Safety and Efficacy of Canagliflozin in Advanced CKD

Safety and Efficacy of Canagliflozin in Advanced CKD

The study objective is to characterize the pharmacokinetics (PK), pharmacodynamics, and surrogate measures of efficacy for canagliflozin in patients with advanced CKD, including those receiving HD.

As the CV and renoprotective effects of SGLT-2 inhibitors appear to be independent of glycemic control, the investigators hypothesize that canagliflozin will reduce albuminuria in patients with advanced CKD in the same manner as observed in patients with higher eGFR. The investigators also hypothesize that the 300 mg dose will be equally safe as the 100 mg dose but will have greater efficacy, given data which suggests efficacy correlates with drug exposure in patients without CKD.

Given its negligible renal elimination, the investigators hypothesize that exposure to canagliflozin 100 mg at steady state will not exceed the standard bioequivalence boundary of 80-125% in patients receiving HD, compared with published estimates with the 300 mg dose at steady state in individuals with preserved kidney function.

Substudy 1:

Patients with eGFR<30 ml/min/1.73m2 and urine albumin to creatinine ratio (UACR)>200 mg/g not receiving dialysis will receive canagliflozin 100 mg po daily for 12 weeks (phase 1). For participants who have tolerated the drug, canagliflozin will be increased to 300 mg po daily for an additional 12 weeks (phase 2) and then stopped. Each phase will be followed by a 2-week window to ascertain surrogate efficacy outcomes.

Substudy 2:

Adult patients on HD for at least 3 months without significant residual renal function will receive canagliflozin 100 mg po daily for 9 days.

Inclusion Criteria:

(Substudy 1- SIP-AKiD-1):

• adult patients with eGFR <30 ml/min/1.73m2
• urine albumin to creatinine ratio (UACR) >200 mg/g
• not receiving dialysis.

(Substudy 2- SIP-AKiD-2):

• adult patients on hemodialysis for at least 3 months
• without significant residual renal function, defined as a urine output <250 ml/24h.

Exclusion Criteria:

• Age <18 years
• type 1 diabetes
• history of euglycemic ketoacidosis
• known hypersensitivity to SGLT-2 inhibitors
• recurrent severe genital or urinary tract infections
• history of atraumatic amputation, gangrene, or active skin ulcer
• use within the last 48 h of an SGLT-2 inhibitor or a combined SGLT-1 and SGLT-2 inhibitor
• liver disease defined by an ALT > 3.0 times the upper limit of normal [ULN] or total bilirubin >1.5 times the ULN or liver cirrhosis of any stage
• gastrointestinal surgery or gastrointestinal disorder that could interfere with trial medication absorption
• pregnancy
• currently breastfeeding
• any other clinical condition that would jeopardize patient safety while participating in this trial.
• Patients receiving digoxin, phenobarbital, phenytoin, rifampin, or ritonavir will be excluded if these agents cannot be safely discontinued