Sodium-glucose cotransporter 2 inhibitor Dapagliflozin prevents ejection fraction reduction, reduces myocardial and renal NF-κB expression and systemic pro-inflammatory biomarkers in models of short-term doxorubicin cardiotoxicity
Authors: Quagliariello Vincenzo , Canale Maria Laura , Bisceglia Irma , Iovine Martina , Paccone Andrea , Maurea Carlo , Scherillo Marino , Merola Alessia , Giordano Vienna , Palma Giuseppe , Luciano Antonio , Bruzzese francesca , Marino Federica Zito , Montella Marco , Franco Renato , Berretta Massimiliano , Gabrielli Domenico , Maurea Nicola 
Published: July 2023

Abstract
Background Anthracycline-mediated adverse cardiovascular events are among the leading causes of morbidity and mortality in cancer patients. Cardioprotective strategies in primary and secondary prevention are still needed in clinical practice to improve cancer patient survival and to avoid drug therapy discontinuation. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) exerts multiple cardiometabolic benefits in patients with/without type 2 diabetes, chronic kidney disease and heart failure with reduced and preserved ejection fraction. We hypothesized that Dapagliflozin, an SGLT2i. administered before and during doxorubicin therapy, could improve cardiac function and reduce pro-inflammatory pathways in preclinical models.Methods Female C57Bl/6 mice were treated with a saline solution (Saline, n = 6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg (DOXO, n = 6), DAPA at 10 mg/kg (DAPA, n = 6) or doxorubicin combined to DAPA (DOXO-DAPA, n = 6). Ejection fraction, radial and longitudinal strain were analysed through transthoracic echocardiography (Vevo 2100). Cardiac troponin, BNP and NT-pro-BNP were quantified. Myocardial expression of NLRP-3 inflammasome and MyD-88 were quantified through selective ELISA methods. Systemic levels of ferroptosis-related biomarkers (MDA and 4-HNA), Galectin-3, hs-CRP and pro-inflammatory chemokines/growth factors (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF) were quantified through selective ELISA methods. After treatments, immunohistochemical (IHC) staining of myocardial and renal p65/NF-kB was performed.Results DAPA prevented the reduction of radial and longitudinal strain and ejection fraction after 10 days of treatment with doxorubicin. A reduced myocardial expression of NLRP-3 and MyD-88 was seen in DOXO-DAPA group compared to DOXO mice (p < 0.001). Systemic levels of IL-1β, IL-6, TNF-α, G-CSF and GM-CSF were significantly reduced after treatment with DAPA, indicating anti-inflammatory properties. Serum levels of galectine-3 and hs-CRP were strongly enhanced in DOXO group; contrary, their expression were reduced in DAPA-DOXO group (p < 0.005). Biomarkers of cardiotoxicity, troponin-T, BNP and NT-pro-BNP were strongly reduced in DOXO-DAPA group, revealing cardioprotective properties of SGLT2-i. The myocardial and renal p65/NF-kB expression of Saline and DOXO mice were distinctly different, and DAPA treatment was associated with larger reductions in tissue p65/NF-kB than DOXO.Conclusion DAPA is able to improve cardiac function and reduce systemic biomarkers involved in heart failure and inflammation. IHC analysis clearly indicates anti-inflammatory properties of DAPA in cardiac and renal tissues during DOXO therapy. The overall picture of the study encourages the use of DAPA in primary prevention of cardiomyopathies induced by anthracyclines in cancer patients.