Investigating the Ability of Type 2 Diabetes Treatments to Modestly Slow Aging Extends to SGLT-2 Inhibitors
There is something of a trend towards picking over the landscape of type 2 diabetes medication in search of therapies that can modestly slow aging, at least in animal models. If metformin is anything to go by, we shouldn't be at all optimistic that this will result in useful outcomes in humans. "Useful" in this context means reliable gains in late life health and life expectancy in metabolically normal people, where those gains are larger than those that can be achieved with exercise, and with minimal side-effects. Otherwise, this seems like time and effort that could be directed to more productive areas of research and development.
Caloric restriction promotes longevity in multiple animal models. Compounds modulating nutrient-sensing pathways have been suggested to reproduce part of the beneficial effect of caloric restriction on aging. However, none of the commonly studied caloric restriction mimetics actually produce a decrease in calories. Sodium-glucose cotransporter 2 inhibitors (SGLT2-i) are a class of drugs which lower glucose by promoting its elimination through urine, thus inducing a net loss of calories. This effect promotes a metabolic shift at the systemic level, fostering ketones and fatty acids utilization as glucose-alternative substrates, and is accompanied by a modulation of major nutrient-sensing pathways held to drive aging, e.g., mTOR and the inflammasome, overall resembling major features of caloric restriction. In addition, preliminary experimental data suggest that SGLT-2i might also have intrinsic activities independent of their systemic effects, such as the inhibition of cellular senescence.
Consistently, evidence from both preclinical and clinical studies have also suggested a marked ability of SGLT-2i to ameliorate low-grade inflammation in humans, a relevant driver of aging commonly referred to as inflammaging. Considering also the amount of data from clinical trials, observational studies, and meta-analyses suggesting a tangible effect on age-related outcomes, such as cardiovascular diseases, heart failure, kidney disease, and all-cause mortality also in patients without diabetes, here we propose a framework where at least part of the benefit provided by SGLT-2i is mediated by their ability to blunt the drivers of aging. To support this postulate, we synthesize available data relative to the effect of this class on: 1) animal models of healthspan and lifespan; 2) selected molecular pillars of aging in preclinical models; 3) biomarkers of aging and especially inflammaging in humans; and 4- COVID-19-related outcomes. The burden of evidence might prompt the design of studies testing the potential employment of this class as anti-aging drugs.