Proteomic Signatures and Blood Adenosine Triphosphate Levels as Markers of Empagliflozin Efficacy in Type 2 Diabetes Mellitus and Heart Failure

Abstract

Empagliflozin, a sodium-glucose cotransporter 2 inhibitor, is approved for the treatment of type 2 diabetes mellitus and heart failure. Its known ability to enhance mitochondrial adenosine triphosphate production and improve cardiac function led us to investigate whether blood adenosine triphosphate levels could serve as a predictive biomarker for treatment response. This prospective study included 120 patients from Kyrgyzstan: 49 with type 2 diabetes mellitus, 43 with heart failure, and 28 with both type 2 diabetes mellitus and heart failure. The mean age of the study population was 63.9±7.1 years, with no significant age difference between groups. Patients received oral empagliflozin at a dose of either 10 or 25 mg daily for 12 weeks. Adenosine triphosphate activity was measured in erythrocytes from whole blood samples before and after treatment. In vitro assays were also performed, incubating patient blood samples with empagliflozin at concentrations of 0.1, 1, and 10 µM. In patients with type 2 diabetes mellitus, empagliflozin significantly reduced body mass index (p=0.001), though HbA1c levels remained unchanged. Among heart failure patients, treatment resulted in a significant increase in left ventricular ejection fraction (p=0.028) and a decrease in B-type natriuretic peptide levels (p=0.01). Blood adenosine triphosphate concentrations increased significantly following empagliflozin treatment in both type 2 diabetes mellitus and heart failure groups. Proteomic analysis identified 12 differentially expressed proteins—ADIPOQ, ARG1, CST3, CPPED1, GSTO1, FN1, ITIH4, LCN2, LCP1, MIF, PCMT1, and SERPINA3—that are functionally linked to type 2 diabetes mellitus and/or heart failure pathophysiology. Our data suggest that blood adenosine triphosphate activity may serve as a potential biomarker for clinical response to empagliflozin in patients with type 2 diabetes mellitus and heart failure. Further studies are warranted to validate these exploratory findings and to evaluate the sensitivity, specificity, and predictive value of blood adenosine triphosphate as a biomarker in these populations.

Keywords

diabetes mellitus type 2 - cardiometabolic disease - heart failure - empagliflozin - proteomics

Publikationsverlauf

Eingereicht: 08. Juli 2025

Angenommen nach Revision: 06. Oktober 2025

Artikel online veröffentlicht:
17. November 2025

• References

• 1 Diabetes Atlas. 11th edn IDF (International Diabetes Federation). Diabetesatlas.org; 2025
• 2 Einarson TR, Acs A, Ludwig C. et al. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol 2018; 17: 83
• 3 Cavender MA, Steg PG, Smith SC. et al. REACH registry investigators. impact of diabetes mellitus on hospitalization for heart failure, cardiovascular events, and death: outcomes at 4 years from the reduction of atherothrombosis for continued health (REACH) registry. Circulation 2015; 132: 923-931
• 4 Lytvyn Y, Bjornstad P, Udell JA. et al. Sodium glucose cotransporter-2 inhibition in heart failure: potential mechanisms, clinical applications, and summary of clinical trials. Circulation 2017; 136: 1643-1658
• 5 Zinman B, Wanner C, Lachin JM. et al. EMPA-REG OUTCOME investigators. empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015; 373: 2117-2128
• 6 Lee MMY, Brooksbank KJM, Wetherall K. et al. Effect of empagliflozin on left ventricular volumes in patients with type 2 diabetes, or prediabetes, and heart failure with reduced ejection fraction (SUGAR-DM-HF). Circulation 2021; 143: 516-525
• 7 Omar M, Jensen J, Ali M. et al. Associations of empagliflozin with left ventricular volumes, mass, and function in patients with heart failure and reduced ejection fraction: a substudy of the empire HF randomized clinical trial. JAMA Cardiol 2021; 6: 836-840
• 8 Vultaggio-Poma V, Sarti AC, Di Virgilio F. Extracellular ATP: a feasible target for cancer therapy. Cells 2020; 9: 2496
• 9 Ledderose C, Valsami EA, Elevado M. et al. Impaired ATP hydrolysis in blood plasma contributes to age-related neutrophil dysfunction. Immun Ageing 2024; 21: 45
• 10 Ranjbarvaziri S, Kooiker KB, Ellenberger M.. et al. Altered cardiac energetics and mitochondrial dysfunction in hypertrophic cardiomyopathy. Circulation 2021; 144: 21
• 11 Di Virgilio F, Vultaggio-Poma V, Falzoni S, Giuliani AL. Extracellular ATP: A powerful inflammatory mediator in the central nervous system. Neuropharmacology 2023; 224: 109333
• 12 Scheuermann-Freestone M, Madsen PL, Manners D. et al. Abnormal cardiac and skeletal muscle energy metabolism in patients with type 2 diabetes. Circulation 2003; 107: 24
• 13 Panwar A, Malik SO, Adib M, Lopaschuk GD. Cardiac energy metabolism in diabetes: emerging therapeutic targets and clinical implications. Am J Physiol Heart Circ Physiol 2025; 328: 5
• 14 Fu Y, Luo N, Klein RL. et al. Adiponectin promotes adipocyte differentiation, insulin sensitivity and lipid accumulation. J Lipid Res 2005; 46: 1369-1379
• 15 Cong X, Chen X, Shen Q. et al. Serum Cystatin C levels increase with increasing visceral fat area in patients with type 2 diabetes mellitus. Sci Rep 2024; 14: 18638
• 16 Iram S, Mashaal A, Go S. et al. Inhibition of glutathione S-transferase omega 1-catalyzed protein deglutathionylation suppresses adipocyte differentiation. BMB Rep 2023; 56: 457-462
• 17 Lindstrom E, Deis J, Bernlohr DA. et al. Lipocalin 2 in obesity and diabetes: Insights into its role in energy metabolism. Endocrines 2025; 6: 4
• 18 Subramani M, Yun JW. Loss of lymphocyte cytosolic protein 1 (LCP1) induces browning in 3T3-L1 adipocytes via β3-AR and the ERK-independent signaling pathway. Int J Biochem Cell Biol 2021; 138: 106053
• 19 Beard DA, Marzban B, Li OY. Reduced cardiac muscle power with low ATP simulating heart failure. Physiol J 2022; 121 (17) 3213-3223
• 20 Petit P, Hillaire-Buys D, Manteghetti M. et al. Evidence for two different types of P2 receptors stimulating insulin secretion from pancreatic B cell. Br J Pharmacol 1998; 125: 1368-1374
• 21 Lopaschuk GD, Karwi QG, Tian R. et al. Cardiac energy metabolism in heart failure. Circ Res 2021; 128: 1487-1513
• 22 Bayeva M, Gheorghiade M, Ardehali H. Mitochondria as a therapeutic target in heart failure. J Am Coll Cardiol 2013; 61: 599-610
• 23 Sun Q, Karwi QG, Wong N. et al. Advances in myocardial energy metabolism: metabolic remodelling in heart failure and beyond Open Access. Cardiovasc Res 2024; 120: 1996-2016
• 24 Thirunavukarasu S, Jex N, Chowdhary A. et al. Empagliflozin treatment is associated with improvements in cardiac energetics and function and reductions in myocardial cellular volume in patients with type 2 diabetes. Diabetes 2021; 70: 2810-2822
• 25 Cai W, Chong K, Huang Y. et al. Empagliflozin improves mitochondrial dysfunction in diabetic cardiomyopathy by modulating ketone body metabolism and oxidative stress. Redox Biol 2024; 69: 103010
• 26 Chase D, Eykyn TR, Shattock MJ. et al. Empagliflozin improves cardiac energetics during ischaemia/reperfusion by directly increasing cardiac ketone utilization. Cardiovasc Res 2023; 119: 2672-2680
• 27 Hundertmark MJ, Adler A, Antoniades C. et al. Assessment of cardiac energy metabolism, function, and physiology in patients with heart failure taking empagliflozin: the randomized, controlled EMPA-VISION trial. Circulation 2023; 147: 1654-1669
• 28 Harris DD, Sabe SA, Broadwin M. et al. Proteomic profiling of SGLT-2 inhibitor canagliflozin in a swine model of chronic myocardial ischemia. Biomedicines 2024; 12: 588
• 29 Verma S, Rawat S, Ho KL. et al. Empagliflozin increases cardiac energy production in diabetes: novel translational insights into the heart failure benefits of SGLT2 inhibitors. JACC Basic Transl Sci 2018; 3: 575-587
• 30 Lee SH, Min KW, Lee BW. et al. Effect of dapagliflozin as an add-on therapy to insulin on the glycemic variability in subjects with type 2 diabetes mellitus (DIVE): A multicenter, placebo-controlled, double-blind, randomized study. Diabetes Metab J 2021; 45: 339-348
• 31 Begum M, Choubey M, Tirumalasetty MB. et al. Adiponectin: a promising target for the treatment of diabetes and its complications. Life 2023; 13: 221
• 32 Li S, Shin HJ, Ding EL. et al. Adiponectin levels and risk of type 2 diabetes: a systematic review and meta-analysis. JAMA 2009; 302: 179-188
• 33 Wang L, Lei L, Xu T. et al. GSTO1 regulates insulin biosynthesis in pancreatic β cells. Biochem Biophys Res Commun 2020; 524: 936-942
• 34 Christensson AG, Grubb AO, Nilsson JA. et al. Serum cystatin C advantageous compared with serum creatinine in the detection of mild but not severe diabetic nephropathy. J Intern Med 2004; 256: 510-518
• 35 Dou F, Liu Q, Lv S. et al. FN1 and TGFBI are key biomarkers of macrophage immune injury in diabetic kidney disease. Medicine. 2023; 102: 35794
• 36 Bhusal A, Lee WH, Suk K. Lipocalin-2 in diabetic complications of the nervous system: physiology, pathology, and beyond. Front Physiol 2021; 12: 638112
• 37 Shin EM, Neja SA, Fidan K, Shin E. et al. Lymphocyte cytosolic protein 1 (LCP1) is a novel TRAF3 dysregulation biomarker with potential prognostic value in multiple myeloma. Genome Instab Dis 2020; 1: 286-299
• 38 Arishe O, McKenzie J, Priviero F. et al. L-arginase induces vascular dysfunction in old spontaneously hypertensive rats. J Afr Assoc Physiol Sci 2019; 7: 119-127
• 39 Xiong YY, Yepuri G, Forbiteh M. et al. ARG2 impairs endothelial autophagy through regulation of MTOR and PRKAA/AMPK signaling in advanced atherosclerosis. Autophagy 2014; 10: 2223-2238
• 40 Mahdi A, Kovamees O, Checa A. et al. Arginase inhibition improves endothelial function in patients with type 2 diabetes mellitus despite intensive glucose-lowering therapy. J Intern Med 2018; 284: 388-398
• 41 Tengbom J, Cederstrom S, Verouhis D. et al. Arginase 1 is upregulated at admission in patients with ST-elevation myocardial infarction. J Intern Med 2021; 290: 1061-1070
• 42 Khan M, Steppan J, Schuleri KH. et al. Upregulation of arginase-II contributes to decreased age-related myocardial contractile reserve. Eur J Appl Physiol 2012; 112: 2933-2941
• 43 Huo Y, Lai Y, Feng Q. et al. Serum ITIH4 in coronary heart disease: a potential anti-inflammatory biomarker related to stenosis degree and risk of major adverse cardiovascular events. Biomark Med 2022; 16: 1279-1288
• 44 Delrue L, Vanderheyden M, Beles M. et al. Circulating SERPINA3 improves prognostic stratification in patients with a de novo or worsened heart failure. ESC Heart Fail 2021; 8: 4780-4790