Application of sodium-glucose cotransporter 2 inhibitor in preparation of medicine for treatment and / or adjuvant treatment of ascites due to cirrhosis

Abstract

The invention discloses a new application of a sodium-glucose cotransporter 2 inhibitor in preparation of drugs for treatment and / or adjuvant treatment of ascites due to cirrhosis. The sodium-glucose cotransporter 2 inhibitor disclosed by the invention can take effect together with furosemide, effectively increases urine sodium and urine excretion of intractable or intractable ascites due to cirrhosis caused by diuretic resistance, improves the uncomfortable symptoms of abdominal distension of the patients, reduces the total amount of ascites, and is good in treatment effect and free of toxic and side effects. The treatment dilemma that the ascites of the patients cannot be effectively reduced by medicines in the prior art is effectively solved.

Description

Technical Field

[0001] The present invention relates to a new use of a sodium-glucose cotransporter 2 inhibitor, specifically a new use of a sodium-glucose cotransporter 2 inhibitor in combination with furosemide in the preparation of a drug for treating and / or assisting in the treatment of refractory or intractable liver cirrhosis ascites, and belongs to the field of pharmaceuticals. Background Art

[0002] Ascites is the most common complication in patients with decompensated cirrhosis, developing in approximately 5% to 10% of compensated cirrhosis patients annually. Despite its prevalence in healthcare settings, its management remains a significant challenge for physicians. Approximately 30% of patients with cirrhosis with ascites experience a poor prognosis or undergo liver transplantation within one year, and the two-year transplant-free survival rate is just over half. Furthermore, ascites significantly impacts patients' quality of life and represents a significant burden, consuming significant healthcare resources. Unplanned readmission rates within 30 days are as high as 37% to 52%, and in developed countries, the cost of treatment for patients with ascites can exceed $20,000 in the final year of life. Ascites is one of the most common complications of decompensated cirrhosis and is primarily caused by portal hypertension and renal sodium and water retention. Cirrhosis leads to increased portal venous pressure, decreased plasma oncotic pressure, and decreased renal excretion of sodium and water; these factors combine to contribute to the development of ascites. Overactivation of the renin-angiotensin-aldosterone system (RAAS) and upregulation of antidiuretic hormone also play an important role in the formation of ascites.

[0003] Currently, the mainstay of medical treatment for ascites in cirrhosis is two diuretics: the loop diuretic furosemide and the aldosterone receptor antagonist spironolactone. Furosemide has a potent and rapid diuretic effect, achieved by blocking the sodium-potassium-chloride cotransporter 2 (NKCC2) located in the thick ascending limb of the loop of Henle. Blocking NKCC2 increases the sodium ion concentration in the distal convoluted tubule luminal fluid, resulting in an osmotic diuresis. However, this diuretic effect is limited to the acute phase. NKCC2 is also present in the macula densa of the distal convoluted tubule of the kidney. Inhibiting NKCC2 in the macula densa leads to increased renin secretion, further activating the already overactive RAAS, which in turn leads to an adaptive increase in sodium reabsorption in the kidney. As a result, a decrease in urinary sodium excretion can be observed after the first 2-3 days of loop diuretic use, leading to a rapid decrease in diuretic effect, a phenomenon known as the "braking phenomenon." In clinical practice, it has been found that even if the dosage of furosemide is increased (up to a maximum of 160 mg per day), it cannot effectively increase urinary sodium and urine excretion. This situation is called diuretic resistance.

[0004] Spironolactone is a potent mineralocorticoid receptor antagonist (MRAs) and a core treatment for secondary ascites in cirrhosis. Spironolactone is converted to active metabolites in the liver. These metabolites bind to mineralocorticoid receptors in the distal convoluted tubule, thereby blocking aldosterone-sensitive sodium channel proteins, reducing sodium reabsorption in the distal convoluted tubule, leading to increased urinary sodium excretion and a diuretic effect. This slow hepatic conversion process gives the drug a long half-life (approximately 13.8 to 16.5 hours). Impaired liver function in patients with cirrhosis further reduces conversion efficiency, leading to a further prolonged half-life (approximately 23.9 to 126 hours). In clinical practice, this slow metabolism makes it difficult to adjust the spironolactone dose to achieve rapid efficacy. Optimal dose adjustment may take weeks, and electrolyte disturbances related to dose accumulation, such as hyperkalemia, are common during treatment. Furthermore, spironolactone blocks both progesterone and androgen receptors, which can cause amenorrhea in women, impotence in men, and breast development.

[0005] In clinical practice, patients with cirrhosis and ascites are often ineffective or intolerant to standard treatments (such as a low-sodium diet combined with diuretics). Specifically, patients experience uncontrolled ascites accumulation even after adjusting to the maximum dose of a combination of adequate doses of diuretics (such as spironolactone and furosemide); or they are unable to tolerate adequate doses of diuretics due to diuretic-related side effects (such as renal impairment and electrolyte imbalance). This condition is referred to as refractory or intractable ascites.

[0006] Furthermore, these two drugs do not effectively regulate the overactivation of the RAAS, the core cause of ascites in patients with cirrhosis. Therefore, they are clinically considered symptomatic medications for short-term relief of clinical symptoms. Current evidence also suggests that these two drugs do not improve the survival of patients with cirrhosis and ascites.

[0007] In summary, drugs with few side effects, which can improve urinary sodium excretion, increase urine volume, and maintain long-term stable therapeutic effects for patients with cirrhosis and refractory or intractable ascites have always been a hot topic of research for technicians in this field and are also an urgent clinical need. Summary of the Invention

[0008] Based on the above-mentioned problems in the prior art, the present invention provides a novel use of a sodium-glucose co-transporter 2 inhibitor, which is mainly used for preparing a drug for treating and / or assisting in the treatment of ascites caused by liver cirrhosis, and for increasing the efficacy of furosemide in treating and / or assisting in the treatment of ascites caused by liver cirrhosis.

[0009] The first aspect of the present invention provides the use of a sodium-glucose co-transporter 2 inhibitor in the preparation of a drug for treating and / or assisting in the treatment of ascites caused by cirrhosis. In a preferred embodiment, the sodium-glucose co-transporter 2 inhibitor is empagliflozin.

[0010] In some embodiments, the cirrhotic ascites is refractory or intractable cirrhotic ascites.

[0011] A second aspect of the present invention provides use of a sodium-glucose co-transporter 2 inhibitor in combination with furosemide in the preparation of a medicament for treating and / or assisting in the treatment of ascites due to liver cirrhosis.

[0012] A third aspect of the present invention provides the use of a sodium-glucose co-transporter 2 inhibitor in the preparation of a furosemide enhancer, wherein the enhancer is a preparation that increases the efficacy of furosemide in treating and / or assisting in treating ascites caused by cirrhosis.

[0013] The fourth aspect of the present invention provides the use of a sodium-glucose co-transporter 2 inhibitor in the preparation of a drug for inhibiting the progression of liver fibrosis caused by cirrhosis, and the use of a sodium-glucose co-transporter 2 inhibitor combined with furosemide in the preparation of a drug for inhibiting the progression of liver fibrosis caused by cirrhosis.

[0014] In some embodiments, the sodium-glucose co-transporter 2 inhibitor is empagliflozin.

[0015] In some embodiments, the ascites caused by cirrhosis in the combination of a sodium-glucose co-transporter 2 inhibitor and furosemide is refractory or intractable ascites caused by cirrhosis.

[0016] A fifth aspect of the present invention provides a pharmaceutical composition for treating and / or assisting in the treatment of ascites caused by cirrhosis, the composition comprising drug A and drug B, which are packaged separately or mixed; drug A is a sodium-glucose co-transporter 2 inhibitor, and drug B is furosemide.

[0017] In some embodiments, drug A in the above pharmaceutical composition is empagliflozin.

[0018] In some embodiments, the pharmaceutical composition is used to treat and / or assist in the treatment of cirrhotic ascites, which is refractory or intractable cirrhotic ascites.

[0019] The present invention has been confirmed by basic research and clinical studies to have the following beneficial effects:

[0020] (1) The sodium-glucose co-transporter 2 inhibitor of the present invention has an excellent therapeutic effect on ascites caused by cirrhosis, especially refractory or intractable ascites caused by cirrhosis, and can significantly improve the sodium excretion of such patients. It also effectively reduces the dosage of traditional diuretics furosemide and spironolactone. In clinical trials, it was also observed that furosemide and spironolactone could be discontinued after the sixth month of use of empagliflozin, and the clinical efficacy was still good, reducing the patient's dependence on furosemide and spironolactone, reducing the side effects of traditional diuretics on patients, and effectively alleviating the discomfort symptoms caused by ascites in such patients.

[0021] (2) The sodium-glucose co-transporter 2 inhibitor proposed in the present invention can work synergistically with furosemide, significantly increasing the efficacy of furosemide in the treatment and / or adjuvant treatment of ascites due to cirrhosis. In particular, it can effectively increase the urinary sodium and urine volume excretion of patients with refractory or intractable ascites due to cirrhosis, improve the abdominal distension and discomfort symptoms of such patients, reduce the total amount of ascites, and have a good therapeutic effect, effectively solving the treatment dilemma that existing drugs cannot effectively reduce ascites in such patients.

[0022] (3) Continuous use of the present invention, as observed through long-term follow-up, effectively resolves the "braking phenomenon" of existing diuretics, such as a rapid decrease in diuretic effect after continuous use. The present invention also demonstrates excellent therapeutic stability in the treatment of patients with diuretic-resistant, refractory or intractable ascites, with sustained use.

[0023] (4) The present invention has the effect of regulating the over-activation of the RAAS system, and therefore has the potential to be used to improve the long-term prognosis of patients with cirrhosis and ascites.

[0024] (5) The experimental data of the present invention show that the combined treatment of empagliflozin and furosemide can inhibit the progression of liver fibrosis in cirrhosis. BRIEF DESCRIPTION OF THE DRAWINGS

[0025] Figure 1 Immunohistochemical staining of SGLT2 in the kidneys of rats with cirrhosis and ascites and control rats;

[0026] Figure 2 Immunofluorescence staining of SGLT2 in the kidneys of rats with cirrhosis and ascites, rats with cirrhosis and ascites plus renal denervation, and control rats.

[0027] Figure 3 Western blot analysis of SGLT2 in rats with cirrhosis and ascites, rats with cirrhosis and ascites plus renal denervation, and control rats (SGLT2 1:500; B-ACTIN 1:50000; Goat Anti-Rabbit HRP 1:15000);

[0028] Figure 4qPCR transcript levels of SGLT2 in rats with cirrhosis and ascites, rats with cirrhosis and ascites + renal denervation, and control rats;

[0029] Figure 5A The changes of urine sodium / urine creatinine ratio in the liver cirrhosis modeling group;

[0030] Figure 5B The changes of urine sodium / urine creatinine ratio in the cirrhosis + renal denervation model group;

[0031] Figure 6A The norepinephrine hormone levels in rats with cirrhosis and cirrhosis + renal denervation;

[0032] Figure 6B The norepinephrine hormone levels in rats with cirrhosis and cirrhosis + renal denervation;

[0033] Figure 6C The norepinephrine hormone levels in rats with cirrhosis and cirrhosis + renal denervation;

[0034] Figure 7 The daily changes in urine sodium concentration before and after the use of empagliflozin combined with furosemide;

[0035] Figure 8 The changes in daily urinary total sodium chloride excretion before and after the use of empagliflozin combined with furosemide;

[0036] Figure 9 The change in daily urine sodium / urine creatinine ratio before and after the use of empagliflozin combined with furosemide;

[0037] Figure 10 The changes in daily urine volume before and after the use of empagliflozin combined with furosemide;

[0038] Figure 11 This is the urinary sodium excretion fraction of the two groups of patients in the first experiment of the present invention during their hospital stay;

[0039] Figure 12 The total urine sodium in 24 hours of the two groups of patients in the first experiment of the present invention;

[0040] Figure 13 This is a graph showing the dynamic changes in urine volume over 24 hours in two groups of patients in Experiment 1 for verifying the present invention;

[0041] Figure 14 This is a graph showing changes in the pleural effusion drainage volume and ascites drainage volume of patients in Experiment 2 for verifying the present invention. DETAILED DESCRIPTION

[0042] To facilitate understanding of the present invention, the present invention will be described more fully below with reference to the accompanying drawings. Preferred embodiments of the present invention are shown in the accompanying drawings. However, the present invention may be implemented in many different forms and is not limited to the embodiments described herein. Rather, these embodiments are provided to provide a more thorough and comprehensive understanding of the present disclosure.

[0043] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as those commonly understood by those skilled in the art of the present invention. The terms used in this specification of the present invention are only for the purpose of describing specific embodiments and are not intended to limit the present invention.

[0044] In the present invention, the technical features described in an open manner include closed technical solutions composed of the listed features, and also include open technical solutions containing the listed features.

[0045] Unless otherwise specified, all embodiments and optional embodiments of the present invention can be combined with each other to form a new technical solution. Unless otherwise specified, all technical features and optional technical features of the present invention can be combined with each other to form a new technical solution.

[0046] Unless otherwise specified, all steps of the present invention may be performed sequentially or randomly, but are preferably performed sequentially.

[0047] The sources of drugs used in this embodiment are:

[0048] 1. Sodium-glucose cotransporter 2 inhibitors (SGLT2)

[0049] (1) The sodium-glucose co-transporter 2 inhibitor SGLT2 used in this example is empagliflozin, which is a commercially available drug approved by my country's National Medical Products Administration.

[0050] (2) Purchase source: Empagliflozin, trade name "Otangjing", manufacturer: Boehringer Ingelheim, Germany. Active ingredient: Empagliflozin.

[0051] (3) Chemical name: (1S)-1,5-Anhydro-1-C-[4-chloro-3-[[4-[[(3S)-tetrahydro-3-furo

[0052] [Methyl]phenyl]-D-glucitol.

[0053] (4) Chemical structure:

[0054]

[0055] Molecular formula: C 23 H 27 ClO7

[0056] Molecular weight: 450.91

[0057] (5) The present invention recommends the use of the following for patients with cirrhosis and refractory / intractable ascites: Each tablet of the empagliflozin described herein contains 10 mg of the drug. Usage: Oral administration, one tablet once or twice daily. Furosemide used in the present invention is a clinically known, approved, and commercially available diuretic.

[0058] 2. Furosemide:

[0059] (1) Furosemide used in the practice of the present invention is a commercially available approved drug.

[0060] Furosemide tablets, also known as furosemide and furosemide, active ingredient: furosemide.

[0061] (2) Chemical name: 2-[(2-furylmethyl)amino]-5-(sulfamoyl)-4-chlorobenzoic acid.

[0062] (3) Chemical structure:

[0063]

[0064] Molecular formula: C 12 H 11 ClN2O5S

[0065] Molecular weight: 330.74

[0066] 3. Spironolactone:

[0067] (1) The spironolactone used in the practice of the present invention is a commercially available approved drug.

[0068] (2) Chemical name: 17α-hydroxy-3-oxo-7α-acetylthio-17β-pregn-4-ene-21-carboxylic acid γ-lactone.

[0069] (3) Chemical structure:

[0070]

[0071] Molecular formula: C 24 H 32 O4S

[0072] Molecular weight: 416.573

[0073] The efficacy experiment of the present invention is divided into three parts. The first part is a basic study that confirms that SGLT2 expression increases in the liver cirrhosis ascites model, and its inhibition can improve the urinary sodium and urine volume excretion of the liver cirrhosis ascites model. At the same time, it confirms that SGLT2 inhibitors can regulate the excessive activation of RAAS in rats with liver cirrhosis ascites model. The second part is a clinical study, in which a small sample validation cohort observation was conducted on patients with refractory ascites of liver cirrhosis and diabetes. It was found that empagliflozin + furosemide can effectively increase urinary sodium and urine volume excretion, and improve ascites symptoms compared with the conventional treatment regimen of furosemide + spironolactone. The third part is the efficacy verification part, which recruits validation set sample cases for a randomized controlled study to clarify the effect of empagliflozin on improving urinary sodium excretion in patients with liver cirrhosis ascites and the effect of reducing and withdrawing traditional diuretics.

[0074] Example 1 Basic research part of the efficacy experiment of the present invention

[0075] 1. Materials and Methods

[0076] Four-week-old SD rats (Weitonglihua) were divided into three groups: initial group, cirrhosis ascites model group (N=12), cirrhosis ascites + renal denervation model group (N=14), and control group (N=7).

[0077] 2. Experimental methods:

[0078] Before initiating the cirrhosis model, rats in the cirrhosis + renal denervation group (hereafter referred to as the cirrhosis + RDN group) underwent renal denervation. Following surgery, rats in the cirrhosis + ascites group (hereafter referred to as the cirrhosis group) and the cirrhosis + RDN group received intraperitoneal injections of carbon tetrachloride for 13 weeks and then received a 1% sodium saline diet for one week. During the saline diet, each rat began receiving oral furosemide (10 mg / kg). After one week of 1% sodium saline diet and furosemide intervention, rats in the cirrhosis and cirrhosis + RDN groups were placed in metabolic cages for 9 hours daily. Each morning upon entering the metabolic cage, half of the rats in the cirrhosis group received oral furosemide (10 mg / kg), while the other half received oral furosemide (10 mg / kg) plus empagliflozin (10 mg / kg). Similarly, half of the rats in the cirrhosis + RDN group continued to receive the original dose of furosemide (10 mg / kg), while the other half received oral furosemide (10 mg / kg) plus empagliflozin (10 mg / kg). Urine was collected every 3 hours for a total of 3 times per metabolic cage day. Total urinary sodium excretion and the dynamic changes in urine sodium and urine creatinine were measured over a 9-hour period. The metabolic cage intervention lasted for 5 days, and the rats were sacrificed on the 6th day.

[0079] Statistics: Continuous data are expressed as mean ± standard deviation (x ± s), and enumeration data are expressed as percentages. Intergroup comparisons of continuous data were performed using the independent sample t-test; comparisons among the three groups were performed using analysis of variance; pre- and post-intervention comparisons were performed using the paired t-test; and enumeration data were performed using the chi-square test or Fisher's exact test. P < 0.05 was considered statistically significant.

[0080] 3. Experimental results and analysis

[0081] 1. The expression of SGLT2 in the kidneys of rats in the cirrhosis group was increased

[0082] Due to death during the modeling process, a total of 8 rats in the cirrhosis group (4 in the empagliflozin + furosemide group and 4 in the furosemide group) completed the metabolic cage, and a total of 10 rats in the cirrhosis + RDN group (5 in the empagliflozin + furosemide group and 5 in the furosemide group) completed the metabolic cage. There was no death in the control group. After the modeling intervention, the rats were killed, and immunohistochemical staining of the kidneys showed that the degree of SGLT2 immunohistochemical staining on the lumen side of the proximal convoluted tubules of the kidneys of the cirrhosis group rats was significantly higher than that of the control rats. Figure 1 As shown, the left picture is the control group, and the right picture is the liver cirrhosis model group. It can be seen that the SGLT2 immunohistochemical staining on the proximal lumen side of the renal tubules is significantly higher than that of the control group. Immunofluorescence also shows that the fluorescence intensity of SGLT2 on the lumen side of the renal proximal tubules is significantly higher than that of the control rats, as shown in Figure 2. Figure 2 As shown, Figure 2 The left image in the middle is the control group, and the right image is the cirrhosis model group. It can be seen that the SGLT2 fluorescence level on the proximal lumen side of the renal tubule is significantly higher than that in the control group. Western Blot analysis of SGLT2 protein showed that the expression of SGLT2 protein in the cirrhosis group was significantly increased. The expression of SGLT2 protein in the cirrhosis + RDN group was lower than that in the cirrhosis group, but higher than that in the control group. Figure 3 As shown in Figure 2, qPCR analysis showed that the transcription level of SGLT2 in the cirrhosis group was lower than that in the control group, and the transcription level of SGLT2 in the cirrhosis + RDN group was lower than that in the cirrhosis group, but higher than that in the control group. Figure 4 As shown,.

[0083] These results confirm that SGLT2 transcription and expression levels are increased in the renal proximal tubules of non-diabetic rats with cirrhosis and ascites. This validation lays the foundation for subsequent intervention with SGLT2 inhibitors.

[0084] 2. SGLT2 inhibitors effectively increase urinary sodium excretion in rats with cirrhosis and ascites

[0085] After modeling, the cirrhosis group had significantly lower urine sodium / creatinine ratios than the control group and the cirrhosis + RDN group. After a week of feeding the rats with 1% sodium chloride saline plus furosemide, continued oral administration of furosemide did not effectively increase urinary sodium excretion. However, furosemide combined with empagliflozin significantly increased urinary sodium excretion, and this increase remained significant throughout the intervention. No decrease in urinary sodium excretion was observed over time during the 5-day observation period.

[0086] The total urinary sodium excretion in the 9-hour baseline of the cirrhosis group after modeling was lower than that in the control group and the cirrhosis + RDN group. After one week of feeding with 1% sodium chloride saline and furosemide, the rats continued to be gavaged with furosemide, but it did not effectively increase the total urinary sodium excretion. However, the urine sodium / urine creatinine ratio of the cirrhosis group increased significantly after the intervention of empagliflozin combined with furosemide. Figure 5A and Figure 5B As shown, Figure 5A Figure 2 shows the change in urine sodium / creatinine ratio in the cirrhosis model group. LC+Empag represents the cirrhosis model rats treated with empagliflozin plus furosemide, while LC+Furo represents the cirrhosis model rats treated with furosemide. The figure shows that urinary sodium excretion was significantly higher with empagliflozin plus furosemide compared to furosemide alone. Figure 5B Changes in the urine sodium / urine creatinine ratio in the cirrhosis + renal denervation model group. R+Empag represents rats undergoing renal denervation and treated with empagliflozin plus furosemide, while R+Furo represents rats undergoing renal denervation and treated with furosemide. The figure shows that empagliflozin plus furosemide significantly increased urinary sodium excretion compared to furosemide alone.

[0087] The degree of liver fibrosis in the cirrhosis + RDN group was milder than that in the simple cirrhosis group. At the same time, the levels of RAAS hormones in the cirrhosis + RDN group were lower than those in the cirrhosis group before entering the metabolic cage. After the intervention of empagliflozin combined with furosemide, the levels of RAAS hormones in the cirrhosis group decreased compared with the baseline, and were also lower than those in the cirrhosis group after the intervention of furosemide. Figure 6A 、 6B As shown in 6C, Figure 6A Norepinephrine levels in rats with cirrhosis and cirrhosis + renal denervation. The figure shows that the baseline norepinephrine level in the cirrhosis group (Cirrhosis) was higher than that in the cirrhosis + renal denervation group (Cirrhosis+RDN). After 5 days of empagliflozin + furosemide (SGLT2+Furosamide) intervention, the norepinephrine levels in both groups decreased, while the norepinephrine level in the group receiving furosemide alone did not change significantly. Figure 6BNorepinephrine levels in rats with cirrhosis and cirrhosis + renal denervation. The figure shows that the baseline circulating angiotensin II (AngII) level in the cirrhosis group (Cirrhosis) was higher than that in the cirrhosis + renal denervation group (Cirrhosis+RDN). After 5 days of empagliflozin + furosemide (SGLT2+Furosamide) intervention, the circulating angiotensin II level in the cirrhosis group decreased. However, there was no significant change in the circulating angiotensin II level in the cirrhosis group rats receiving furosemide (Furosamide) alone. Figure 6C Norepinephrine levels in rats with cirrhosis and cirrhosis + renal denervation. The figure shows that the baseline plasma total renin level in the cirrhosis group (Cirrhosis) was higher than that in the cirrhosis + renal denervation group (Cirrhosis+RDN). After 5 days of empagliflozin + furosemide (SGLT2+Furosamide) intervention, the plasma total renin level in both groups decreased, while the plasma total renin level in the group receiving furosemide alone did not change significantly.

[0088] In summary, oral administration of furosemide to rats did not effectively increase urinary sodium excretion. However, empagliflozin, a drug of the present invention, was effective in increasing urinary sodium excretion in rats with cirrhosis and ascites that had already received a loading dose of furosemide. Furthermore, after combined treatment with empagliflozin and furosemide, RAAS hormone levels in rats with cirrhosis were lower than those in rats receiving furosemide alone. Furthermore, RAAS hormone levels decreased in rats in the cirrhosis + RDN group, suggesting that the combination of empagliflozin and furosemide can inhibit the progression of liver fibrosis in cirrhotic rats.

[0089] Example 2 Clinical research part of the efficacy experiment of the present invention

[0090] Recruitment and informed consent of study subjects

[0091] A total of 5 patients aged ≥18 years will be recruited to participate in the study. The study started in June 2023, and all participants were diagnosed with decompensated cirrhosis and refractory ascites. Patients who meet the following inclusion criteria will be screened for inclusion. Cirrhosis of the liver with ascites will be screened by the principal investigator and outpatient physicians, and patients who are planned to be hospitalized for cirrhosis of the liver with ascites will be recruited from outpatient clinics, and written informed consent will be obtained from the participants. The diagnosis of refractory ascites requires at least one of the following three conditions:

[0092] Diuretic ineffectiveness: Even with adequate diuretic doses (e.g., spironolactone at least 100 mg / day and furosemide at least 40 mg / day), the patient's ascites cannot be effectively controlled. Effective control of ascites usually means a daily weight loss of about 0.5 kg (for patients without edema) or 1 kg (for patients with edema);

[0093] Diuretic intolerance: Patients cannot tolerate appropriate diuretic treatment and may experience worsening renal function, electrolyte imbalance (especially hyponatremia or hypokalemia), increased creatinine, or other serious adverse reactions even at low doses;

[0094] Recurrent ascites accumulation: Even after large amounts of ascites have been drained and the patient has received the maximum tolerated dose of diuretics, ascites can rapidly accumulate again in a short period of time.

[0095] 1. Inclusion criteria:

[0096] Subjects must meet all of the following inclusion criteria to be eligible for this study:

[0097] ①Age 18-65 years old.

[0098] ② Weight (including ascites) greater than or equal to 50 kg, and body mass index (BMI) ≥ 18 and

[0099] BMI≤35.

[0100] ③ Relatively stable patients with decompensated cirrhosis and ascites (identified by senior hepatologists), defined as patients whose spironolactone and furosemide doses have remained relatively stable for the past three months, with either drug increasing by no more than 100% or decreasing by no more than 50% during this period, without effective resolution of ascites (ascites failing to steadily decrease to below moderate volume), and with no change in diuretic dose in the two weeks prior to enrollment.

[0101] ④ estimated glomerular fltration rate (eGFR) ≥45 mL·min-1·1.73m-2.

[0102] ⑤ Have the ability to make independent judgments and can sign informed consent independently.

[0103] 2. Exclusion criteria

[0104] Subjects who meet any of the following criteria are not eligible for inclusion in this study:

[0105] ①Systolic blood pressure is less than 95 mmHg or diastolic blood pressure is less than 60 mmHg.

[0106] ② The patient has had esophageal / gastric varicose vein bleeding within 3 months.

[0107] ③ Suffered from hepatic encephalopathy of grade II or above within 3 months.

[0108] ④Patients with advanced liver cancer.

[0109] ⑤ Those who have been addicted to alcohol or drugs in the past 6 months.

[0110] ⑥ Those who had consumed alcohol in the 2 weeks before enrollment.

[0111] ⑦Used SGLT2 inhibitors in the past 3 months.

[0112] ⑧ Patients with a MELD score greater than 20 or an expected median life expectancy of less than 6 months.

[0113] ⑨Anemia, hemoglobin less than 8g / dL.

[0114] ⑩ Use of diuretic or diuretic drugs other than spironolactone and furosemide, such as tolvaptan or thiazide diuretics, in the past 2 weeks.

[0115] There is heart failure with significantly reduced left ventricular ejection function, BNP greater than 1000ng / ml or left ventricular ejection fraction less than 40% within 3 months.

[0116] The presence of abnormal bladder function, severe prostatic hyperplasia, or urinary incontinence.

[0117] Urinary tract infection occurred 3 months before enrollment, or urinary tract infection, such as pyelonephritis or cystitis, was indicated during enrollment screening.

[0118] Currently participating in other clinical trials.

[0119] 3. Early Termination Criteria

[0120] ① Severe hypotension occurs during the study, with systolic blood pressure lower than 85 mmHg or systolic blood pressure decreased by 10% compared with the patient's screening period.

[0121] ②Symptomatic hypoglycemia events occur.

[0122] ③ Metabolic acidosis / ketoacidosis occurs.

[0123] ④ Electrolyte imbalance worsens and is difficult to correct through clinical medical intervention.

[0124] ⑤ New abdominal infection or urinary tract infection.

[0125] ⑥ New symptoms of lower limb arterial ischemia.

[0126] ⑦The patient requested to withdraw from the study.

[0127] ⑧The dose of diuretics increased by more than 100% during the study period.

[0128] ⑨Use tolvaptan during the study.

[0129] ⑩ Terlipressin was used during the study.

[0130] During the study, creatinine increased by more than 50% of baseline or the absolute value exceeded 132umol / L, accompanied by a significant decrease in urine volume.

[0131] Patients are not suitable for study continuation due to progression of the underlying disease or complications, or the development of an unidentified disease, such as hepatic encephalopathy or upper gastrointestinal bleeding.

[0132] 1. This study is a prospective, open-label, single-arm, before-after controlled study

[0133] Patients with cirrhosis and refractory ascites were recruited and given basic treatment, including conventional diuretics and albumin infusion. For tense ascites, drainage was performed. The observation period was 8 days. The first 3 days were routine treatment. Starting in the morning of the 4th day, patients were given oral empagliflozin (Otangjing) 10 mg combined with furosemide 20 mg daily. The remaining patients received no conventional treatment. The criteria for refractory ascites were based on the criteria specified by the European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010; 53(3): 397-417.

[0134] For specimen collection, the patient collected all urine every 24 hours, measured the mixed urine at 8 a.m. the next day, and drew a tube for testing.

[0135] Evaluation: Daily urine volume was collected to monitor urinary sodium excretion. Weight and changes were also monitored daily. Abdominal circumference was measured on the first and eighth days of hospitalization to observe changes in abdominal circumference. Average urine sodium, urine sodium / urine creatinine, and urine volume for days 1-3 of hospitalization were compared with those for days 4-8. Weight and ascites volume were measured by ultrasound (day 1 and day 8).

[0136] At the same time, the total daily urine sugar excretion was evaluated and the daily urinary calorie loss was calculated.

[0137] Safety Assessment: Blood pressure was measured daily. The study was terminated immediately if systolic blood pressure dropped below 90 mmHg or diastolic blood pressure dropped below 55 mmHg. Patients were observed for vulvar infections. Patients were observed for symptomatic hypoglycemia or for random capillary blood glucose levels dropping below 3.8 mmol / L during hospitalization.

[0138] Statistics:

[0139] Descriptive statistical analysis was performed on the baseline characteristics of all participants. Continuous variables (such as age, urine volume, urinary sodium excretion, and volume of pleural and ascites fluid) were presented using mean ± standard deviation (SD). If the data distribution did not conform to a normal distribution, the median and interquartile range (IQR) were used. Categorical variables (such as gender and comorbidities) were presented using frequency and percentage.

[0140] For the main study variables (urinary sodium excretion, urine volume, pleural and ascites volume), the paired sample t-test or Wilcoxon signed-rank test will be used to compare the changes before and after treatment. This depends on whether the data conform to the normal distribution. Before the test, the Shapiro-Wilk test will be used to assess the normality of the data. The comparison before and after treatment will be based on the amount of change for each patient (post-test value minus pre-test value). For all significant results, the effect size (such as Cohen's d) and its 95% confidence interval will be calculated to assess the clinical significance of the changes before and after treatment. Missing data handling will clearly record any missing data. If the amount of missing data is small and lower than the corresponding value, pairwise deletion can be considered. If the data are missing randomly, multiple imputation methods will be used to fill in the missing data.

[0141] Safety Data: Continuous safety indicators (e.g., blood pressure): If normal distribution is observed, repeated measures ANOVA or mixed effects model should be used to compare changes in blood pressure at different time points. If data do not conform to normal distribution, Friedman test (a nonparametric method) should be used for comparison. Categorical safety indicators (e.g., incidence of hypoglycemic events): McNemar test or Cochran's Q test should be used to compare differences in two or more related sample ratios. For comparisons between two time points, especially when event rates are low, Fisher's exact test should be used.

[0142] Statistical software was R 4.12 or SPSS 26.0. The significance level for all hypothesis tests was set at a two-sided test α = 0.05.

[0143] 2. Experimental results and analysis

[0144] This study was approved by the Ethics Committee of Beijing You'an Hospital, Capital Medical University.

[0145] Data were collected from patients who visited the ward of Beijing You'an Hospital affiliated to Capital Medical University from October 2023 to February 2024, and all patients signed informed consent.

[0146] A total of five eligible patients with cirrhosis and refractory ascites were enrolled. No patients dropped out during the study. Four patients had hepatitis B cirrhosis and one had alcoholic cirrhosis. Four were male and one was female, with a mean age of 62 ± 11 years, a mean history of liver disease of 8 ± 5 years, and a mean history of ascites of 3 ± 1 year. All patients had Child-Class C liver function test results, and two had pleural effusions. Diuretic doses on admission were 40-80 mg furosemide and 100-200 mg spironolactone daily.

[0147] 1) Before and after comparison of urinary sodium excretion.

[0148] The average urine sodium value of the five patients was 35.23±11.45 when they received the standard treatment without empagliflozin three days before admission. Starting from the fourth day, they received 10 mg of empagliflozin combined with 20 mg of furosemide daily for a total of 5 days. The average urine sodium value during the five days was 59.83±14.49, and the difference before and after was statistically significant (P<0.001). Figure 7 As shown in the before-after observation, the 1st to 3rd day was routine treatment (including furosemide alone), and the 4th to 8th day was empagliflozin + furosemide intervention day. Mixed effect model analysis showed that the urine sodium concentration of patients after intervention was significantly increased compared with that before intervention.

[0149] (P<0.05), and the urine sodium concentration increased steadily without attenuation over 5 days.

[0150] Table 1 Changes in urine sodium in patients during the study period

[0151]

[0152] *Day 4 is the dosing day. Urine sodium data were measured 6 hours after dosing. The remaining urine sodium data were collected at 6 am in the morning.

[0153] 2) Comparison of total sodium chloride excretion in 24-hour urine before and after

[0154] Three days before admission, the five patients received standard treatment without empagliflozin, and the average total urinary sodium chloride excretion per 24 hours was 1.99±0.79. Starting on the fourth day, they received empagliflozin 10 mg combined with furosemide 20 mg daily for 5 days. The average total urinary sodium chloride excretion per 24 hours during the 5 days was 4.50±1.48. The difference before and after the intervention was statistically significant (P<0.001).

[0155] 0.001) Figure 8 As shown, Figure 8The changes in daily urinary total sodium chloride excretion before and after the use of empagliflozin combined with furosemide were observed. Days 1-3 were routine treatment (including furosemide alone), and days 4-8 were empagliflozin + furosemide intervention days. Mixed effect model analysis showed that the total sodium chloride excretion in the urine of patients per 24 hours after the intervention was significantly increased compared with that before the intervention.

[0156] (P<0.001), and the excretion volume increased steadily without attenuation.

[0157] Table 2 Changes in 24-hour total urinary sodium excretion in patients during the study period

[0158]

[0159] *Day 4 is the dosing day

[0160] 3) Comparison of urine sodium / urine creatinine values ​​before and after

[0161] Three days before admission, when the five patients received standard treatment without empagliflozin, the average urine sodium / urine creatinine*100 value was 0.80±0.30. Starting on the fourth day, they received empagliflozin 10 mg combined with furosemide 20 mg daily for 5 days. The average urine sodium / urine creatinine*100 value over the five days was 1.69±0.53, and the difference before and after the intervention was statistically significant (P<0.001). Figure 9 As shown, Figure 9 The study compared the daily urine sodium / creatinine ratio before and after the use of empagliflozin combined with furosemide. Days 1-3 were routine treatment (including furosemide alone), while days 4-8 were intervention days for empagliflozin plus furosemide. Mixed-effects model analysis showed a significant increase in urine sodium / creatinine ratio after the intervention compared with the pre-intervention period (P < 0.001), with a steady increase and no attenuation.

[0162] Table 3 Changes in urine sodium and urine creatinine during the study period

[0163]

[0164] *Day 4 is the dosing day

[0165] IV) Comparison of 24-hour urine excretion before and after

[0166] The five patients received standard treatment without empagliflozin for three days before admission, with an average urine output of 940 ± 199 per 24 hours. Starting on the fourth day, they received empagliflozin 10 mg combined with furosemide 20 mg daily for five days. The average urine output per 24 hours during the five days was 1296 ± 297. A mixed-effects model showed a slight increase in urine output before and after the intervention, with a statistically significant difference (P < 0.001). Figure 10Figure 2 shows the daily urine volume changes before and after the use of empagliflozin combined with furosemide. Days 1-3 were routine treatment (including furosemide alone), while days 4-8 were intervention days for empagliflozin plus furosemide. Mixed-effects model analysis showed a significant increase in urine volume after the intervention compared to before (P < 0.001), with the increase remaining stable and showing no signs of fading.

[0167] Table 4 Changes in 24-hour urine volume during the study period

[0168]

[0169] *Day 4 is the dosing day

[0170] 5) Changes in the amount of pleural and abdominal fluid at admission and discharge

[0171] The five patients described above were hospitalized for an average of 13 ± 5 days. On day 8, the volume of ascites in all patients had significantly decreased compared to admission, with no signs of recurrent increases. Considering the patient benefit, empagliflozin plus furosemide was continued until discharge. At discharge, all patients had minimal or only physiological ascites.

[0172] Table 5 Changes in the amount of pleural and abdominal fluid in patients during the study period

[0173]

[0174] In the table above, a large amount of pleural effusion is 2 points, a small amount is 1 point, and no pleural effusion is 0 points. A large amount of ascites is 3 points, a moderate amount of ascites is 2 points, a small amount of ascites is 1 point, and no ascites is 0 points. The score is the pleural effusion score + the ascites score.

[0175] 6) Safety Record

[0176] All patients did not experience symptoms of hypoglycemia, urinary tract infection, or hypotension while taking empagliflozin + furosemide until discharge.

[0177] Summary: The results suggest that after the empagliflozin + furosemide intervention, urinary sodium and total urinary sodium excretion increased significantly, and there was an increasing trend in urine excretion, but it was not statistically significant. This suggests that the empagliflozin + furosemide combination can alleviate patients' sodium retention. In addition, the study found that urinary sodium excretion did not gradually decrease over time during the intervention, suggesting that this combination did not experience the "braking" phenomenon seen with furosemide alone, that is, the attenuation of diuretic efficacy. In addition, this small cohort study also found no additional adverse reactions when empagliflozin was used in patients with cirrhosis.

[0178] Example 3 Efficacy verification experiment 1 of the present invention

[0179] The inventors recruited patients with diabetes and ascites due to liver cirrhosis at Beijing You'an Hospital affiliated to Capital Medical University and Baoding People's Hospital and conducted a randomized controlled study to determine the effect of empagliflozin on improving urinary sodium excretion in patients with diabetes and ascites due to liver cirrhosis.

[0180] A total of 11 patients in the control group were included in this validation experiment. They received conventional medical treatment; 10 patients in the empagliflozin group received 10 mg of empagliflozin orally daily on the basis of conventional medical treatment.

[0181] Experimental results: We found that the urinary sodium excretion fraction, 24-hour total urine sodium and 24-hour urine volume of patients using empagliflozin showed the above trend. In addition, the study found that the need for diuretics in the empagliflozin group was lower than that in the control group after treatment (Table 6). The dynamic changes of urinary sodium excretion fraction, 24-hour total urine sodium and 24-hour urine volume in the two groups of patients during their hospital stay were as follows: Figure 11 、 12 and 13.

[0182] Table 6 Diuretic use in the empagliflozin group and the control group in the controlled study

[0183]

[0184] Example 4: Experiment 2 for verifying the efficacy of the present invention

[0185] The inventors also conducted a before-and-after study at Beijing You'an Hospital affiliated with Capital Medical University on a patient with diabetes and refractory cirrhosis with ascites to evaluate the effects of empagliflozin monotherapy on proximal sodium reabsorption and diuretic requirements. The patient had decompensated cirrhosis and massive pleural and ascites. Prior to admission, he had been taking a long-term oral regimen of spironolactone 120 mg / day and furosemide 40 mg / day, and still required weekly paracentesis. After admission, he received oral empagliflozin 10 mg once daily in addition to conventional medical treatment.

[0186] The observation results showed that after the initiation of empagliflozin, the patient's urinary sodium excretion fraction (FENa), 24-hour total urinary sodium and 24-hour urine volume all showed a continuous upward trend. Specifically, FENa increased from 0.10% at baseline to 0.43% on the 14th day and 1.00% at the 4th week. In sync with sodium excretion, 24-hour urinary sodium increased from 29.2mmol to 125.4mmol, and 24-hour urine volume also increased significantly. From the 4th week, spironolactone was reduced to 80mg / d and furosemide to 20mg / d; both diuretics were discontinued at week 12. After six months of continuous use of empagliflozin, the ascites and pleural effusion disappeared completely, and there was no hypotension, electrolyte imbalance or deterioration of renal function, as shown in Table 7 and Figure 14 shown.

[0187] This case provides direct clinical evidence that "empagliflozin can significantly improve sodium excretion in patients with refractory cirrhotic ascites and achieve withdrawal of traditional diuretics", and strengthens the external reproducibility of the results of randomized controlled trials.

[0188] Table 7 Six-month follow-up results of empagliflozin for refractory ascites in cirrhosis

[0189]

Claims

1. Use of a sodium-glucose co-transporter 2 inhibitor in the preparation of a drug for the treatment and / or adjuvant treatment of ascites caused by cirrhosis.

2. The use according to claim 1, characterized in that The sodium-glucose co-transporter 2 inhibitor is empagliflozin.

3. The use according to claim 1 or 2, characterized in that The liver cirrhosis ascites is refractory or intractable liver cirrhosis ascites.

4. Use of a sodium-glucose co-transporter 2 inhibitor combined with furosemide in the preparation of a drug for the treatment and / or adjuvant treatment of ascites caused by cirrhosis.

5. Use of a sodium-glucose cotransporter 2 inhibitor in the preparation of a furosemide synergist, characterized in that: The synergist is a preparation that increases the efficacy of furosemide in treating and / or assisting in treating ascites caused by liver cirrhosis.

6. The use according to claim 4 or 5, characterized in that The sodium-glucose co-transporter 2 inhibitor is empagliflozin.

7. Use of a sodium-glucose co-transporter 2 inhibitor in the preparation of a drug for inhibiting the progression of liver fibrosis in cirrhosis.

8. Use of a sodium-glucose co-transporter 2 inhibitor combined with furosemide in the preparation of a drug for inhibiting the progression of liver fibrosis in cirrhosis.

9. The use according to claim 7 or 8, characterized in that The sodium-glucose co-transporter 2 inhibitor is empagliflozin.

10. A pharmaceutical composition for treating and / or assisting in treating ascites due to liver cirrhosis, characterized in that: The pharmaceutical composition comprises drug A and drug B, which are packaged separately or mixed; drug A is a sodium-glucose co-transporter 2 inhibitor, and drug B is furosemide.

11. The pharmaceutical composition according to claim 9, characterized in that The sodium-glucose co-transporter 2 inhibitor is empagliflozin.

12. The pharmaceutical composition according to claim 9 or 10, characterized in that Cirrhosis ascites is refractory or intractable cirrhosis ascites.

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