Type 2 diabetes (T2D) is characterized by chronic hyperglycemia resulting from a deficiency in insulin signaling, because of insulin resistance and/or defects in insulin secretion; it is also associated with increases in glucagon and endogenous glucose production (EGP)1. Gliflozins, including dapagliflozin, are a new class of approved oral antidiabetic agents that specifically inhibit sodium-glucose co-transporter 2 (SGLT2) function in the kidney2,3,4,5, thus preventing renal glucose reabsorption and increasing glycosuria in diabetic individuals while reducing hyperglycemia. However, gliflozin treatment in subjects with T2D increases both plasma glucagon and EGP6,7 by unknown mechanisms. In spite of the rise in EGP, T2D patients treated with gliflozin have lower blood glucose levels than those receiving placebo, possibly because of increased glycosuria6,7; however, the resulting increase in plasma glucagon levels represents a possible concerning side effect, especially in a patient population already affected by hyperglucagonemia. Here we demonstrate that SGLT2 is expressed in glucagon-secreting alpha cells of the pancreatic islets. We further found that expression of SLC5A2 (which encodes SGLT2) was lower and glucagon (GCG) gene expression was higher in islets from T2D individuals and in normal islets exposed to chronic hyperglycemia than in islets from non-diabetics. Moreover, hepatocyte nuclear factor 4-α (HNF4A) is specifically expressed in human alpha cells, in which it controls SLC5A2 expression, and its expression is downregulated by hyperglycemia. In addition, inhibition of either SLC5A2 via siRNA-induced gene silencing or SGLT2 via dapagliflozin treatment in human islets triggered glucagon secretion through KATP channel activation. Finally, we found that dapagliflozin treatment further promotes glucagon secretion and hepatic gluconeogenesis in healthy mice, thereby limiting the decrease of plasma glucose induced by fasting. Collectively, these results identify a heretofore unknown role of SGLT2 and designate dapagliflozin an alpha cell secretagogue.
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We thank the Agence de la Biomedecine and Lille University core facilities for biotherapy, experimental research, and histology; R. Boutry for excellent technical assistance; and L. Schäffer (Novo Nordisk, Bagsvaerd, Denmark) for providing the S961 insulin receptor antagonist. We are grateful to J. Girard (Institut Cochin, Paris, France) and J.-C. Henquin (Université de Louvain, Brussels, Belgium) for their comments and stimulating discussions. This work was presented in part at the 2014 annual meetings of the American Diabetes Association and the European Association to Study Diabetes. This work was supported by grants from the Conseil Régional Nord-Pas-de-Calais and the European Commission (FEDER 12003944 to F.P.), the Fondation de l'Avenir (Matmut Award to F.P.), and the European Genomic Institute for Diabetes (ANR-10-LABX-46 to F.P.). The European Consortium for Islet Transplantation is funded by the Juvenile Diabetes Research Foundation International. B.S. is a member of the Institut Universitaire de France. International.
The authors declare no competing financial interests.
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Bonner, C., Kerr-Conte, J., Gmyr, V. et al. Inhibition of the glucose transporter SGLT2 with dapagliflozin in pancreatic alpha cells triggers glucagon secretion. Nat Med 21, 512–517 (2015). https://doi.org/10.1038/nm.3828
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