass
spectrometry (LC–MS/MS) procedure with a lower limit of
quantification (LLOQ) of 1 ng/mL for 0.2 mL of plasma. To
measure urinary ipragliflozin, collected urine was stored at
4 8C until the end of the collection period, then mixed and
stored at 20 8C before being sent to Mitsubishi Chemical
Medience Corp. Urinary ipragliflozin concentrations were
measured using a validated LC–MS/MS procedure with a LLOQ
of 2 ng/mL for 0.2 mL of plasma.
2.4. Safety
Safety parameters, including adverse events (AEs), laboratory
tests (hematology, biochemistry, and urinalysis; performed at
Mitsubishi Chemical Medience Corp.), vital signs (supine blood
pressure and supine pulse rate), and 12-lead electrocardiogra-
phy were monitored throughout the study. Treatment-
emergent adverse events (TEAEs) were classified according
to system organ class and preferred term (MedDRA version
10.1).
2.5. Statistical analysis
We planned to enroll eight subjects per group, considering the
number of subjects that was deemed sufficient for pharmaco-
dynamic assessment of ipragliflozin, and considering the
feasibility of the study. For this study, we defined three sets of
patients for statistical analyses: the pharmacodynamic,
pharmacokinetic, and safety analysis sets. The pharmacody-
namic analysis set (PDAS) consisted of all patients who
received at least one dose of the study drug and had adequate
data for the plasma glucose profile or UGE at the end of the
study. The pharmacokinetic analysis set (PKAS) consisted of
all subjects who received at least one dose of the study drug
and whose plasma ipragliflozin concentration was measured
one or more times. The safety analysis set (SAF) consisted of all
patients who received at least one dose of the study drug.
Baseline characteristics are presented as the number of
patients or mean  standard deviation (SD). The mean  SD
values were calculated for pharmacokinetic and pharmaco-
dynamic parameters at each time-point. The changes from
baseline (i.e., Day 1 to Day 14 or Day 1 to Day 15) in
pharmacodynamic parameters (FPG, plasma glucose AUC0–3h,
plasma glucose AUC0–24h, and FSI) were compared by analysis
of covariance with the baseline value as a covariate and
treatment group as a fixed effect. For UGE and urine volume,
the cumulative values were calculated at each time-point,
together with their changes from baseline. Clinical laboratory
parameters at each time-point were analyzed descriptively.
For the serum concentrations of total ketone bodies and free
fatty acids, the changes from baseline (Day 1) to Day 15 are
presented, and the differences from placebo were estimated
using 95% confidence interval (CI). TEAEs are presented as the
number of patients.
3. Results
3.1. Patient disposition and characteristics
Between November 2009 and March 2010, 30 patients were
enrolled in this study. Two patients discontinued during the
treatment period because of TEAEs (one each treated with 50
and 100 mg ipragliflozin), so no pharmacokinetic or pharma-
codynamic data at the end of treatment could be obtained for
these patients. Therefore, 28 patients were included in the
PDAS and PKAS. All 30 patients were included in the SAF.
Table 1 summarizes the characteristics of patients in each
group, using the PDAS. Baseline HbA1c levels were similar
between the placebo and 100 mg ipragliflozin groups, but were
higher in the 50-mg group, whereas FPG and 24-h UGE values
were similar in all three groups.
3.2. Pharmacodynamics
In both ipragliflozin groups, the plasma glucose levels
measured throughout the day were lower on Day 14 than at
baseline (i.e., Day 1), whereas plasma glucose profiles were
similar on Days 1 and 14 in the placebo group (Fig. 1A–C). FPG
decreased significantly from Day 1 to Day 15 in both
ipragliflozin groups compared with the placebo group.
Additionally, PPG levels measured at 1 and 2 h after breakfast
were lower on Day 14 than on Day 1 in both ipragliflozin
groups, but not in the placebo group. The mean  SD changes
in 2-h PPG were 60.1  45.5 mg/dL and 62.9  34.3 mg/dL in
the 50 and 100 mg ipragliflozin groups, versus 1.9  39.8 mg/
dL in the placebo group (Fig. 2A). Plasma glucose AUC0–3h
(postprandial) and AUC0–24h (all day) decreased significantly
 diabetes research and clinical practice 106 (2014) 50–56 53

Table 1 – Patient characteristics (PDAS).

Placebo (n = 10) 50 mg ipragliflozin (n = 9) 100 mg ipragliflozin (n = 9)
Sex
Male 5 (50.0) 6 (66.7) 8 (88.9)
Female 5 (50.0) 3 (33.3) 1 (11.1)
Age (years) 60.0  7.72 59.3  9.64 57.0  13.19
BMI (kg/m2) 26.23  2.83 25.07  3.11 26.84  3.46
Body weight (kg) 66.72  7.72 68.44  13.58 75.07  13.89
HbA1c, %* (mmol/mol) 8.4  0.9 (67.7  10.01) 8.9  0.8 (73.3  8.59) 8.2  1.0 (65.2  11.42)
FPG (mg/dL) 177.5  33.8 172.9  25.5 165.3  35.1
FSI (mU/mL) 7.23  4.07 5.48  2.23 7.27  3.83
1-h PPG (mg/dL) 306.8  48.4 294.0  44.0 286.1  44.6
2-h PPG (mg/dL) 310.3  63.5 292.3  46.8 274.0  57.2
24-h UGE (g) 27.0  35.2 29.1  33.2 23.5  29.4
Prior diabetes medication (yes) 7 (70.0) 4 (44.4) 3 (33.3)
Glycoalbumin, % of total albumin 23.81  4.84 24.86  4.47 22.59  6.00
*
HbA1c values were measured according to Japanese Diabetes Society (JDS) standards and are presented in National Glycohemoglobin
Standardization Program (NGSP) units [11] and as International Federation of Clinical Chemistry (IFCC) units (mmol/mol) [12,13].
PDAS, pharmacodynamic analysis set; FPG, fasting plasma glucose; PPG, postprandial glucose; FSI, fasting serum insulin.

from Day 1 to Day 14 in both ipragliflozin groups compared
with the placebo group (Table 2). Mean serum insulin levels on
Day 14 were generally lower than those on Day 1 in both
ipragliflozin groups, but not in the placebo group (Fig. 1D–F).
FSI decreased significantly in both ipragliflozin groups but not
in the placebo group.
3.3. Urinary pharmacodynamics
Mean 24-h UGE increased significantly from Day 1 to Day 14
by 80.6  22.2 g and 89.7  12.3 g in the 50 and 100 mg
ipragliflozin groups, respectively, although the changes were
similar in both groups. By contrast, 24-h UGE did not change
significantly in the placebo group (increase of 5.3  19.3 g)
from Day 1 to Day 14 (Fig. 2B). The mean 24-h urine volume
remained unchanged from Day 1 to Day 14 in the placebo
group (there was a non-significant decrease of 61 mL), but
increased slightly in the 50 and 100 mg ipragliflozin groups by
224.4 mL and 203.3 mL, respectively.
3.4. Pharmacokinetics
Ipragliflozin was rapidly absorbed in both dose groups, reaching
peak concentrations within 1 h after dosing. Thereafter, plasma

Fig. 1 – ((A)–(C)) Plasma glucose profiles on Days S1 and 14 in the placebo (A), 50 mg ipragliflozin (B), and 100 mg ipragliflozin
(C) groups. ((D)–(F)) Serum insulin profiles on Days S1 and 14 in the placebo (D), 50 mg ipragliflozin (E), and 100 mg
ipragliflozin (F) groups. Values are shown as the mean W SD.
54 diabetes research and clinical practice 106 (2014) 50–56

Fig. 2 – (A) Changes in 2-h postprandial plasma glucose from Day S1 to Day 14. (B) Changes in mean cumulative urinary
glucose excretion (UGE) over 24 h from Day S1 to Day 14. Values are shown as the mean W SD.

ipragliflozin concentrations declined in a biphasic manner. 3.5. Other outcomes

Supplementary Table 1 summarizes the pharmacokinetic
parameters, including Cmax, AUC0–24h, tmax, t1/2, CL/F, and CLR
in the PKAS. The mean plasma Cmax and AUC0–24h were
approximately 1.7- and 1.9-fold higher, respectively, in the
100-mg group than in the 50-mg group. tmax, t1/2, and CL/F
were similar in both groups. In terms of urinary pharmacoki-
netics, Ae was about 2-fold higher in the 100-mg group than in
the 50-mg group. Ae% was very low in both groups. The mean
Cmax in patients with T2DM was approximately 10–30% higher
than the previously reported value in healthy subjects. By
contrast, the mean AUC0–24h was comparable in both
populations [5]. Nevertheless, the differences in Cmax be-
tween the two studies are small and are unlikely to be
clinically relevant.
Glycoalbumin, assessed in the PDAS, increased slightly in the
placebo group (0.46  1.44%) but decreased in the 50 mg
(2.63  1.73%) and 100 mg (1.74  1.25%) ipragliflozin
groups from Day 1 to Day 15. The mean changes in body
weight, assessed in the PDAS, were 1.51  0.523 kg and
1.19  0.443 kg in the 50 and 100 mg ipragliflozin groups
versus 0.20  0.572 kg in the placebo group.
3.6. Safety
Safety was assessed in all 30 patients enrolled in the study.
Five patients in the 50 mg ipragliflozin group experienced
seven TEAEs and three in the 100 mg ipragliflozin group

Table 2 – Changes in pharmacodynamic parameters from baseline to Day 14 (PDAS).

Placebo (n = 10) 50 mg ipragliflozin (n = 9) 100 mg ipragliflozin (n = 9)
Plasma glucose AUC0–3h, (h mg/dL) 2.3  99.5 172.6  106.6 174.6  92.0
Difference in adjusted mean change (95% CI)* – 184.8 (274.7, 94.9) 200.6 (293.3, 107.9)
Plasma glucose AUC0–24h (h mg/dL) 63.8  732.5 1103.7  693.9 919.9  636.0
Difference in adjusted mean change (95% CI)* – 1214.1 (1844.4, 583.9) 1094.5 (1735.4, 453.7)
FPG (mg/dL) 0.3  20.5 31.6  24.3 35.8  29.1
Difference in adjusted mean change (95% CI)* – 33.7 (54.3, 13.1) 40.9 (61.8, 20.0)
1-h PPG (mg/dL)y 3.5  23.8 53.1  34.2 58.7  32.4
2-h PPG (mg/dL)y 1.9  39.8 60.1  45.5 62.9  34.3
FSI (mU/mL) 0.54  2.08z 1.31  1.21 2.38  1.88
Difference in adjusted mean change (95% CI)* – 2.26 (3.86, 0.65) 2.93 (4.50, 1.36)
Serum insulin AUC0–3h (h mU/mL)y 8.8  18.7 9.7  7.2 9.4  11.1
Serum insulin AUC0–24h (h mU/mL)y 4.4  70.3 93.8  57.2 53.1  77.3
Body weight (kg)y 0.20  0.57 1.51  0.52 1.19  0.44
Glycoalbumin (%)y 0.46  1.44 2.63  1.73 1.74  1.25
Values are means  SD or means (95% CI). PDAS, pharmacodynamic analysis set; FPG, fasting plasma glucose; PPG, postprandial glucose; FSI,
fasting serum insulin.
*
ANCOVA with baseline value as a covariate. Significance was defined as an upper limit of the 95% CI of <0 mg/dL, <0 mU/mL or <0 h mg/dL.
y
Analyzed descriptively.
z
n = 9.
 diabetes research and clinical practice 106 (2014) 50–56 55

Table 3 – Summary statistics and changes from baseline in total serum ketone and free fatty acid levels (SAF).
Time-point Day 1 End of Follow-up Change from Difference vs.
treatment baselinez placebo (95% CI)
Total serum ketones* (mmol/L)
Placebo (n = 10) 110.9  140.7 125.3  170.4 80.8  68.4 (26.8–253.0) 14.3  36.8
(24.8–499.0) (30.0–600.0) (30.0, 101.0)
50 mg (n = 10) 78.2  52.9 268.8  174.6y 51.2  26.5y (22.0–99.9)y 187.6  170.5y 173.2 (56.9–289.5)
(27.1–213.0) (59.9–553.0)y (22.8, 448.0)y
100 mg (n = 10) 98.8  75.1 347.6  255.3y 44.7  16.5 (25.1–75.3) 248.8  239.9 234.5 (73.2–395.7)
(32.6–261.0) (138.0–974.0)y (71.0, 788.0)
Free fatty acids (mEq/L)
Placebo (n = 10) 0.48  0.16 0.49  0.19 0.51  0.21 (0.18–0.82) 0.006  0.130
(0.30–0.75) (0.24–0.85) (0.220, 0.240)
50 mg (n = 10) 0.52  0.16 0.57  0.10 0.39  0.13 (0.22–0.67) 0.042  0.217 0.036 (0.132, 0.204)
(0.24–0.79) (0.34–0.71) (0.450, 0.300)
100 mg (n = 10) 0.46  0.15 0.57  0.16 0.33  0.08 (0.18–0.47) 0.106  0.146 0.100 (0.030, 0.230)
(0.27–0.72) (0.38–0.81) (0.080, 0.330)
Values are means  SD (range). SAF, safety analysis set.
*
Includes acetoacetic acid and 3-hydroxybutyric acid.
y
n = 9.
z
Change from Day 1 to Day 14.

experienced three TEAEs (Supplementary Table 2). There were
five drug-related TEAEs in four patients in the 50-mg group,
and two drug-related TEAEs in two patients in the 100-mg
group. All TEAEs were classified mild in severity (i.e., did not
affect daily activities), with the exception of a nonfatal
myocardial infarction in one patient in the ipragliflozin
50 mg group, which was assessed as moderate (i.e., it affected
normal daily activities). The myocardial infarction was
observed in the follow-up period (Day 21), after 14 days of
repeated dosing with ipragliflozin was completed. The patient
was discharged on Day 27, and recovery was confirmed on Day
51. Two patients discontinued treatment because of mild
TEAEs (toxic skin eruption and rash). No hypoglycemic events,
urinary tract infection, genital infection, or pollakiuria were
reported. Elevations of serum ketone bodies were reported as
TEAEs in one patient in each of the ipragliflozin groups. The
total serum ketone levels, which included acetoacetic acid and
3-hydroxybutyric acid levels, increased in both ipragliflozin
groups, but not in the placebo group, from Day 1 to Day 14
(Table 3). The total serum ketone levels tended to be lower at
the follow-up visit than on Day 1 in all three groups. The
mean  SD changes in free fatty acid levels were
0.042  0.217 mEq/L and 0.106  0.146 mEq/L in the 50 and
100 mg ipragliflozin groups, respectively, versus
0.006  0.130 mEq/L in the placebo group.
4. Discussion
Ipragliflozin is a potent and selective inhibitor of SGLT2
in vitro, and increases UGE in a dose-dependent manner
in vivo [4]. Clinical studies have demonstrated that ipragli-
flozin increases UGE in healthy subjects without changing
plasma glucose levels [5,6]. In healthy Japanese subjects, up to
70 g of glucose was excreted over 24 h after a single 300 mg
dose, while up to 50 g of glucose was excreted over 24 h after
multiple doses of 50 or 100 mg [5]. The present study showed
that 24-h UGE after multiple doses of 50 or 100 mg ipragliflozin
approached the maximum of around 90 g in Japanese T2DM
patients. These results suggest that increased drug exposure
hardly affected the pharmacodynamic properties of 50 or
100 mg ipragliflozin, compared with lower doses. This also
indicates that the increase in UGE is determined by the plasma
glucose level and renal function (i.e., glomerular filtration rate)
within the therapeutic dose range [9].
A phase II study showed that treatment with 50 or 100 mg
ipragliflozin for 12 weeks produced significant reductions in
HbA1c, FPG, and body weight in Japanese T2DM patients [7].
However, the daily pharmacodynamic profiles after adminis-
tering ipragliflozin have not been reported in Japanese T2DM
patients until now. The present study showed that 50 and
100 mg ipragliflozin improved FPG, FSI, PPG, AUC0–3h (post-
prandial), and AUC0–24h (all day) in Japanese T2DM patients.
Urine volume increased slightly from baseline in both
ipragliflozin groups, although the changes were small because
of the urine volume measured at baseline (2000–2800 mL).
Mean water intake measured at each time remained almost
unchanged in all three groups. As expected, the reductions in
FPG and PPG were coupled with significant increases in UGE in
both ipragliflozin groups, whereas no changes in glucose
profiles or UGE occurred in the placebo group. The reductions
in plasma glucose levels led to reductions in glucose load,
which consequently reduced the demand for insulin to
support metabolic activity. Additionally, the reductions in
plasma glucose levels probably led to a reduction in
glucotoxicity, as shown by the reductions in glycoalbumin.
In this study, TEAEs were reported in seven and three
patients in the 50 and 100 mg ipragliflozin groups, respective-
ly, but none were reported in the placebo group. These
included cardiac disorders, laboratory disorders, and skin and
subcutaneous tissue disorders.
Elevated ketone bodies were reported as a TEAE in two
patients. As the blood glucose levels were well controlled in
both patients, the elevated serum ketone bodies were
considered to be related to compensatory fatty acid metabo-
lism. The increase in total serum ketone levels was probably
56 diabetes research and clinical practice 106 (2014) 50–56
caused by the increase in glucose excretion, which upregu-
lated fatty acid mobilization and metabolism, leading to the
production of ketone bodies as a byproduct of fatty acid
oxidation, and loss of fat mass. Considering that approxi-
mately 81–90 g of glucose was excreted per day, and 1 g of
glucose corresponds to 4 kcal, as much as 350 kcal/day was
excreted in urine. Consistent with this concept, it was reported
that 10 mg dapagliflozin once daily added to metformin was
associated with a placebo-corrected change in fat mass of
1.48 kg ( p = 0.0001) over 24 weeks, which was mediated by
reductions in visceral and subcutaneous adipose tissue
volumes [10].
Several limitations of this study should be described. In
particular, the study was only 14 days long, which means the
improvements in glycemic control cannot be generalized to
the longer-term outcomes. However, our objective was not to
examine the long-term outcomes, but rather to investigate the
pharmacodynamic and pharmacokinetic properties of ipragli-
flozin in Japanese patients with T2DM.
In conclusion, the present results have confirmed the
pharmacodynamic and pharmacokinetic properties of ipragli-
flozin in Japanese patients with T2DM, as increases in UGE
lead to improvements in FPG and PPG.
Disclosure
TK, NA, AU, KK, SY, and IN are employees of Astellas Pharma
Inc. RS is an employee of Astellas Pharma Global Develop-
ment. AK and SK have acted as consultants for Astellas
Pharma Inc.
Conflicts of Interest
There is no conflict of interest.
Acknowledgements
Ipragliflozin is under development by Astellas Pharma Inc. and
Kotobuki Pharmaceutical Co., Ltd. This study was sponsored
by Astellas. Medical writing and editorial support was funded
by Astellas and provided by Dr. Nicholas D. Smith and
ELMCOMTM.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.diabres.2014.07.020.
references
[1] Neumiller JJ, White Jr JR, Campbell RK. Sodium-glucose co-
transport inhibitors: progress and therapeutic potential in
type 2 diabetes mellitus. Drugs 2010;70:377–85.
[2] Wright EM. Renal Na(+)-glucose cotransporters. Am J
Physiol Renal Physiol 2001;280:F10–8.
[3] Nair S, Wilding JP. Sodium glucose cotransporter 2
inhibitors as a new treatment for diabetes mellitus. J Clin
Endocrinol Metab 2010;95:34–42.
[4] Tahara A, Kurosaki E, Yokono M, Yamajuku D, Kihara R,
Hayashizaki Y, et al. Pharmacological profile of ipragliflozin
(ASP1941), a novel selective SGLT2 inhibitor, in vitro and
in vivo. Naunyn Schmiedebergs Arch Pharmacol
2012;385:423–36.
[5] Kadokura T, Saito M, Utsuno A, Kazuta K, Yoshida S,
Kawasaki S, et al. Ipragliflozin (ASP1941), a selective
sodium-dependent glucose cotransporter 2 inhibitor, safely
stimulates urinary glucose excretion without inducing
hypoglycemia in healthy Japanese subjects. Diabetol Int
2011;2:172–82.
[6] Veltkamp SA, Kadokura T, Krauwinkel WJ, Smulders RA.
Effect of ipragliflozin (ASP1941), a novel selective sodium-
dependent glucose co-transporter 2 inhibitor, on urinary
glucose excretion in healthy subjects. Clin Drug Investig
2011;31:839–51.
[7] Kashiwagi A, Kazuta K, Yoshida S, Nagase I. Randomized,
placebo-controlled, double-blind glycemic control trial of
novel SGLT2 inhibitor ipragliflozin in Japanese patients with
type 2 diabetes mellitus. J Diabetes Investig 2014;5:382–91.
[8] Schwartz SL, Akinlade B, Klasen S, Kowalski D, Zhang W,
Wilpshaar W. Safety, pharmacokinetic, and
pharmacodynamic profiles of ipragliflozin (ASP1941), a
novel and selective inhibitor of sodium-dependent glucose
co-transporter 2, in patients with type 2 diabetes mellitus.
Diabetes Technol Ther 2011;13:1219–27.
[9] Ferrannini E, Veltkamp SA, Smulders RA, et al. Renal
glucose handling: impact of chronic kidney disease and
sodium-glucose cotransporter 2 inhibition in patients with
type 2 diabetes. Diabetes Care 2013;36:1260–5.
[10] Bolinder J, Ljunggren O, Kullberg J, Johansson L, Wilding J,
Langkilde AM, et al. Effects of dapagliflozin on body weight,
total fat mass, and regional adipose tissue distribution in
patients with type 2 diabetes mellitus with inadequate
glycemic control on metformin. J Clin Endocrinol Metab
2012;97:1020–31.
[11] Kashiwagi A, Kasuga M, Araki E, Oka Y, Hanafusa T, Ito H,
et al. International clinical harmonization of glycated
hemoglobin in Japan: from Japan Diabetes Society to
National Glycohemoglobin Standardization Program
values. Diabetol Int 2012;3:8–10.
[12] Hoelzel W, Weykamp C, Jeppsson JO, Miedema K, Barr JR,
Goodall I, et al. IFCC reference system for measurement of
hemoglobin A1c in human blood and the national
standardization schemes in the United States, Japan, and
Sweden: a method-comparison study. Clin Chem
2004;50:166–74.
[13] Weykamp C, John WG, Mosca A, Hoshino T, Little R, Jeppsson
JO, et al. The IFCC reference measurement system for HbA1c:
a 6-year progress report. Clin Chem 2008;54:240–8.