WO2021239844A1

WO2021239844A1 - Sglt-2 inhibitors or il-1r antagonists for reduction of hypoglycaemia in prediabetes

Info

Publication number: WO2021239844A1
Application number: PCT/EP2021/064114
Authority: WO
Inventors: Marc Donath
Original assignee: Universitätsspital Basel
Priority date: 2020-05-27
Filing date: 2021-05-26
Publication date: 2021-12-02

Abstract

The present invention relates to the use of SGLT-2 inhibitors and/or interleukin-1-receptor antagonists or non-agonist antibodies reactive to interleukin-1β or IL-1 receptor and IL-1 accessory protein in the treatment of prevention of postprandial (or reactive) hypoglycaemia in prediabetes.

Description

SGLT-2 inhibitors or IL-1R antagonists for reduction of hypoglycaemia in prediabetes

The present invention relates to the use of SGLT-2 inhibitors, particularly empagliflozin, and/or interleukin (IL)-1 -receptor antagonists, particularly anakinra, or non-agonist antibodies reactive to interleukin-1 b or IL-1 receptor and IL-1 accessory protein, in the treatment of prevention of postprandial-hypoglycaemia (also termed reactive hypoglycaemia) in prediabetes.

Background of the Invention

Postprandial (“after having a meal”) hypoglycaemia is characterised by recurrent episodes of symptomatic hypoglycaemic events occurring within four hours after a high carbohydrate meal. It is due to an endogenous insulin secretion defect and is not due to anti-diabetic treatment nor to anatomical changes as in patients after bariatric surgery.

Postprandial hypoglycemia in patients with prediabetes is commonly observed but no exact data for its prevalence are known. Prediabetes affects approximately 10-30% of the Swiss population.

Subjects with prediabetes may develop postprandial hypoglycemia. The occurrence of hypoglycemia is probably due to a dysfunction of the insulin producing b-cell characterized by a delayed and exaggerated insulin secretion leading to an initial peak in glycaemia followed by a rapid fall and eventually resulting in hypoglycemia. The latter occurring typically within 1 to 4 hours after food intake. Importantly, postprandial hypoglycemia is not due to anti-diabetic drugs such as sulfonylurea or exogenous insulin.

It is conceivable that recurrent episodes of postprandial hypoglycemia in prediabetics lead to increased food intake and weight gain, eventually resulting in diabetes. Thus, a better understanding of postprandial hypoglycemia and potential treatment opportunities are warranted.

Based on the above-mentioned state of the art, the objective of the present invention is to provide means and methods to treat postprandial (or reactive) hypoglycaemia, particularly in patients in prediabetes. This objective is attained by the subject-matter of the independent claims of the present specification.

Summary of the Invention

A first aspect of the invention relates to the use of an SGLT-2 inhibitor for treatment of prevention of postprandial (or reactive) hypoglycaemia in prediabetes. A second aspect of the invention relates to the use of an interleukin-1 -receptor antagonist for treatment of postprandial (or reactive) prevention of hypoglycaemia in prediabetes.

A third aspect of the invention relates to the use of a non-agonist antibody or antibody-like molecule specifically binding to one of

- IL-1 b or

IL-1 receptor type I or

IL-1 receptor accessory protein (IL1 RAP), in treatment of prevention of hypoglycaemia in prediabetes.

Brief Description of the Figures

Fig. 1 Study flow diagram

Fig. 2 Procedures at each study day

Detailed Description of the Invention Terms and definitions

For purposes of interpreting this specification, the following definitions will apply and whenever appropriate, terms used in the singular will also include the plural and vice versa. In the event that any definition set forth below conflicts with any document incorporated herein by reference, the definition set forth shall control.

The terms “comprising,” “having,” “containing,” and “including,” and other similar forms, and grammatical equivalents thereof, as used herein, are intended to be equivalent in meaning and to be open ended in that an item or items following any one of these words is not meant to be an exhaustive listing of such item or items, or meant to be limited to only the listed item or items. For example, an article “comprising” components A, B, and C can consist of (i.e., contain only) components A, B, and C, or can contain not only components A, B, and C but also one or more other components. As such, it is intended and understood that “comprises” and similar forms thereof, and grammatical equivalents thereof, include disclosure of embodiments of “consisting essentially of” or “consisting of.”

Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit, unless the context clearly dictate otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range, is encompassed within the disclosure, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the disclosure. Reference to “about” a value or parameter herein includes (and describes) variations that are directed to that value or parameter per se. For example, description referring to “about X” includes description of “X.”

As used herein, including in the appended claims, the singular forms “a,” “or,” and “the” include plural referents unless the context clearly dictates otherwise.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art (e.g., in cell culture, molecular genetics, nucleic acid chemistry, hybridization techniques and biochemistry). Standard techniques are used for molecular, genetic and biochemical methods (see generally, Sambrook et al., Molecular Cloning: A Laboratory Manual, 4th ed. (2012) Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y. and Ausubel et al., Short Protocols in Molecular Biology (2002) 5th Ed, John Wiley & Sons, Inc.) and chemical methods.

The term SGLT-2 inhibitors in the context of the present specification relates to all drugs of this class including but not limited to empagliflozin (CAS No. 864070-44-0), canagliflozin (CAS No. 842133-18-0), dapagliflozin (CAS No. 461432-26-8), ertugliflozin (CAS No. 1210344-57-2), ipragliflozin (CAS No. 761423-87-4), luseogliflozin (CAS No. 898537-18-3), sotagliflozin (CAS No. 1018899-04-1 ), and tofogliflozin (CAS No. 1201913-82-7).

The term interleukin-1 -receptor antagonists or non-agonist antibodies reactive to interleukin- 1b or to IL1 receptor type I in the context of the present specification relates to drugs blocking the production or action of IL-1 , IL-1 b and IL-1a. This includes the IL-1 receptor antagonist IL-1 Ra (anakinra), antibodies blocking the action of IL-1 b, IL-1a, and IL-1 receptor accessory protein (IL1 RAP) and small molecules blocking the production of I L- 1 b , such as NLRP3 inhibitors.

In the context of the present specification, the term antibody refers to whole antibodies including but not limited to immunoglobulin type G (IgG), type A (IgA), type D (IgD), type E

(IgE) or type M (IgM), any antigen binding fragment or single chains thereof and related or derived constructs. A whole antibody is a glycoprotein comprising at least two heavy (H) chains and two light (L) chains inter-connected by disulfide bonds. Each heavy chain is comprised of a heavy chain variable region (VH) and a heavy chain constant region (CH). The heavy chain constant region is comprised of three domains, CH1 , CH2 and CH3. Each light chain is comprised of a light chain variable region (abbreviated herein as Vi_) and a light chain constant region (CL). The light chain constant region is comprised of one domain, CL. The variable regions of the heavy and light chains contain a binding domain that interacts with an antigen.

The constant regions of the antibodies may mediate the binding of the immunoglobulin to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component of the classical complement system. Similarly, the term encompasses a so- called nanobody or single domain antibody, an antibody fragment consisting of a single monomeric variable antibody domain.

The term antibody-like molecule in the context of the present specification refers to a molecule capable of specific binding to another molecule or target with high affinity, particularly characterized by a Kd < 10E-8 mol/l. An antibody-like molecule binds to its target similarly to the specific binding of an antibody. The term antibody-like molecule encompasses a repeat protein, such as a designed ankyrin repeat protein (Molecular Partners, Zurich), an engineered antibody mimetic protein exhibiting highly specific and high-affinity target protein binding (see US2012142611 , US2016250341 , US2016075767 and US2015368302, all of which are incorporated herein by reference). The term antibody-like molecule further encompasses, but is not limited to, a polypeptide derived from armadillo repeat proteins, a polypeptide derived from leucine-rich repeat proteins and a polypeptide derived from tetratricopeptide repeat proteins.

The term antibody-like molecule further encompasses a specifically binding polypeptide derived from a protein A domain, fibronectin domain FN3, consensus fibronectin domains, a lipocalins (see Skerra, Biochim. Biophys. Acta 2000, 1482(1 -2):337-50), a polypeptide derived from a Zinc finger protein (see Kwan et al. Structure 2003, 11 (7):803-813), Src homology domain 2 (SH2) or Src homology domain 3 (SH3), a PDZ domain, gamma-crystallin, ubiquitin, a cysteine knot polypeptide or a knottin, cystatin, Sac7d, a triple helix coiled coil (also known as alphabody), a Kunitz domain or a Kunitz-type protease inhibitor and a carbohydrate binding module 32-2.

The term postprandial hypoglycaemia or reactive hypoglycaemia in the context of the present specification relates to recurrent episodes of symptomatic hypoglycemia occurring within four hours after a high carbohydrate meal. It is due to an endogenous insulin secretion defect and is not due to anti-diabetic treatments nor to anatomical changes as in patients after bariatric surgery. It often occurs in obese individuals, typically in prediabetes or in early stages of the disease.

As used herein, the term treating or treatment of any disease or disorder (e.g. hypoglycaemia) refers in one embodiment, to ameliorating the disease or disorder (e.g. slowing or arresting or reducing the development of the disease or at least one of the clinical symptoms thereof). In another embodiment "treating" or "treatment" refers to alleviating or ameliorating at least one physical parameter including those which may not be discernible by the patient. In yet another embodiment, "treating" or "treatment" refers to modulating the disease or disorder, either physically, (e.g., stabilization of a discernible symptom), physiologically, (e.g., stabilization of a physical parameter), or both. Methods for assessing treatment and/or prevention of disease are generally known in the art, unless specifically described herein below.

The following terms are used:

HbA1c: glycated hemoglobin a.k.a. hemoglobin A1c, A1c, HgbAlc, Hb1c.

IFG: impaired fasting glucose FPG: fasting plasma glucose IGT: impaired glucose tolerance oGTT: oral glucose tolerance test Detailed description of the invention

To the inventors’ knowledge, no clinical data have been published investigating the effect of SGLT2-inhibitors nor anakinra or any other drug impacting on the IL-1 R/IL-1 b interaction on patients with postprandial (reactive) hypoglycaemia, particularly in patients in prediabetes. Patients with a prediabetes or at early stages of the diseases often develop this type of hypoglycaemia. Importantly, it is not due to untoward effects of anti-diabetic drugs but to a dysfunction of the insulin producing b-cell. Thereby the dysfunctional insulin secretion is characterized by a delayed and exaggerated insulin secretion leading to an initial peak in glycaemia followed by a rapid fall eventually resulting in hypoglycemia. The latter occurring typically within 1 to 4 hours after food intake.

As underlying mechanism the inventors suggest that postprandial (reactive) hypoglycaemia is related to their observation that postprandially, IL-1 b increases and stimulates insulin secretion. Indeed a pathological activation of the innate immune system is observed in obese and diabetic individuals. This may potentiate postprandial I L- 1 b , leading to an exaggerated stimulation insulin secretion.

Accordingly, treatment with either SGLT2-inhibitors, which reduce the peak of blood sugar, or any drug impacting on the IL-1 R/IL-1 b interaction, will prevent postprandial hypoglycemia.

A first aspect of the invention relates to the use of an SGLT-2 inhibitor in treatment of prevention of postprandial (or reactive) hypoglycaemia, particularly in prediabetes.

In certain embodiments, the SGLT-2 inhibitor is selected from empagliflozin, canagliflozin, dapagliflozin, ertugliflozin, ipragliflozin, luseogliflozin, sotagliflozin, and tofogliflozin. In certain embodiments, the SGLT-2 inhibitor is empagliflozin. Empagliflozin (CAS No. 864070-44-0; marketed as Jardiance®; Boehringer Ingelheim) is a highly selective, reversible inhibitor of the sodium glucose co-transporter 2 (SGLT2) and a novel treatment modality as monotherapy or in combination with metformin, sulfonylurea or insulin in patients with type 2 diabetes mellitus. SGLT2 is predominantly expressed in the proximal tubule of the kidney and reabsorbs approximately 90 percent of the filtered glucose leading to an increased glucosuria (64 g glucose per day). In Switzerland, 10 mg tablets are available, containing the active substance empagliflozinum and the adjuvant lactosum monohydricum. The effect of glucose-excretion relies on glucose plasma concentration as well as glomerular filtration rate and rises after the intake of the first dose of empagliflozin (Jardiance®) with a median T_{max O}f 1.5 h and a mean Plasma-AUC in the steady state of 1.87 nmol.h/l allowing once daily dosing.

Contraindications for its use are a history of serious hypersensitivity to empagliflozin or any component of the formulation. Clinical trials have shown an acceptable safety profile for empagliflozin. Recently, it was shown for patients with type 2 diabetes and a high cardiovascular risk who received empagliflozin as compared with placebo, had a significant lower rate of the primary composite cardiovascular outcome and of death from any cause when the study drug was added to standard care.

In mid- and long-term use, adverse events such as pollakisuria, increased thirst and the occurrence of urinary- or genital tract infections were reported. Since glucose-excretion is dependent on the filtered load, it has a low propensity to cause hypoglycemia. Mild hypoglycemias have been reported in the combined treatment with insulin or sulfonylurea.

In certain embodiments, the SGLT-2 inhibitor is administered once a day. In certain embodiments, the SGLT-2 inhibitor is administered three to one hours before a meal. In certain embodiments, the SGLT-2 inhibitor is administered two hours before a meal.

In certain embodiments, the SGLT-2 inhibitor is administered at a dose of 5-20 mg/day. In certain embodiments, the SGLT-2 inhibitor is administered at a dose of 10 mg/day.

Empagliflozin is rapidly absorbed after oral administration and maximum plasma concentration is observed after 1.5 h of administration, leading to glucosuria for at least 24 hours. Empagliflozin 10 mg is approved for treatment of diabetes mellitus type 2 in Switzerland, and is well tolerated with a favourable safety profile. Therefore, this standard dose was used.

A second aspect of the invention relates to an interleukin-1 -receptor antagonist for use in treatment of prevention of hypoglycaemia in prediabetes.

In certain embodiments, the interleukin-1 -receptor antagonist is anakinra.

Anakinra (CAS NO 143090-92-0; Kineret®; r-metHulL-1 ra, Swedish Orphan Biovitrum AB) is a recombinant, non-glycoslyated form of the human interleukin-1 receptor antagonist (IL-1 Ra). It is commonly administered as a 100 mg/0.67ml solution for SC injection. Anakinra differs from native human IL-1 Ra in that it has the addition of a single methionine residue at its amino terminus. Anakinra consists of 153 amino acids and has a molecularweight of 17.3 kilodaltons, and Anakinra is produced by recombinant DNA technology using an E. coli bacterial expression system. Other forms of this drug that may vary slightly in structure or administration form while having the same biological effect may be used instead.

Mild and transient injection reactions might occur in 20-50% after 2-4 weeks of injections. In the present study, only a single injection was applied and therefore injection site reactions were not expected.

Anakinra is approved for the treatment of rheumatoid arthritis in the US by the FDA as well as in Europe by the EMA and has an acceptable risk / benefit profile in this indication, with more than 100,000 patients treated.

In certain embodiments, the interleukin-1 -receptor antagonist is administered once a day. In certain embodiments, the interleukin-1 -receptor antagonist is administered four to two hours before a meal. In certain embodiments, the interleukin-1 -receptor antagonist is administered three hours before a meal.

In certain embodiments, the interleukin-1 -receptor antagonist is administered at a dose of 50- 200 mg/day. In certain embodiments, the interleukin-1 -receptor antagonist is administered at a dose of 100 mg/day.

Anakinra is rapidly absorbed after subcutaneous administration and maximum plasma concentration is observed after 4 h of administration. Anakinra 100 mg is approved for the treatment of rheumatoid arthritis. Therefore, this standard dose is used.

A third aspect of the invention relates to a non-agonist antibody or antibody-like molecule specifically binding to one of

- IL-1 b or

IL-1 receptor type I or

IL-1 receptor accessory protein (IL1 RAP) for use in treatment of prevention of postprandial (or reactive) hypoglycaemia, particularly in prediabetes.

In certain embodiments, non-agonist antibody or antibody-like molecule specifically binding to one of IL-1 b or IL-1 receptor type I is selected from rilonacept (CAS No. 501081-76-1), canakinumab (CAS No. 914613-48-2), gevokizumab (CAS No. 1129435-60-4), LY2189102 (CAS No. 1376450-71-3), MABpl (CAS No. 1401965-15-8), MEDI-8968, CYT013, slL-1 Rl, slL-1 Rll, EBI-005 (CAS No. 1357527-05-9), CMPX-1023, VX-765 (CAS No. 273404-37-8) and BI-5041 .

In certain embodiments, the term prediabetes, when used to define the present invention, can be characterized by one or several of the following parameters: a. Glycated haemoglobin (HbA1c) 5.7-6.4%; and/or b. Fasting plasma glucose: 6.1-6.9 mmol/l; and/or c. 2 h plasma glucose following ingestion of 75 gr glucose: 7.8-11.0 mmol/l.

Similarly within the scope of the present invention is a method or treating postprandial (or reactive) hypoglycaemia, particularly in prediabetes, in a patient in need thereof, comprising administering to the patient an SGLT-2 inhibitor or an interleukin-1 receptor antagonist protein according to the above description.

Similarly, a dosage form for the prevention or treatment of postprandial (or reactive) hypoglycaemia, particularly in prediabetes, is provided, comprising a SGLT-2 inhibitor or an interleukin-1 receptor antagonist protein according to any of the above aspects or embodiments of the invention.

The skilled person is aware that any specifically mentioned drug may be present as a pharmaceutically acceptable salt of said drug. Pharmaceutically acceptable salts comprise the ionized drug and an oppositely charged counterion. Non-limiting examples of pharmaceutically acceptable anionic salt forms include acetate, benzoate, besylate, bitatrate, bromide, carbonate, chloride, citrate, edetate, edisylate, embonate, estolate, fumarate, gluceptate, gluconate, hydrobromide, hydrochloride, iodide, lactate, lactobionate, malate, maleate, mandelate, mesylate, methyl bromide, methyl sulfate, mucate, napsylate, nitrate, pamoate, phosphate, diphosphate, salicylate, disalicylate, stearate, succinate, sulfate, tartrate, tosylate, triethiodide and valerate. Non-limiting examples of pharmaceutically acceptable cationic salt forms include aluminium, benzathine, calcium, ethylene diamine, lysine, magnesium, meglumine, potassium, procaine, sodium, tromethamine and zinc.

The term hypoglycaemia includes, but is not limited to, symptomatic hypoglycaemia.

Dosage forms may be for enteral administration, such as nasal, buccal, rectal, transdermal or oral administration, or as an inhalation form or suppository. Alternatively, parenteral administration may be used, such as subcutaneous, intravenous, intrahepatic or intramuscular injection forms. Optionally, a pharmaceutically acceptable carrier and/or excipient may be present. Pharmaceutical Compositions and Administration

Another aspect of the invention relates to a pharmaceutical composition comprising a compound of the present invention, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier. In further embodiments, the composition comprises at least two pharmaceutically acceptable carriers, such as those described herein.

In certain embodiments of the invention, the compound of the present invention is typically formulated into pharmaceutical dosage forms to provide an easily controllable dosage of the drug and to give the patient an elegant and easily handleable product.

The pharmaceutical composition can be formulated for oral administration, parenteral administration, or rectal administration. In addition, the pharmaceutical compositions of the present invention can be made up in a solid form (including without limitation capsules, tablets, pills, granules, powders or suppositories), or in a liquid form (including without limitation solutions, suspensions or emulsions).

The dosage regimen for the compounds of the present invention will vary depending upon known factors, such as the pharmacodynamic characteristics of the particular agent and its mode and route of administration; the species, age, sex, health, medical condition, and weight of the recipient; the nature and extent of the symptoms; the kind of concurrent treatment; the frequency of treatment; the route of administration, the renal and hepatic function of the patient, and the effect desired. In certain embodiments, the compounds of the invention may be administered in a single daily dose, or the total daily dosage may be administered in divided doses of two, three, or four times daily.

In certain embodiments, the pharmaceutical composition or combination of the present invention can be in unit dosage of about 1-1000 mg of active ingredient(s) for a subject of about 50-70 kg. The therapeutically effective dosage of a compound, the pharmaceutical composition, or the combinations thereof, is dependent on the species of the subject, the body weight, age and individual condition, the disorder or disease or the severity thereof being treated. A physician, clinician or veterinarian of ordinary skill can readily determine the effective amount of each of the active ingredients necessary to prevent, treat or inhibit the progress of the disorder or disease.

The pharmaceutical compositions of the present invention can be subjected to conventional pharmaceutical operations such as sterilization and/or can contain conventional inert diluents, lubricating agents, or buffering agents, as well as adjuvants, such as preservatives, stabilizers, wetting agents, emulsifiers and buffers, etc. They may be produced by standard processes, for instance by conventional mixing, granulating, dissolving or lyophilizing processes. Many such procedures and methods for preparing pharmaceutical compositions are known in the art, see for example L. Lachman et al. The Theory and Practice of Industrial Pharmacy, 4th Ed, 2013 (ISBN 8123922892).

Wherever alternatives for single separable features are laid out herein as “embodiments”, it is to be understood that such alternatives may be combined freely to form discrete embodiments of the invention disclosed herein.

The invention is further illustrated by the following examples and figures, from which further embodiments and advantages can be drawn. These examples are meant to illustrate the invention but not to limit its scope.

Description of the Fipures Fig. 1 Study flow diagram

Fig. 2 Procedures at each study day

The inventors recently conducted a study in patients with gastric bypass surgery and postprandial hypoglycemia. They could show that glucose-induced IL-1 b leads to an exaggerated insulin response in this condition. Indeed, both the SGLT2-inhibitor empagliflozin and the IL-1 receptor antagonist anakinra reduced postprandial insulin release and prevented hypoglycemia. Moreover, analysis of monocytes revealed a hyper-reactive inflammatory state.

The inventors hypothesize that a similar mechanism may underlie postprandial (or reactive) hypoglycemia as it often occurs in patients with prediabetes. Indeed, patients with a prediabetes have a pathological activation of the innate immune system. This may lead to an IL-1 b mediated over-activation and dysfunction of b-cells. Therefore, similar therapeutic approach using empagliflozin and anakinra may also improve postprandial hypoglycemia of prediabetes. This hypoglycemic events are not a complication of diabetes treatment but due to endogenous overproduction of insulin.

Study outcome

Primary outcome:

Reduction of incidence of symptomatic hypoglycemia following a standardized mixed-meal test defined by acute hypoglycemic symptoms, blood glucose level below 3.0 mmol/l and resolution of symptoms Secondary outcomes:

• Severity of symptoms of hypoglycemia according to the Edinburgh Hypoglycemia Scale

• Nadir plasma glucose

• Changes in the area under the curve (AUC), peak and nadir values, and slopes of: o glucose o insulin o c-peptide o glucagon o GLP-1 o Cortisol o Growth Hormone following a mixed meal.

• changes of inflammatory parameters in supernatants of LPS-stimulated and unstimulated peripheral blood mononuclear cells (IL1 b, IL6, TNF a, IL-10, IL-1 Ra)

• changes of RNAseq in peripheral blood mononuclear cells (PBMC) in subjects o with and without hypoglycemia o under placebo vs. anakinra o under placebo vs. empagliflozin.

Study design

It is a placebo controlled, double-blind, randomized, cross-over proof-of-concept study. Inclusion / Exclusion criteria Inclusion criteria:

• Subjects with prediabetes defined by HbA1c 5.7-6.4 % or IFG (FPG: 6.1-6.9 mmol/l) or IGT (2 h oGTT: 7.8-11.0 mmol/l)

• Hypoglycemia occuring 1 to 4 h following ingestion of a standardized liquid mixed- meal (75 g carbohydrates) and fulfilling the Whipple's triad [appearance of typical symptoms, low plasma glucose (< 3.0 mM, particularly <2.8mM) and relief of symptoms following glucose administration]

• Age > 18 years • For subjects with reproductive potential, willingness to use contraceptive measures adequate to prevent the subject or the subject’s partner from becoming pregnant during the study

Exclusion criteria:

• Upper gastrointestinal surgery

• Diagnosis of any type of diabetes mellitus

• Unstable/unsubstituted thyroid disease

• Hereditary fructose intolerance

• Signs of current infection

• Use of investigational drug up to one week prior to start of treatment phase

• Glucocorticoid therapy

• Neutropenia (leukocyte count < 1.5 * 109/L or ANC < 0.5 * 109/L)

• Anemia (hemoglobin < 11 g/dL for males, < 10 g/dL for females)

• Clinically significant kidney or liver disease (creatinine > 1.5 mg/dL, AST/ALT > 2 ^c ULN, alkaline phosphatase > 2 ^c ULN, or total bilirubin [tBili] > 1.5 * ULN)

• Uncontrolled congestive heart failure

• Uncontrolled malignant disease

• Currently pregnant or breastfeeding

• Known or suspected non-compliance, drug or alcohol abuse

• No subjects meeting the criteria for vulnerability

• Inability to follow the procedures of the study, e.g. due to language problems, psychological disorders, dementia, etc. of the participant,

• Participation in another study with investigational drug within the 30 days preceding and during the present study,

• Previous enrolment into the current study,

Enrolment of the investigator, his/her family members, employees and other dependent persons. Measurements and procedures:

Subjects will be informed about the scope of the study and screened, after written informed consent was given. After an 8 h fasting period, subject will perform an extended (4h) oral mixed-meal test (75 g carbohydrates, Ensure plus® 375 ml, drinking time 5 minutes). If subjects fulfill all requirements, study intervention dates will be scheduled. The preceding first study visit shall take place within 1-21 days after screening.

Subjects will be randomized (see Figure 1) and receive at each of the 3 study days either empagliflozin or anakinra along with the respective placebo or double placebos. Randomization will be done by adapted block randomization by an independent scientific staff member of the University Hospital Basel to ensure equal distribution. Independent study nurses will administer the drugs/placebo to the blind-folded study participant to ensure appropriate masking. The study medication will be dispensed three hours (anakinra or saline injection s.c.) or two hours (empagliflozin or placebo p.o.) before ingestion of the liquid mixed-meal (Ensure plus® 375 ml, 75 g carbohydrates, 562 kcal, drinking time 5 minutes). Patients will be observed over a period of 4 hours with regular clinical and laboratory assessment of hypoglycemia (see Figure 2). Immediately before and 60 min after meal intake peripheral mononuclear cells (PBMCs) will be collected for bulk isolation, in vitro stimulation and RNA sequencing analysis. An extended period of 4 h is necessary to ensure detection of late phase hypoglycemia and for safety reasons. In case of symptomatic hypoglycemia 10 g of glucose (100 ml) will be given intravenously as a bolus and repeated if needed.

Subjects will be dismissed only without hypoglycemic symptoms and with a blood glucose level > 4 mmol/l.

Study participants will receive a financial compensation of 300 CHF at study end for full participation.

Study Product / Intervention:

Standard dose of empagliflozin (Jardiance®; Boehringer Ingelheim GmbH), i. e. 10 mg. Jardiance is an orally available inhibitor of SGLT2 and approved for the treatment of type 2 diabetes mellitus.

Standard dose of anakinra (Kineret®; r-metHulL-1ra, Swedish Orphan Biovitrum AB), i. e. 100 mg s. c. Kineret is approved for the treatment of rheumatoid arthritis.

Control Intervention:

1 ml of saline s. c. (placebo)

Winthrop tablet p.o. (placebo) Number of Participants with Rationale:

The number of participants for the entire study is 12 subjects.

Study Duration:

One year. For each subject: Screening date (4.5 h if mixed-meal test needs to be done otherwise for subjects The number of participants for the entire study is 12 subjects with confirmed postprandial hypoglycemia 1.5 h), three study days (each 7.5 hours) within 14-21 days. A minimum of 4 days in between the study days is required to minimize carry-over effects.

Statistical Considerations: Analysis will be done on a per-protocol basis. Multiple attempts will be made to obtain missing data and reasons for withdrawal will be reported. Missing values will be assumed to be missing at random and imputed using multiple imputation.

Effects will be regarded as statistically significant at a two-sided p-value < 0.05. Analysis of continuous dependent outcome variables will be done using linear mixed effect models fit by maximum likelihood. Analysis of the binary dependent outcome variable occurrence of severe hypoglycemia requiring glucose rescue will be done using a generalized linear additive mixed effect model fit by maximum likelihood (Laplace approximation). Models will be fit including fixed effects for categorical variables such as gender, the occurrence of hypoglycemia, treatment and in case of values measured in cell culture supernatants, activation status (non-stimulated, LPS-simulated), as well as the continuous variables time and BMI as indicated. A random-effect for subject will be equally included (random by subject intercepts, fixed slopes). Models will be computed using R. Treatment effects will be presented as mean effect size estimates with 95% Cls, test-statistics and p-values.

Claims

1. An SGLT-2 inhibitor for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes.

2. The SGLT-2 inhibitor for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to claim 1, wherein said SGLT-2 inhibitor is selected from empagliflozin, canagliflozin, dapagliflozin, ertugliflozin, ipragliflozin, luseogliflozin, sotagliflozin, and tofogliflozin, particularly wherein said SGLT-2 inhibitor is empagliflozin.

3. The SGLT-2 inhibitor for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of the preceding claims, wherein said SGLT-2 inhibitor is administered once a day, particularly three to one hours before a meal, more particularly two hours before a meal.

4. The SGLT-2 inhibitor for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of the preceding claims, wherein said SGLT-2 inhibitor is administered at a dose of 5-20 mg/day.

5. The SGLT-2 inhibitor for use in treatment or prevention postprandial (or reactive) hypoglycaemia of hypoglycaemia in prediabetes according to any one of the preceding claims, wherein the hypoglycaemia is symptomatic hypoglycaemia.

6. An interleukin-1 -receptor antagonist for use in treatment or prevention of postprandial (or reactive) hypoglycaemia hypoglycaemia in prediabetes.

7. The interleukin-1 -receptor antagonist for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to claim 6, wherein said interleukin-1 -receptor antagonist is anakinra.

8. The interleukin-1 -receptor antagonist for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of claims 6 to 7, wherein said interleukin-1 -receptor antagonist is administered once a day, particularly four to two hours before a meal, more particularly three hours before a meal.

9. The interleukin-1 -receptor antagonist for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of claims 6 to 8, wherein said interleukin-1 -receptor antagonist is administered at a dose of 50-200 mg/day.

10. The interleukin-1 -receptor antagonist for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of claims 6 to 9, wherein the hypoglycaemia is symptomatic hypoglycaemia.

11. A non-agonist antibody or antibody-like molecule specifically binding to one of

- IL-1 b or

IL-1 receptor type I

IL-1 receptor accessory protein (IL1 RAP) for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes, particularly symptomatic postprandial (or reactive) hypoglycaemia in prediabetes.

12. The SGLT-2 inhibitor, the interleukin-1 -receptor antagonist or the non-agonist antibody or antibody-like molecule for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of the preceding claims, wherein the prediabetes is characterized by one or several of the following parameters: a. Glycated haemoglobin (HbA1c) 5.7-6.4%; and/or b. Fasting plasma glucose: 6.1-6.9 mmol/l; and/or c. 2 h plasma glucose following ingestion of 75 gr glucose: 7.8-11.0 mmol/l.

13. The SGLT-2 inhibitor, the interleukin-1 -receptor antagonist or the non-agonist antibody or antibody-like molecule for use in treatment or prevention of postprandial (or reactive) hypoglycaemia in prediabetes according to any one of the preceding claims, wherein the postprandial (or reactive) hypoglycaemia is characterized by blood glucose below 2.8 mMol/L.