Compound for management of feline diabetes

Abstract

To provide methods of managing feline diabetes, the methods comprising administering to a feline in need thereof a total daily dosage of about 5 to 50 mg of Compound 1 having the following formula or a pharmaceutically acceptable form thereof.SOLUTION: Provided herein are methods of managing feline diabetes by administering to a feline in need thereof an effective amount of an SGLT inhibitor, wherein the effective amount is 10 to 30% inclusive of the dose required to produce an elevated frequency of diarrhea or loose stool in a healthy feline.SELECTED DRAWING: Figure 8

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to U.S. Provisional Application No. 62 / 818,589, filed March 14, 2019, which is incorporated by reference in its entirety and for all purposes. STATEMENT OF RIGHTS TO FEDERALLY SPONSORED RESEARCH AND DEVELOPMENT INVENTIONS

[0002] Not applicable Reference to a "Sequence Listing," a Table, or a Computer Program Listing Appendix submitted on a Compact Disc

[0003] Not applicable [Background technology]

[0004] Diabetes is a disease characterized by persistently high blood sugar levels (hyperglycemia), which can adversely affect multiple organ systems and, in severe cases, can lead to death. Diabetes has been observed in companion animals, including cats, dogs, and horses, as well as in humans. As in the human population, diabetes in cats is a growing health problem and is associated with both aging and obesity.

[0005] In veterinary medicine, the goals of treatment take into account the care and needs of the owner or human responsible for the animal's care. A disease treatment approach that aims to improve the health of the animal but has a negative impact on the owner, for example, increasing the owner's anxiety about the animal's health, is considered inferior to an approach that has a lower targeted efficacy but reduces the owner's anxiety. As a result, veterinary goals emphasize disease management as opposed to simple disease treatment.

[0006] There are two major forms of diabetes in humans: type 1 (T1DM), also known as insulin-dependent diabetes mellitus (IDDM), and type 2 (T2DM), also known as non-insulin-dependent or non-insulin-dependent diabetes mellitus (NIDDM).

[0007] Type 1 diabetes results from the body's inability to produce insulin, most often due to the loss of endocrine cells known as beta cells, which are found in groups called islets within the exocrine pancreas in many organisms. Type 2 diabetes is a disease of insulin resistance, in which beta cells in the pancreatic islets can produce insulin, but the tissues responsible for uptake of glucose from the blood do not respond appropriately to the insulin they produce. Over the course of persistent T2DM, beta cells may become less able to produce insulin and / or may succumb to the stress of constantly high insulin production. In such situations, exogenous insulin may be required to maintain normal blood glucose levels (euglycemia). However, the risk is that excessive insulin administration can lead to hypoglycemia, which can lead to coma and death.

[0008] Insulin stimulates the uptake and metabolism of glucose by the liver, muscle, and adipose tissue, thereby decreasing blood glucose concentrations. Insulin stimulates the storage of glucose in the liver and muscle as glycogen and in adipose tissue as triglycerides. Insulin also promotes the utilization of glucose in muscle for energy. Thus, insufficient insulin levels in the blood or reduced sensitivity to insulin can cause excessively high levels of glucose in the blood. When blood glucose levels exceed a certain critical level, called the renal threshold for glucosuria, glucose begins to appear in the urine. Before the advent of reliable blood-based tests for diabetes, the appearance of glucose in the urine was often the first sign of the disease.

[0009] Under normal conditions, the kidneys allow low-molecular-weight compounds, including glucose, from the blood to be excreted from the body as glomerular filtrate. From this filtrate, the kidneys selectively recover almost all water, sodium, potassium, and chloride ions, as well as important metabolites such as vitamins, glucose, other sugars, and amino acids. This dynamic, valuable process of releasing nearly the entire contents of plasma and then selectively reabsorbing only these target components underlies the kidney's ability to excrete many unpredictable and diverse toxins. The glucose reabsorption mechanism provides homeostatic maintenance when plasma glucose concentrations become too high. When blood glucose concentrations exceed the renal threshold for glucosuria, a portion of the excess glucose is released into the urine, partially mitigating the adverse effects of elevated plasma glucose.

[0010] As the degree of glycosuria increases, an increase in urine output is observed; the result of this phenomenon is known as osmotic diuresis. Glucose in the filtrate osmotically prevents the reabsorption of water to concentrate the urine, resulting in a high rate of water loss and dehydration. Dehydration causes increased thirst and water consumption. The inability to utilize the energy of glucose ultimately leads to weight loss despite increased appetite. Excessive water intake (polydipsia), food intake (polyphagia or hyperphagia), and urine production (polyuria) are common symptoms of advanced diabetes.

[0011] The toxic effects of excessive plasma concentrations of glucose include nonenzymatic (spontaneous) glycosylation of cells and tissues. Glycosylation products can accumulate in tissues and ultimately form cross-linked proteins, termed advanced glycation end products. Although the detailed mechanisms are largely unknown, it is well known that diabetes increases the likelihood or severity of several conditions, potentially leading to painful neuropathy, circulatory problems, gangrene, amputation, kidney failure, blindness, myocardial infarction, and stroke.

[0012] Measuring overall glycemic control is an important component of a diabetes management plan. Measuring serum glucose in an analytical laboratory or measuring blood glucose using a point-of-care device, such as a home glucose meter, can help assess glycemic status. While glucose meters measure glucose in whole blood, analytical laboratories typically measure glucose in serum, the liquid phase resulting from blood clotting. Individual serum glucose or blood glucose values ​​can vary significantly throughout the day, typically rising after meals and decreasing after prolonged fasting. This diurnal variation can reduce the usefulness of spot testing of serum or blood samples to determine glycemic control resulting from a given therapeutic intervention.

[0013] To better assess the degree of diabetic control in cats, it is common to collect multiple blood samples over the course of a day, typically as an admission study where the cat is kept in a veterinary clinic for the duration of the measurement. The resulting profile of blood glucose as a function of time, known as a blood glucose curve, is often performed to confirm an initial diagnosis or evaluate the effectiveness of a management plan.

[0014] Restraining cats in a veterinary clinic can be stressful for cats, and one reported consequence of stress is hyperglycemia. Therefore, blood glucose curves obtained in the clinic are unlikely to be confounded by technical limitations affecting blood collection and measurement accuracy, but may consist of unreliably elevated values ​​that reflect the effects of cortisol, the primary hormone released under stress, and may not represent the natural course of a cat's daily blood glucose concentration fluctuations. Therefore, clinic measurements should always be considered for the potential to underestimate the degree of glycemic control.

[0015] According to guidelines published by the International Society for Feline Medicine (see Sparkes et al., 2015; J Feline Med Surg 17:235), the primary goal of feline diabetes management, as measured by blood glucose curve criteria, is to maintain blood glucose between a maximum of 10–14 mmol / L (180–252 mg / dL) and a minimum of 4.5–8.0 mmol / L (80–144 mg / dL). Because insulin is the only approved medication for diabetes, and excessive administration can cause dangerous hypoglycemia, both maximum and minimum values ​​are specified. According to these guidelines, a diabetic cat is adequately controlled when its blood glucose curve readings are within the range of 80–252 mg / dL.

[0016] Related guidelines published by the American Animal Hospital Association (see Rucinsky et al., 2010 J Am Anim Hosp Assoc 46:215) recommend home glucose chart management, targeting an average blood glucose level of less than 250 mg / dL, with no single blood glucose reading exceeding 300 mg / dL and a minimum of 80-150 mg / dL.

[0017] Blood glucose curves are inconvenient and expensive to maintain. Alternatively, it would be desirable to develop surrogate measures of blood glucose control that reflect average blood glucose levels over long periods of time, e.g., weeks to months, and that can be measured with a single blood sample.

[0018] In humans, nonenzymatically glycated hemoglobin provides a convenient method for determining long-term glycemic control. The N-terminal valine residue of hemoglobin A1 undergoes spontaneous chemical reaction with reducing sugars, of which glucose is the most abundant in blood. The first step is the formation of an enamine (Schiff base) between the glucose aldehyde tautomer and the N-terminal amino group. The second step, called the Amadori rearrangement, tautomerizes to form a β-ketoamine, often referred to as an Amadori adduct. Because the average lifespan of a human red blood cell is approximately 120 days, the extent of nonenzymatic glycosylation represents the average accumulation of glycation products over an average period of half this time. The rate measurement of glycated hemoglobin is based on the average accumulation of glycated hemoglobin A1. 1c (HbA 1c ) measurement is the basis for the measurement called HbA 1c A blood sample with a % GI % of less than 6.5 is typically considered to reflect good or adequate glycemic control, while a higher % GI % is typically interpreted as indicating the presence of diabetes.

[0019] Feline red blood cells have a shorter half-life than human red blood cells, and HbA 1c Concentrations are much lower and cannot be measured with high accuracy. Instead, the preferred method for measuring continuous glycemic status in cats is serum fructosamine assays, which also measure nonenzymatic adducts generated by the reaction of reducing sugars with primary amines. Mechanistically, these adducts form via a reaction sequence identical to that of the N-terminal amino group of hemoglobin, but can also form on the ε-amino side chain of lysine, forming the structure known as fructoserine in the case of glucose. The fructosamine test measures total serum ketoamines by reversing the Amadori rearrangement. Under alkaline conditions, the Amadori product reverts to the original enamine, which reduces nitroblue tetrazolium to a colored formazan dye that can be quantified spectrophotometrically at 540 nm. The fructosamine assay measures total β-ketoamines, the largest component of which is attributable to serum albumin, the most abundant protein in plasma. Because albumin has a half-life of approximately 20 days, fructosamine assays effectively measure a 3-week history of glycemic control.

[0020] According to guidelines published by the International Society of Feline Medicine (see Sparkes et al., 2015; J Feline Med Surg 17:235), serum fructosamine concentrations below 350 μmol / L indicate either excellent glycemic control, insulin overdose, or diabetic remission; concentrations between 350 and 450 μmol / L indicate good glycemic control; concentrations between 450 and 550 μmol / L indicate moderate glycemic control; and concentrations above 550 μmol / L indicate poor glycemic control. These ranges, which establish a maximum normal serum fructosamine concentration of approximately 350 μmol / L, are based on laboratory testing.

[0021] Currently, there are no approved oral hypoglycemic medications for managing diabetes in cats. Standard treatment for feline diabetes involves twice-daily insulin injections titrated to the desired effect. Cats exhibit considerable inter-individual variability in insulin sensitivity and must be closely monitored to ensure that fatal or neurologically catastrophic hypoglycemia does not occur. While insulin administration can help control diabetes and slow disease progression, providing appropriate insulin doses and timing can be challenging. For example, although it is recommended that insulin be timed before or after meals, coordinating consistent timing of feeding and insulin is difficult, often resulting in low compliance.

[0022] Thus, there is a need in the art for improved methods and compositions for reducing hyperglycemia and the clinical signs associated with hyperglycemia in feline diabetes, particularly methods that do not involve injections and do not require careful dose adjustment to maintain the health of cats. The present disclosure addresses this need and provides related advantages. In particular, the present disclosure provides methods and compositions for managing feline diabetes that include compounds that inhibit the glucose transport proteins known as SGLT1 and SGLT2.

[0023] Much of what is known about these proteins comes from rodent and human studies and is not necessarily applicable to cats. Cats are obligate carnivores and typically consume very little carbohydrate. Cats lack the sweet taste receptors present in rodents and humans, and the receptors and transporters involved in sensing and moving carbohydrates are not expected to function in the same manner as their rodent and human counterparts. Therefore, what follows is a description of the general properties of carbohydrate transport that reflects the best of our current understanding and may differ in important ways from the description of transport in cats.

[0024] Because glucose does not spontaneously diffuse across the cell membrane, rodents and humans have two classes of integral membrane proteins called transporters to facilitate the movement of glucose from the extracellular medium into the cell. One class, called "equilibrating," does not favor either the inside or the outside, but allows glucose to move from an area of ​​high concentration to an area of ​​low concentration (moving in the equilibrium direction). As the cell consumes glucose, this most often results in a net flow into the cell. The other class, called "concentrating," relies on the natural gradient of sodium ions from the extracellular compartment to the intracellular compartment. This gradient is driven by the intracellular Na + to extracellular K + Na by an energy-requiring (ATP-consuming) mechanism + maintained by the active pumping of Na + and the extracellular concentration of K + Sodium-glucose-coupled transporters (SGLTs) transport one glucose and one Na per action (in the case of SGLT2). + ions, or (in the case of SGLT1) one glucose and two Na + Transports ions across membranes. + Ions efficiently transport glucose along with them into the cell, thus concentrative transporters allow dilute extracellular glucose to be concentrated inside the cell.

[0025] Most cells exhibit only equilibrative transport. The intestine and kidney rely on concentrative transport to take up glucose from the diet or to recover glucose from the urine. In species studied to date, SGLT1 is present in both the intestine and kidney, while SGLT2 is found in the kidney and is anatomically upstream of SGLT1 in the renal tubule. SGLT2 has a lower Na transport rate than SGLT1. + Glucose is obtained through the loss of SGLT2, and under normal conditions, it is responsible for the reuptake of approximately 90% of the glucose in the filtrate. In the absence of SGLT2, SGLT1 partially compensates, retaining 40-50% of the glucose. The remainder is excreted in the urine. Genetic deficiency of SGLT2 is known in mice and humans and is generally a benign and subclinical syndrome that is only detected in humans by random urine testing. Genetic deficiency of SGLT1 is potentially fatal in humans due to severe diarrhea that can only be managed by strict dietary restriction of carbohydrates. Both SGLT1 and SGLT2 act to convert large amounts of water into sodium. + In humans and rodents, SGLT1 can transport both glucose and galactose. Whether galactose is a substrate for feline SGLT1 is currently unknown.

[0026] Much of the early research into the physiology of renal glucose reuptake was spurred by the recognition of phlorizin, a natural product isolated from apple tree bark that was ultimately found to be an inhibitor of SGLT1 and SGLT2 in multiple species.

[0027] Phlorizin (also known in some sources as phloridzin, phloridizin, phlorhizin, and phloridzine) was noted in the 19th century to promote diabetes. At the time, diabetes was primarily characterized by the presence of glucose in the urine, so phlorizin was thought to be a diabetes inducer and was referred to in early literature as "phlorizin diabetes." However, it was soon recognized that phlorizin-induced diabetes resulted from a different mechanism than diabetes caused by pancreatic damage or removal, and before the turn of the century, E. Hedon (Compt Rend Soc Biol 4:60 1897) reported that experimental diabetes in dogs could be treated by administration of phlorizin. A translation of his observations from the French indicates the following: "Another fact, which has not yet been observed, to the best of the present knowledge, is that when phlorizin is administered to pancreatectomized animals in complete diabetes, the hyperglycemia disappears, and then an inverse relationship is observed between diabetes and glucose (as observed by Minkowski), in that the former develops at a greater rate, while the latter decreases until a return to normal conditions is observed." By the 1920s, the action of phlorizin on the kidney had been elucidated, and a comprehensive review of its effects was published (see Nash Physiol. Rev. 7: 385 1927).

[0028] The use of phlorizin to reverse hyperglycemia produced by experimental diabetes in cats was reported by Lukens and colleagues in 1943 (Lukens et al., Endocrinology 32:475 1943), followed by additional results in 1961 (Lukens et al., Diabetes 10:182 1961). The beneficial effects of phlorizin in feline diabetes included reduced stress on insulin-producing islet cells in the pancreas and a dramatic reduction in hyperglycemia. Lukens et al. demonstrated many effects considered characteristic of the action of hypoglycemic agents in diabetic cats. These researchers showed, for example, that phlorizin could protect animals from the onset of diabetes, restore normal glucose tolerance to diabetic animals, and prevent the depletion of islets of Langerhans in the presence of experimental diabetes (Lukens et al., 1943, 1961). A key component of the studies conducted by Lukens and colleagues was the subcutaneous administration of an olive oil suspension of the phlorizin compound. This administration effectively functioned as a sustained-release depot, delivering the active agent over several days, without which these researchers' results may not have been possible. Phlorizin, an O-glucose glycoside, is susceptible to metabolism by β-glucose-degrading enzymes and has a short half-life in most species.

[0029] Recent U.S. Patent Publication No. 2015 / 0164856A1 teaches the use of one or more SGLT2 inhibitors to treat diabetes in felines. This publication teaches that SGLT2 inhibitors can be used for various purposes, such as preventing the loss of pancreatic beta cell mass or inhibiting beta cell degeneration, preventing or treating diabetes, and treating various diseases or conditions associated with diabetes. U.S. Patent Publication No. 2015 / 0164856A1's emphasis on SGLT2 inhibition distinguishes it from the very similar arguments and assertions of Lukens and coworkers. While phlorizin acts as a mixed SGLT1 / 2 inhibitor in most species, affecting both transporters, U.S. Patent Publication No. 2015 / 0164856A1 teaches the inhibition of SGLT2 alone. Indeed, U.S. Patent Publication No. 2015 / 0164856A1 does not mention SGLT1. It is also noteworthy that the selectivity of phlorizin for SGLT1 and SGLT2 in cats is not currently understood, nor is the relative contribution of the two transporters to renal glucose reuptake in cats.

[0030] U.S. Patent Publication No. 2015 / 0164856A1 also fails to disclose, as is well known in the art, that predicting the effect of a compound in one species based on experience with another species is one of the most dangerous predictions in drug development. Because target protein structures change evolutionarily, it is extremely difficult to accurately predict interspecies effects. Furthermore, species-dependent nonspecific effects are well known in the art. The rate and form of xenobiotic metabolism are important determinants of drug exposure and are known to exhibit significant variability between species. In part, this means that strong genetic selection applied to xenobiotic metabolic pathways allows some species to consume food sources that are toxic to others. Summary of the Invention

[0031] Provided herein are methods for managing diabetes in cats, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1 (bexagliflozin) having the following formula: [ka]

[0032] Other objects, features, and advantages of the present invention will become apparent to those skilled in the art from the following detailed description and drawings. [Brief explanation of the drawings]

[0033] [Figure 1] FIG. 1 shows the powder X-ray diffraction (XRPD) spectrum of crystalline (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol.

[0034] [Figure 2] FIG. 2 shows a listing of the XRPD data for the XRPD spectrum of FIG.

[0035] [Figure 3] FIG. 3 shows the Raman spectrum of crystalline (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol.

[0036] [Figure 4] FIG. 4 shows a list of Raman peaks in the Raman spectrum of FIG.

[0037] [Figure 5] Figure 5 shows urinary glucose measurements in healthy cats administered bexagliflozin in an inpatient setting.

[0038] [Figure 6] FIG. 6 shows weight loss over time in healthy cats when administered high daily doses of bexagliflozin.

[0039] [Figure 7] Figure 7 shows the least squares means with model-adjusted 95% confidence intervals of the five in-clinic blood glucose curve measurements for each curve from the 8-hour visit. The mean blood glucose concentrations observed within the clinic decreased with treatment duration to a highly statistically significant extent.

[0040] [Figure 8] Figure 8 shows the mean values ​​of the individual measurements that make up the blood glucose curves by visit as a function of sample collection time. After the first measurement, the blood glucose curves showed little difference between visits. At week 8, the mean of the five blood glucose measurements was 114.9 mg / dL (95% CI: 102.8, 128.4).

[0041] [Figure 9] Figure 9 shows the mean serum fructosamine values ​​for cats by visit. The graph shows least squares means with model-adjusted 95% confidence intervals. The inserted value, Δ, represents the least squares mean difference from the initial value to week 8, expressed as a percentage of the upper limit of normal with the corresponding 95% confidence interval. At week 8, the population mean serum fructosamine was 86.7% (95% CI: 80.0%, 93.9%) of the upper limit of normal, indicating a highly significant change in fructosamine concentrations.

[0042] [Figure 10] Figure 10 shows the model-adjusted least squares means with 95% confidence intervals for serum glucose concentrations in cats. The insets show the least squares mean difference with the corresponding 95% confidence intervals from the initial value to week 8. The mean serum glucose at week 8 was 144 (95% CI: 127, 163), a highly significant change in serum glucose concentration.

[0043] [Figure 11]Figure 11 shows the least squares means with model-adjusted 95% confidence intervals for cat weight by visit. The inset shows the least squares mean difference with 95% confidence intervals from initial value to week 8 as a percentage of initial weight. Although the confidence intervals are wide because the population was heterogeneous with respect to weight, the treatment effect on weight gain per cat was highly significant.

[0044] [Figure 12] Figure 12 shows the mean owner scores for polydipsia (excessive drinking) that declined across visits. Although the data were not normally distributed, non-parametric tests (which indicate significant differences between values ​​but do not identify specific pairs) were highly significant.

[0045] [Figure 13] Figure 13 shows the mean owner scores for polyuria (excessive urination) that decreased by visit. Although the data were not normally distributed, non-parametric tests (which show significant differences between values ​​but do not distinguish between specific pairs) were highly significant.

[0046] [Figure 14] Figure 14 shows the mean owner scores for polyphagia (excessive eating) that declined by visit. Although the data were not normally distributed, non-parametric tests (which indicate significant differences between values ​​but do not distinguish between specific pairs) were significant.

[0047] [Figure 15] Figure 15 shows the mean serum β-hydroxybutyrate concentrations with 95% confidence intervals by visit. The wide variation at the first visit reflects the large range of values ​​among the cats participating in the study. At week 8, the mean serum β-hydroxybutyrate concentration was 1.76 mg / dL (95% CI: 1.40, 2.20), which was below the upper limit of normal in the study laboratory (1.9 mg / dL), a highly significant change from the start of the study. DETAILED DESCRIPTION OF THE INVENTION I. Overview

[0048] The present invention discloses a surprising species dependency in the potency and selectivity of bexagliflozin, a compound originally developed for the treatment of human type 2 diabetes.

[0049] Bexagliflozin is a C-arylglucoside that is a highly selective inhibitor of human sodium-glucose-coupled transporter 2 (SGLT2), an integral membrane protein expressed on the apical plasma membrane of renal tubular epithelium in the S1 and S2 compartments of the proximal tubule of the kidney. It is responsible for the majority of glucose reuptake in the filtrate under normal physiological conditions. Bexagliflozin is 2400-fold more selective for human SGLT2 than for human SGLT1. Bexagliflozin produces significantly saturable glycosuria in mice, rats, cats, dogs, rabbits, monkeys, and humans. Experiments using genetic rodent models of diabetes have shown that bexagliflozin can reduce blood glucose levels and partially alleviate disease, even in the presence of preexisting, active glycosuria. Therefore, the presence of glycosuria does not preclude the use of bexagliflozin for the management of diabetes.

[0050] In the present invention, bexagliflozin was found to be 5 times more potent against feline SGLT2 than against human SGLT2 and 235 times more potent against feline SGLT1 than against human SGLT1. As a dual SGLT1 / 2 inhibitor in cats, bexagliflozin produces both desirable and undesirable effects characteristic of its mechanism of action. In particular, in diabetic cats, bexagliflozin induces significant glycosuria and rapid relief of hyperglycemia, while at high doses it also exhibits a tendency to induce loose stools and diarrhea, characteristic consequences of SGLT1 inhibition. Thus, the in vitro prediction of low selectivity is substantiated by in vivo observations.

[0051] In humans, null or hypomorphic mutations in the genes encoding SGLT1 and SLC5A1 cause severe neonatal diarrhea, which is thought to reflect increased luminal fluid volume and microbial overgrowth. However, partial inhibition of SGLT1 reduces glucose (and, in at least some species, galactose) absorption, potentially reducing the effect of dietary carbohydrates on plasma glucose concentrations, potentially resulting in desirable therapeutic outcomes. Because the site of action is the intestine rather than the kidney, the benefits of dual SGLT1 and SGLT2 inhibitors are not diminished by declining renal function, potentially enabling diabetic cats with renal disease or impairment to benefit from bexagliflozin. When an inhibitor acts on both SGLT1 and SGLT2, it may be referred to as an SGLT inhibitor.

[0052] Therefore, a balance must be struck to benefit from the dual SGLT1 and SGLT2 inhibitor effects. If an SGLT inhibitor has too much activity at SGLT1 relative to SGLT2, the intestinal effects will dominate, and the ensuing diarrhea, while not necessarily adverse to hyperglycemia, will have adverse effects on the cat owner and their well-being. The adverse effects of SGLT1 inhibition in humans and other species are not limited to diarrhea, but may include other intestinal effects such as flatulence, abdominal pain, and bloating.

[0053] Therefore, it is preferable to have lower activity against SGLT1 than against SGLT2. While the limited data available does not allow for an optimal ratio to be estimated, one factor to keep in mind is the local concentration of the compound. When delivered orally, drug concentrations in the intestinal lumen can be many times higher than those in plasma. Thus, even relatively weak SGLT1 inhibitors can have relatively potent in vivo effects. While some in vitro data can help guide the selection of an appropriate combination of SGLT1 and SGLT2 inhibitors, evaluation of actual efficacy in cats remains the best guide. The dose threshold for adverse intestinal effects should be set several times higher than the lowest dose that produces 90% of the maximum pharmacodynamic effect.

[0054] The frequency and severity of diarrhea may vary depending on the cat's diet or weight, breed, medical history, or other specific factors. The threshold at which diarrhea or loose stools become unpleasant for the owner is also influenced by multiple factors. For the purposes of this description, an increase in diarrhea frequency is defined as a frequency that exceeds 10% of the frequency of defecation in unmedicated cats. Therefore, a preferred dual inhibitor will increase the frequency of diarrhea or loose stools in healthy cats by at least three times, more preferably at least five times, and its minimum dose will be that amount that results in 90% of the maximum urinary glucose excretion in healthy cats fed a common non-prescription diet, such as a dry food diet.

[0055] Diarrhea caused by SGLT1 inhibition can be reduced by providing a diet low in carbohydrates. As noted above, cats are obligate carnivores and consume very little carbohydrate in their domesticated environment. In contrast, commercial dry food diets for non-diabetic cats may provide as much as 50% of their caloric value in the form of carbohydrates.

[0056] In some countries, prescription diets containing low carbohydrate content are available for the management of feline diabetes. These diets typically consist of wet (canned) food, although dry food diets with reduced carbohydrate content are also available. A recommendation from a research group of the International Society of Feline Medicine (ISFM) explains that although a preferred carbohydrate content has not been determined, diets with 12% or less of their calories derived from carbohydrates may be suitable for diabetic cats (Sparkes et al., 2015; J Feline Med Surg 17:235). Some non-prescription canned food diets also have minimal carbohydrate content.

[0057] Much of the carbohydrate in dry food diets comes from grains or grain-derived sources, which typically comprise only a small proportion of natural diets. Reduced-grain diets are offered by some cat food suppliers as healthier alternatives to traditional diets. To the extent that these diets provide less metabolizable energy in the form of carbohydrates, these carbohydrates can be a useful addition to a diabetes management plan.

[0058] Bexagliflozin has been studied in diabetic mice, rats, and humans. In addition to the information below, this compound is currently being studied in cats. In each organism, this compound lowers blood glucose levels and increases HbA in rodents and humans. 1c It has been found to improve long-term measures of glycemic control, such as fructosamine levels, in cats. However, in cats, the effects of bexagliflozin are extremely potent and qualitatively superior to those observed in other organisms. In the majority of diabetic cats, bexagliflozin induces clinical remission of the disease and results in serum fructosamine levels within the reference range for healthy cats. Despite the high efficacy of bexagliflozin in cats, no clinically significant signs of hypoglycemia have been observed to date. The combination of high efficacy and low risk makes bexagliflozin an excellent option for the management of feline diabetes. Of particular interest and utility is the observation that bexagliflozin as monotherapy, in a market study in which owners administered the drug to cats in an unsupervised (home) environment, demonstrated that fructosamine levels within the normal laboratory reference range were restored in the majority of cats.

[0059] An unexpected and important therapeutic benefit was the increased body weight of treated cats, an effect that was counter to the expected action of this compound in both healthy and diabetic animals. Weight loss is a common and consistent observation among diabetic humans administered bexagliflozin; for example, weight loss in cats administered SGLT2 inhibitors is taught in U.S. Patent Publication No. 2015 / 0164856.

[0060] As is clear to those skilled in the art, the effectiveness of a drug depends on the severity and duration of disease, the metabolic rate of the active ingredient or its active metabolite, and the regularity of the drug administration.Dosage error, especially omission, can have a significant impact on the apparent usefulness of the drug.In fact, omission occurs frequently, and the frequency of omission can be a decisive factor in the effectiveness of the drug.

[0061] The combination may also affect the efficacy of the drugs. For example, because dual SGLT1 and SGLT2 inhibitors inhibit glucose reuptake in the kidney, they may be expected to lose efficacy as renal filtration decreases, either as a natural result of aging or due to the progression of kidney disease. While the dual SGLT1 and SGLT2 inhibitors of the present invention are not considered an attractive management option for cats with severe kidney disease, they may be effective in the setting of mild to moderate kidney impairment and have been found to be effective in a wide age range of cats in clinical studies.

[0062] When humans first develop T2DM, they rarely experience a diabetic crisis. Instead, the disease progresses gradually and is diagnosed through routine laboratory findings or patient complaints, such as increased thirst and frequent urination, that portend more advanced disease. However, diabetic cats often present to veterinarians with acute illness, characterized by extremely high blood glucose levels, glycosuria, and weight loss. Characteristic hyperglycemia-related clinical signs in cats include polydipsia (excessive fluid intake), polyphagia (excessive food intake), polyuria (excessive urination), and weight loss. It is often the weight loss and lethargic behavior that cause concern for owners. Diabetic cats are malnourished due to the significant loss of glucose in urine (via the renal mechanisms described above), yet surprisingly, administration of bexagliflozin, which increases urinary glucose secretion, paradoxically prevents weight loss and causes weight gain in many cats. Similarly, administration of bexagliflozin to diabetic cats would be expected to exacerbate the clinical signs of hyperglycemia (polydipsia, polyphagia, and polyuria) because these signs are mechanistically caused by pathological glycosuria. However, contrary to this expectation, administration of bexagliflozin to diabetic cats attenuates the clinical signs of polydipsia, polyphagia, and polyuria, even though the cats are receiving a drug that is expected to exacerbate these signs. Not surprisingly, due to the drug's mechanism of action, these cats continue to exhibit severe glycosuria. Therefore, although bexagliflozin would be expected to exacerbate the clinical signs of hyperglycemia by its mechanism, in clinical studies, bexagliflozin reversed weight loss, allowing cats to return to normal or near-normal behavior.

[0063] A definitive explanation for the mechanism by which bexagliflozin improves hyperglycemia-related clinical signs in diabetic cats has not yet been presented. However, by inhibiting SGLT1 and SGLT2, sufficient additional glucose may be released into the urine to lower plasma glucose concentrations. Lowering plasma glucose concentrations may increase the proportion of glucosuria attributable to medication effects, as opposed to disease, further improving glycemic control. Ultimately, glucose excretion rates balance excess glucose production, improving hyperglycemia-related clinical signs.

[0064] Diabetes in cats may be associated with acromegaly, a condition resulting from hyperplasia of the growth hormone-producing compartment of the pituitary gland, leading to inadequate production of growth hormone. The subsequent increase in growth hormone triggers an increase in insulin-like growth factor 1 (IGF-1), which antagonizes the action of insulin. Insulin resistance in diabetic cats is often associated with acromegaly (Scott-Moncrieff, JC, Vet Clin North Am Small Anim Pract (2010) 40:241), and it has been estimated that up to one-quarter of diabetic cats in Europe may have acromegaly (Niessen PLoS One. 2015 10:e0127794). Managing diabetic cats with acromegaly often requires very high doses of insulin. Effective non-insulin-dependent antidiabetic drugs would be an important addition to the options available for managing feline diabetes.

[0065] Methods and compositions for administering Compound 1 (bexagliflozin) to reduce hyperglycemia and clinical signs associated with hyperglycemia in diabetic cats are described herein. The methods described herein include specific dosages and frequencies. Surprisingly, administration of Compound 1 provides therapeutic benefit to diabetic cats as the only treatment that results in serum fructosamine concentrations below the upper normal limit of the laboratory reference range in the majority of animals, i.e., within the normal range for healthy cats. Compound 1 effectively treats diabetes in cats not treated with other antidiabetic drugs. In comparison, administration of Compound 1 to diabetic rats and mice did not result in significant increases in blood glucose or HbA 1c Similarly, when Compound 1 is administered to humans with type 2 diabetes, it often results in a significant increase in blood glucose or HbA 1c Additional medications are needed to bring levels back into the normal range.

[0066] Advantageously, Compound 1 does not cause hypoglycemia, and therefore administration of Compound 1 does not require careful control of the dose or the timing of said dose.

[0067] Moreover, in some cases, the methods of managing feline diabetes described herein result in clinical remission in said cat. II. Definition

[0068] "Compound 1" refers to the chemical substance (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol having the following formula: [ka]

[0069] As used herein, "pharmaceutically acceptable form" refers to pharmaceutically acceptable salts, polymorphs, co-crystals, and single crystalline forms of a given compound.

[0070] As used herein, "clinical remission" refers to a sustained decrease, reduction, or decline in one or more clinical measures of a disease, such that these measures fall within an acceptable range of test values ​​obtained from a healthy population. These test values ​​are said to be "within the normal range." "Clinical remission" does not imply cessation of treatment. As used herein, "clinical remission" does not require that all clinical measures of a disease be within the normal range. For example, a cat with serum fructosamine within the normal range but fasting serum glucose above the upper limit of the normal range may be said to be in clinical remission.

[0071] As used herein, "normal range" may depend on the equipment and procedures of the testing laboratory and may therefore vary from laboratory to laboratory. When a value is within the "normal range" as used herein, the phrase means within the range established by the particular laboratory that provides the result at the time of measurement.

[0072] As used herein, "treatment-free remission" refers to a state of remission that persists after the administration of a therapeutic agent has ceased.

[0073] As used herein, "clinical signs associated with hyperglycemia" refer to one or more of the following characteristic signs: polydipsia, polyphagia, polyuria, or weight loss. The clinical sign of weight loss can be quantified by directly measuring the cat's weight during a clinic visit. Recording other signs typically requires the owner to observe the cat's behavior and its consequences.

[0074] As used herein as adjectives, the terms "cat" and "feline" are used interchangeably and refer to or relating to animals of the cat family, especially those kept as pet or companion animals, typically belonging to the family Felidae, the species Silvestris catus or catus, and including that part of the family often referred to as the domestic cat or house cat.

[0075] As used herein, the term "cat" used as a noun refers to an animal of the feline family.

[0076] As used herein, "managing diabetes" or "diabetes management" refers to the process by which an owner or other person responsible for the animal's care addresses the disease by specific measures aimed at alleviating or curing the disease, providing symptomatic relief, or otherwise altering the animal's health status through various methods. These measures may include modifying the animal's diet, such as providing a special or prescription diet or other change in the type or amount of food offered, or encouraging or providing exercise or activity that results in increased metabolic energy expenditure, or providing herbal preparations, dietary supplements, or medications.

[0077] As used herein, "blood glucose level," "blood glucose concentration," or "blood glucose level" refers to the measurement of glucose in whole blood. Typically, the sample taken is capillary blood, and blood glucose is measured by a point-of-care testing device such as a blood glucose meter.

[0078] As used herein, "blood glucose curve" refers to measurements of blood glucose concentrations in serial samples of whole blood obtained over time, typically over a period ranging from 8 to 24 hours, as a means of assessing the degree and adequacy of disease control, for example, to determine whether too much therapeutic drug is being administered or, conversely, whether low blood glucose levels are being observed.

[0079] As used herein, "serum glucose," "serum glucose concentration," or "serum glucose level" refers to the glucose concentration measured in the liquid phase of clotted whole blood, typically venous blood. Serum glucose concentrations are often determined in clinical practice by automated procedures performed in diagnostic testing laboratories.

[0080] As used herein, "serum fructosamine," "serum fructosamine concentration," or "serum fructosamine level" refers to the concentration of fructosamine measured in the liquid phase of clotted whole blood, typically venous blood. Serum fructosamine concentrations are often determined in clinical practice by automated procedures performed in diagnostic testing laboratories.

[0081] As used herein, "plasma glucose" or "plasma glucose concentration" refers to the glucose concentration obtained by measurement of the liquid phase of whole blood, typically venous blood, separated from the cellular components of the blood in a manner that does not cause the blood to clot.

[0082] As used herein, the term "fasted," as applied to the circumstances surrounding collection of a sample for testing, indicates that the animal from which the sample is drawn has been deprived of food for an extended period of time, typically six hours or more if the sample is collected in the morning, and usually overnight. Fasting samples are useful for measuring analytes such as glucose and lipids that are significantly affected by feeding.

[0083] As used herein, "reduction of clinical signs associated with hyperglycemia" and "amelioration of clinical signs associated with hyperglycemia" refer to the amelioration of polydipsia, polyphagia, polyuria, or prevention of weight loss from the start of management of one or more signs.

[0084] As used herein, "amelioration of polydipsia" means a reduction in the observed frequency or amount of water or liquid consumed, or a reduction in the frequency with which the cat seeks out unusual sources of water that it does not normally consume.

[0085] As used herein, "amelioration of bulimia" means a reduction in the amount of food consumed, or a reduction in the frequency of begging or asking for abnormal amounts of food, or a reduction in the frequency of begging or asking for food in abnormal situations, such as immediately after being fed.

[0086] As used herein, "amelioration of polyuria" means a reduction in the frequency of urination or urine production, or a reduction in abnormal behaviors associated with urination, such as urination outside of or overflowing a litter box provided for that purpose.

[0087] As used herein, "preventing weight loss" means resulting in a loss of 5% or less of body weight from the start of treatment. For the avoidance of doubt, "preventing weight loss" also includes any weight gain from the start of treatment.

[0088] As used herein, the definition of "hypoglycemia" refers to a clinical condition in which a measured blood glucose concentration is below the upper limit of the blood glucose range defined by the ISFM (Sparkes et al., 2015; J Feline Med Surg 17:235), which is less than 3.0-3.5 mM (53-63 mg / dL). For the avoidance of doubt, hypoglycemia refers to a blood glucose concentration below 63 mg / dL.

[0089] Clinical markers of diabetes include, but are not limited to, serum fructosamine levels, blood glucose or serum glucose levels, or glycosylated hemoglobin levels. The management regimen may be for at least 1, 3, 7, 14, 28 days or more, or for 1, 2, 3, 4, or more months, or for the remaining lifespan of the cat. In some embodiments, the management regimen is 2 months. In some embodiments, clinical remission is durable, i.e., lasts for the lifespan of the cat. In some embodiments, management-free remission is achieved. In some embodiments, the management-free remission period is at least 1, 3, 7, 14, 28, or more days, or for 1, 2, 3, 4, or more months, or for the remaining lifespan of the cat. The duration of management-free remission depends on many factors, such as the cat's species, its diet, and the amount of daily exercise. As a non-limiting example, clinical remission can be identified by a serum fructosamine level below the upper normal limit of the laboratory reference range. As a further non-limiting example, clinical remission can be identified by a fasting plasma glucose concentration of 170 mg / dL or less.

[0090] As used herein, the "upper limit of normal" or "ULN" of a testing laboratory reference range refers to the lowest upper limit of a laboratory test value that is considered to be found within the normal variation of a sample extracted from a healthy population. The upper limit of normal is typically provided by the testing laboratory in conjunction with the transmission of test results to a physician and may change from laboratory to laboratory or within a single laboratory from time to time depending on test calibration, test administration, or sample preparation. For example, during the course of the field study reported below, the upper limit of normal for serum fructosamine was changed from 356 μmol / L to 275 μmol / L due to a change in testing methodology at the central laboratory.

[0091] As used herein, "antidiabetic agent" refers to a drug, agent, or composition containing a drug commonly used to treat diabetes in humans or manage diabetes in animals. Common antidiabetic agents for the treatment of human T2DM include, but are not limited to, α-glucosidase inhibitors, amylin analogs, biguanides, dipeptidyl peptidase 4 inhibitors, incretins or incretin mimetics, insulin, meglitinides, non-sulfonylurea secretagogues, SGLT2 inhibitors, sulfonylureas, and thiazolidinediones. It is generally accepted that oral medications for the treatment of human T2DM are of little use in managing diabetes in cats. Currently, no oral medications for the management of feline diabetes have been approved by regulatory authorities in the United States, the European Union, or Japan.

[0092] As used herein, a "low-carbohydrate diet" refers to the food that a cat receives from the start of its treatment. In particular, a low-carbohydrate diet is one in which the relative amount of carbohydrate consumed does not exceed a certain threshold level. A low-carbohydrate diet typically contains less than 40%, 35%, 30%, 26%, 20%, 15%, 12%, or a lower percentage of calories from carbohydrates.

[0093] As used herein, a "diabetic diet" refers to the food a cat receives from the start of its treatment. In particular, a diabetic diet is a diet that contains a relatively high amount of protein and a low amount of carbohydrates. A high amount of protein includes 60%, 65%, 70%, 75%, 80% or more of its calories from protein, while a low amount of carbohydrates is as defined above. In certain embodiments, a diabetic diet does not include dry cat food.

[0094] As used herein, "increased frequency of diarrhea or loose stools" means that the frequency of either diarrhea or loose stools increases by more than 10% compared to the frequency of defecation in an animal not receiving the drug. As used herein, "diarrhea" does not include incidental causes such as infection with bacteria, viruses, parasites, or intestinal parasites, but instead refers to diarrhea resulting from SGLT1 inhibition. In some embodiments, "diarrhea" refers to loose or liquid stools occurring at least once per day for at least three days during the course of treatment.

[0095] "SGLT inhibitors" as used herein refers to compounds that have activity against both SGLT1 and SGLT2, and in particular to those compounds that have a favorable ratio of SGLT2 activity to SGLT1 activity, so that benefits in diabetes and intestinal carbohydrate malabsorption can be achieved with a lower risk of unfavorable gastrointestinal symptoms such as diarrhea, loose stools, flatulence, bloating, etc.

[0096] As used herein, the term "administering" refers to delivery by oral, buccal, nasal, rectal, vaginal, or cutaneous routes, or other topical contact, or by intravenous, intraperitoneal, intramuscular, intralesional, or subcutaneous routes, or by implantation of a sustained-release device or formulation, such as a pump, gel, reservoir, or erodible material. Administration can be by any route, including parenteral and transmucosal (e.g., oral, nasal, vaginal, rectal, or transdermal). Parenteral administration includes, for example, intravenous, intramuscular, intraarterial, intradermal, subcutaneous, intraperitoneal, intraventricular, intrathecal, and intracranial. Other modes of delivery include, but are not limited to, the use of liposomal formulations, intravenous infusion, transdermal patches, and the like.

[0097] As used herein, "a method of managing, inducing, reducing, ameliorating, or preventing a disorder, disease, or condition comprising administering a compound or composition" also means the use of a compound or composition to manage, induce, reduce, ameliorate, or prevent a disorder, disease, or condition, as well as the use of a compound or composition to prepare a medicament for managing, inducing, reducing, ameliorating, or preventing a disorder, disease, or condition. III. How to manage diabetes in cats

[0098] In one aspect, provided herein is a method of managing diabetes in a cat, the method comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1 having the following formula: [ka]

[0099] In some aspects, provided herein are methods for reducing hyperglycemia-related clinical signs in cats with diabetes, the methods comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

[0100] In some aspects, provided herein are methods for ameliorating hyperglycemia-related clinical signs in cats with diabetes, the methods comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

[0101] In some aspects, provided herein are methods for inducing clinical remission of diabetes in a cat, the methods comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

[0102] In some aspects, provided herein are methods for reducing serum fructosamine concentrations in a diabetic cat to below the upper limit of normal of a laboratory reference range, the method comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof. In some embodiments, the upper limit of normal of the laboratory standard is 356 μmol / L or 275 μmol / L.

[0103] In some aspects, provided herein are methods for improving glycemic control in a diabetic cat, such that the cat has a blood glucose curve with all blood glucose readings between a maximum of 10 mmol / L (180 mg / dL) and a minimum of 4.5 mmol / L (80 mg / dL), the method comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

[0104] In one aspect, provided herein is a method for preventing weight loss in a diabetic cat, the method comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

[0105] In some aspects, provided herein are methods for managing diabetes in cats exhibiting IGF-1 concentrations above the upper normal limit of a testing laboratory reference range, the methods comprising administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof. In some embodiments, the upper normal limit of the testing laboratory reference range is 92 nmol / L.

[0106] In some embodiments, the methods provided herein comprise administering to a cat in need thereof a total daily dose of about 5-50 mg of Compound 1, or a pharmaceutically acceptable form thereof. Carbohydrates are commonly present in commercially available cat foods, and maintaining a low-carbohydrate diet improves the cat's clinical pathology. In some embodiments, the low-carbohydrate diet is a canned diet. Cats on a canned diet are not fed dry cat food. In some embodiments, the low-carbohydrate diet is a diabetic diet. Diabetic diets are generally high in protein and low in carbohydrates. In some embodiments, diabetic diets contain little or no dry cat food. In some embodiments, the low-carbohydrate diet is a ketogenic diet. Ketogenic diets include diets high in seafood, meat, poultry, and eggs. In some embodiments, the low-carbohydrate diet is a grain-free diet.

[0107] In some embodiments, the low carbohydrate diet comprises less than 40% of calories in the form of carbohydrates. In some embodiments, the low carbohydrate diet comprises less than 35% of calories in the form of carbohydrates. In some embodiments, the low carbohydrate diet comprises less than 30% of calories in the form of carbohydrates. In some embodiments, the low carbohydrate diet comprises less than 26% of calories in the form of carbohydrates.

[0108] In some embodiments, compound 1 is the bisproline conjugate of (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol, having the formula: [ka] The bisproline conjugate of Compound 1 is administered to a cat in need thereof. Further information regarding bisproline conjugates can be found in International Patent Publication No. WO 2010 / 022313, the contents of which are incorporated herein by reference for all purposes.

[0109] In some embodiments, Compound 1 is a crystalline form of (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol, having the formula: [ka] The crystalline form of Compound 1 is administered to a cat in need thereof.

[0110] The crystalline form of this compound is characterized by the X-ray powder diffraction pattern shown in Figure 1. In some embodiments, the X-ray powder diffraction (XRPD) pattern comprises one or more peaks at the following 2θ: 5.4, 11.2, 11.3, 11.9, 12.9, 15.5, 16.3, 17.8, 19.1, 20.0, 20.6, 20.7, 21.2, 22.8, 23.0, 23.4, 23.6, 23.9, 24.7, 25.4, 25.8, 27.8, and 28.2° (±0.1°), wherein the XRPD is α1 In another embodiment, the crystalline form of the compound is characterized by an XRPD pattern comprising two or more, three or more, four or more, or five or more peaks at 5.4, 11.2, 11.3, 11.9, 12.9, 15.5, 16.3, 17.8, 19.1, 20.0, 20.6, 20.7, 21.2, 22.8, 23.0, 23.4, 23.6, 23.9, 24.7, 25.4, 25.8, 27.8, and 28.2 degrees 2θ (±0.1°). In some other embodiments, the crystalline form of the compound is characterized by an XRPD pattern comprising peaks at 12.9, 19.1, and 20.7 degrees 2θ (±0.1°). In still other embodiments, the crystalline form of the compound is characterized by an XRPD pattern comprising peaks at 11.2, 12.9, 15.5, 17.8, 19.1, 20.0, and 20.7 degrees 2θ (±0.1 degrees). In still other embodiments, the crystalline form of the compound is characterized by an XRPD pattern comprising peaks at 5.4, 11.2, 11.9, 12.9, 15.5, 16.3, 17.8, and 19.1 degrees 2θ (±0.1 degrees). In still other embodiments, the crystalline form of the compound is characterized by an XRPD pattern comprising peaks at 5.4, 11.2, 11.9, and 12.9 degrees 2θ (±0.1 degrees). In another embodiment, the crystalline form of the compound is characterized by an XRPD pattern comprising peaks at 11.2 and 12.9 degrees 2θ (±0.1 degrees). In other embodiments, the crystalline form of the compound is characterized by XRPD peaks substantially according to FIG.

[0111] The crystalline compound of the present invention is also characterized by a Raman spectrum substantially in accordance with Figure 3 and peaks substantially in accordance with Figure 4. In some embodiments, the crystalline form of the compound has peaks at about 353, 688, 825, 1178, 1205, 1212, 1608, 2945, 3010, and 3063 cm -1 In another embodiment, the crystalline form of the compound is characterized by a Raman spectrum comprising one or more peaks at about 353, 688, and 825 cm. In another embodiment, the crystalline form of the compound is characterized by a Raman spectrum comprising two or more, three or more, four or more, or five or more peaks at about 353, 688, and 825 cm. -1 In some embodiments, the crystalline form of the compound is characterized by Raman peaks substantially in accordance with FIG.

[0112] In some embodiments, the therapeutically effective amount of Compound 1 is a total daily dose of about 5 mg to 50 mg (e.g., about 5, 7.5, 10, 12.5, 15, 17.5, 20, 22.5, 25, 30, 35, 40, 45, or 50 mg / day). In some embodiments, the total daily dose of Compound 1 is about 10-20 mg. In some embodiments, the total daily dose of Compound 1 is about 15 mg.

[0113] Compound 1 may be administered to cats via several suitable routes. In some embodiments, Compound 1 is administered orally. Further methods of administration are described in the following paragraphs.

[0114] In some embodiments, Compound 1 is administered in combination with an additional therapeutic agent. In some embodiments, Compound 1 is administered as monotherapy, i.e., Compound 1 confers a clear therapeutic benefit in managing diabetes in cats when it is the only antidiabetic agent administered to the cat.

[0115] Advantageously, administration of Compound 1 does not need to be timed with food or other events. In some embodiments, the total daily dose is administered once daily, regardless of other activities (including food timing). In some embodiments, the total daily dose is administered twice daily, regardless of other activities (including food timing). In some embodiments, the dose is mixed with cat food. In some embodiments, the dose is delivered to the cat as a single solid dosage form. In some embodiments, the dose is delivered as an oral solution or oral suspension. In some embodiments, the maximum liquid volume delivered is 1 mL. In some embodiments, the maximum volume delivered is 0.5 mL. In some embodiments, the dose is adjusted according to the cat's weight. In some embodiments, a single dose strength is provided to all cats.

[0116] Over the course of management, serum fructosamine levels and / or blood glucose or serum glucose levels can be monitored to provide evidence of glycemic control. Clinical signs such as polyuria, polydipsia, polyphagia, or weight loss may also be monitored. If ongoing signs of diabetes persist, the management plan may be modified to include other features, including other drug therapies.

[0117] When a cat maintains clinical remission, the cat maintains a certain therapeutic benefit from the treatment regimen. In some embodiments, clinical remission is maintained when the cat does not display one or more clinical markers of feline diabetes. As described above, symptoms of feline diabetes include elevated serum fructosamine levels, elevated blood glucose or serum glucose levels, polyuria, polydipsia, and polyphagia.

[0118] In some embodiments, cats that maintain clinical remission are determined by the feline's serum fructosamine concentration. In some embodiments, the feline's serum fructosamine concentration is compared to the upper limit of normal of the test laboratory's reference range. In some embodiments, the upper limit of normal of the test laboratory's control standard is about 356 μmol / L or about 275 μmol / L. In some embodiments, cats in clinical remission exhibit serum fructosamine concentrations at or below the upper limit of normal of the test laboratory's reference range. In some embodiments, cats in clinical remission exhibit serum fructosamine concentrations at or below 360 μmol / L. In some embodiments, cats in clinical remission exhibit serum fructosamine concentrations at or below 350 μmol / L. In some embodiments, cats in clinical remission exhibit serum fructosamine concentrations at or below the upper limit of normal of the test laboratory from which the sample is submitted.

[0119] In some embodiments, a cat maintaining clinical remission is determined by the cat's blood glucose or serum glucose concentration. In some embodiments, a cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 250 mg / dL. In some embodiments, a cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 200 mg / dL. In some embodiments, a cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 190 mg / dL. In some embodiments, a cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 180 mg / dL. A cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 170 mg / dL. In some embodiments, a cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 160 mg / dL. In some embodiments, a cat in clinical remission maintains a blood glucose or serum glucose concentration of less than 150 mg / dL.

[0120] The methods described herein alleviate, reduce, or eliminate symptoms of diabetes in cats. For example, in some embodiments, the feline's serum fructosamine concentration measured after completion of the management regimen is reduced in the cat. In some embodiments, the feline's blood glucose or serum glucose concentration measured after completion of the management regimen is reduced in the cat.

[0121] In some embodiments, the feline serum fructosamine concentration is reduced by at least about 20% after completion of the management plan. In some embodiments, the feline serum fructosamine concentration is reduced by at least about 30% after completion of the management plan. In some embodiments, the feline serum fructosamine concentration is reduced by at least about 40% after completion of the management plan. In some embodiments, the feline serum fructosamine concentration is reduced by at least about 50% after completion of the management plan.

[0122] In some embodiments, the cat's serum fructosamine concentration is lower than the upper limit of normal of the laboratory reference range after completion of the management plan. In some embodiments, the upper limit of normal of the laboratory reference standard is about 356 μmol / L or about 275 μmol / L. In some embodiments, the cat's serum fructosamine concentration is less than 500 μmol / L after completion of the management plan. In some embodiments, the cat's serum fructosamine concentration is less than 450 μmol / L after completion of the management plan. In some embodiments, the cat's serum fructosamine concentration is less than 400 μmol / L after completion of the management plan. In some embodiments, the cat's serum fructosamine concentration is less than 350 μmol / L after completion of the management plan.

[0123] In some embodiments, the feline's blood glucose or serum glucose concentration is reduced by at least about 20% after completion of the management plan. In some embodiments, the feline's blood glucose or serum glucose concentration is reduced by at least about 30% after completion of the management plan. In some embodiments, the feline's blood glucose or serum glucose concentration is reduced by at least about 40% after completion of the management plan. In some embodiments, the feline's blood glucose or serum glucose concentration is reduced by at least about 50% after completion of the management plan.

[0124] In some embodiments, the cat's blood glucose or serum glucose concentration is less than 250 mg / dL after completion of the management plan. In some embodiments, the cat's blood glucose or serum glucose concentration is less than 200 mg / dL after completion of the management plan. In some embodiments, the cat's blood glucose or serum glucose concentration is less than 190 mg / dL after completion of the management plan. In some embodiments, the cat's blood glucose or serum glucose concentration is less than 180 mg / dL after completion of the management plan. In some embodiments, the cat's blood glucose or serum glucose concentration is less than 170 mg / dL after completion of the management plan. In some embodiments, the cat's blood glucose or serum glucose concentration is less than 160 mg / dL after completion of the management plan. In some embodiments, the cat's blood glucose or serum glucose concentration is less than 150 mg / dL after completion of the management plan.

[0125] As noted above, it is preferable for the SGLT inhibitor to have lower activity against SGLT1 than against SGLT2, and inhibition of SGLT1 may cause diarrhea. Thus, the SGLT inhibitors of the present disclosure provide pharmacodynamic effects in treating diabetes in cats at dosage concentrations below the threshold concentration for intestinal adverse effects. Accordingly, in a further aspect, there is provided herein a method of managing diabetes in cats, the method comprising administering an effective amount of an SGLT inhibitor to a cat in need thereof, wherein the effective amount is 10-30% or less of the dose required to cause increased diarrhea or loose stools in a healthy cat. In some embodiments, the healthy cat is fed a commercially available dry food diet. In some embodiments, the healthy cat is a cat that has not shown increased frequency of diarrhea or loose stools prior to administration of the SGLT inhibitor. In some embodiments, the healthy cat is not diabetic.

[0126] In some embodiments, the effective amount is no more than 10, 12, 16, 18, 20, 22, 24, 26, 28, or 30% of the dose required to cause diarrhea or increased loose stools in healthy cats. In some embodiments, the effective amount is no more than 30% of the dose required to cause diarrhea or increased loose stools in healthy cats. In some embodiments, the effective amount is no more than 20% of the dose required to cause diarrhea or increased loose stools. In some embodiments, the effective amount is no more than 10% of the dose required to cause diarrhea or increased loose stools.

[0127] An effective amount includes a dose that produces at least 90% of the maximum pharmacodynamic effect of said SGLT inhibitor.

[0128] Also provided herein is a method for managing diabetes in a cat, the method comprising administering to a cat in need thereof an effective amount of an SGLT inhibitor, wherein the SGLT inhibitor increases the frequency of diarrhea or loose stools in a healthy cat at a dose 3 to 10 times or more the effective amount. In some embodiments, the healthy cat is fed a commercially available dry food diet. In some embodiments, the healthy cat is a cat that has not shown an increase in the frequency of diarrhea or loose stools prior to treatment. In some embodiments, the healthy cat is not diabetic.

[0129] In some embodiments, the SGLT inhibitor causes an increase in the frequency of diarrhea or loose stools in healthy cats at doses 3, 4, 5, 6, 7, 8, 9, or 10 times or more the effective dose. In some embodiments, the SGLT inhibitor causes an increase in the frequency of diarrhea or loose stools in healthy cats at doses 3 times or more the effective dose. In some embodiments, the SGLT inhibitor causes an increase in the frequency of diarrhea or loose stools in healthy cats at doses 5 times or more the effective dose. In some embodiments, the SGLT inhibitor causes an increase in the frequency of diarrhea or loose stools in healthy cats at doses 10 times or more the effective dose.

[0130] An effective amount includes a dose that produces at least 90% of the maximum pharmacodynamic effect of said SGLT inhibitor.

[0131] The methods described herein are useful for managing all forms of feline diabetes. In some embodiments, the feline diabetes is type 1 diabetes. In some embodiments, the feline diabetes is type 2 diabetes. IV. Pharmaceutical Compositions

[0132] Compound 1 may be formulated into a variety of compositions suitable for delivery to a subject. Compositions suitable for administration to a subject typically include Compound 1 (or a pharmaceutically acceptable form thereof) and a pharmaceutically acceptable carrier.

[0133] Compound 1 may be incorporated into various preparations for therapeutic administration. More specifically, Compound 1 may be formulated into pharmaceutical compositions, either together or separately, by mixing with suitable pharmaceutically acceptable carriers or diluents, and may be formulated into preparations in the form of solid, semi-solid, liquid, or gaseous forms, such as tablets, capsules, pills, powders, granules, dragees, gels, slurries, ointments, solutions, suppositories, injections, inhalants, and aerosols. Thus, the administration of the compounds of the present invention may be achieved in various ways, including oral, buccal, parenteral, intravenous, intradermal (e.g., subcutaneous, intramuscular), transdermal, etc. Furthermore, Compound 1 may be administered in a local, rather than systemic, manner, such as a depot or sustained-release preparation.

[0134] Pharmaceutical compositions for administering Compound 1 may conveniently be presented in unit dosage form and may be prepared by any method known in the art of pharmaceutics and drug delivery. All methods include the step of combining the active ingredient with a carrier that includes one or more accessory ingredients. In general, pharmaceutical compositions are prepared by uniformly and intimately bringing the active ingredient into association with liquid carriers, or finely divided solid carriers, or both, and then, if necessary, shaping the product into the desired formulation.

[0135] Suitable formulations for use in the present invention can be found in Remington: "The Science and Practice of Pharmacy," 21st Ed., Gennaro, Ed., Lippincott Williams & Wilkins (2003), incorporated herein by reference. The pharmaceutical compositions described herein can be prepared in a manner known to those skilled in the art, i.e., by conventional mixing, dissolving, granulating, dragee-making, pulverizing, emulsifying, encapsulating, entrapping, or lyophilizing processes. The following methods and excipients are merely exemplary and are in no way limiting.

[0136] In some embodiments, Compound 1 is prepared for delivery in a sustained-, controlled-, extended-, timed-, or delayed-release formulation, such as a semipermeable matrix of a solid hydrophobic polymer containing the therapeutic agent. Various types of sustained-release materials are established and well known to those skilled in the art. Current sustained-release formulations include film-coated tablets, multiparticulate or pellet systems, matrix technologies using hydrophilic or lipophilic materials, and wax-based tablets containing pore-forming excipients (see, e.g., Huang, et al. Drug Dev. Ind. Pharm. 29:79 (2003); Pearnchob, et al. Drug Dev. Ind. Pharm. 29:925 (2003); Maggi, et al. Eur. J. Pharm. Biopharm. 55:99 (2003); Khanvilkar, et al., Drug Dev. Ind. Pharm. 228:601 (2002); and Schmidt, et al., Int. J. Pharm. 216:9 (2001)). Depending on the design, sustained release delivery systems can release compounds over a period of hours or days, e.g., 4, 6, 8, 10, 12, 16, 20, 24 hours, or longer. Typically, sustained release formulations may be prepared using naturally occurring or synthetic polymers, e.g., polymeric vinylpyrrolidones such as polyvinylpyrrolidone (PVP); carboxyvinyl hydrophilic polymers; hydrophobic and / or hydrophilic hydrocolloids such as methylcellulose, ethylcellulose, hydroxypropylcellulose, and hydroxypropylmethylcellulose; and carboxypolymethylene.

[0137] Timed-release or sustained-release formulations may also be prepared using natural ingredients such as titanium dioxide, silicon dioxide, zinc oxide, and minerals, including clay (see U.S. Patent No. 6,638,521, which is incorporated herein by reference). Sustained-release formulations that can be used to deliver Compound 1 (in any of the forms described herein) include those described in U.S. Patent Nos. 6,635,680; 6,624,200; 6,613,361; 6,613,358; 6,596,308; 6,589,563; 6,562,375; 6,548,084; 6,541,020; 6,537,579; 6,528,080; and 6,524,621, each of which is incorporated herein by reference. Particularly interesting controlled release formulations include those described in U.S. Patent Nos. 6,607,751, 6,599,529; 6,569,463; 6,565,883; 6,482,440; 6,403,597; 6,319,919; 6,150,354; 6,080,736; 5,672,356; 5,472,704; 5,445,829; 5,312,817; and 5,296,483, each of which is incorporated herein by reference.Those skilled in the art will readily recognize other applicable sustained release formulations.

[0138] For oral administration, Compound 1 can be easily formulated in combination with pharmaceutically acceptable carriers known in the art. These carriers allow the compound to be formulated as tablets, pills, dragees, capsules, emulsions, lipophilic and hydrophilic suspensions, liquids, gels, syrups, slurries, suspensions, etc., for oral ingestion by patients in need thereof. Pharmaceutical preparations for oral use can be prepared by mixing the compound with a solid excipient, milling the resulting mixture as needed, and processing the granular mixture after adding appropriate excipients as needed to obtain tablets or dragee cores. Suitable excipients are, in particular, sugars, including lactose, sucrose, mannitol, or sorbitol; and fillers, such as corn starch, wheat starch, rice starch, potato starch, gelatin, tragacanth gum, methylcellulose, hydroxypropylmethylcellulose, sodium carboxymethylcellulose, and / or cellulose preparations, such as polyvinylpyrrolidone (PVP). If desired, disintegrating agents may be added, such as cross-linked polyvinyl pyrrolidone, agar, or alginic acid or a salt thereof such as sodium alginate.

[0139] The tablets of the present disclosure contain the active ingredient mixed with non-toxic pharmaceutically acceptable excipients suitable for tablet manufacture. These excipients may be, for example, inert diluents such as cellulose, silicon dioxide, aluminum oxide, calcium carbonate, sodium carbonate, glucose, mannitol, sorbitol, lactose, calcium phosphate, or sodium phosphate; granulating and disintegrating agents such as cornstarch or alginic acid; binders such as PVP, cellulose, PEG, starch, gelatin, or acacia; and lubricants such as magnesium stearate, stearic acid, or talc. These tablets may be uncoated or coated in the intestine or elsewhere by known techniques to delay disintegration and absorption in the gastrointestinal tract, thereby providing a sustained action over a longer period of time. For example, time-delay materials such as glyceryl monostearate or glyceryl distearate may be employed. They may also be coated to form osmotic therapeutic tablets for controlled release.

[0140] Orally usable pharmaceutical preparations include push-fit capsules made of gelatin and soft, sealed capsules made of gelatin and plasticizers such as glycerol or sorbitol. Push-fit capsules may contain the active ingredient mixed with a filler such as lactose, a binder such as starch, and / or a lubricant such as talc or magnesium stearate, and optionally, stabilizers. In soft capsules, the active compound may be dissolved or suspended in a suitable liquid such as fatty oils, liquid paraffin, or liquid polyethylene glycol. Stabilizers may also be added. All preparations for oral administration should be in a dosage suitable for such administration.

[0141] Formulations for oral use may also be provided as hard gelatin capsules in which the active ingredient is mixed with an inert solid diluent such as microcrystalline cellulose, lactose, starch, pregelatinized starch, or kaolin, or as soft gelatin capsules in which the active ingredient is mixed with water or an oil medium such as peanut oil, liquid paraffin, or olive oil. Additionally, emulsions may be prepared with water-immiscible ingredients such as oils and stabilized with surfactants such as monodiglycerides, PEG esters, and the like.

[0142] In some cases, Compound 1 may be formulated for parenteral administration, for example, by injection, such as bolus injection, or continuous infusion. For injection, the compound may be dissolved, suspended, or emulsified in an aqueous or non-aqueous solvent, such as vegetable oil or other similar oils, synthetic aliphatic acid glycerides, higher fatty acid esters, or propylene glycol, and optionally formulated into a preparation with conventional additives such as solubilizers, isotonicity agents, suspending agents, emulsifiers, stabilizers, and preservatives. Preferably, Compound 1 may be formulated in an aqueous solution, preferably in a physiologically compatible buffer such as Hank's solution, Ringer's solution, or physiological saline buffer. Injectable preparations may be provided in a unit dosage form, such as in ampoules or multi-dose containers, with added preservatives. The composition may take the form of a suspension, solution, or emulsion in an oily or aqueous medium, and may contain agents such as suspending agents, stabilizers, and / or dispersing agents.

[0143] Formulations for parenteral administration include aqueous solutions of Compound 1 in water-soluble form (in any of the forms described herein). Suspensions of Compound 1 may also be prepared as appropriate oily injection suspensions. Suitable lipophilic solvents or vehicles include fatty oils such as sesame oil, or synthetic fatty acid esters such as ethyl oleate or triglycerides, or liposomes. Aqueous injection suspensions may contain substances that increase the viscosity of the suspension, such as sodium carboxymethylcellulose, sorbitol, or dextran. In some cases, the suspension may also contain suitable stabilizers or agents that increase the solubility of the compound, allowing for the preparation of highly concentrated solutions. Alternatively, Compound 1 may be in powder form for constitution with a suitable vehicle, such as sterile, pyrogen-free water, before use.

[0144] Systemic administration can also be via transmucosal or transdermal routes. For transmucosal or transdermal administration, a penetrant appropriate to the barrier to be permeated is used in the formulation. For topical administration, Compound 1 can be formulated into ointments, creams, salves, powders, and gels. In one embodiment, the transdermal delivery agent can be DMSO. Transdermal delivery systems can include, for example, patches. For transmucosal administration, a penetrant appropriate to the barrier to be permeated is used in the formulation. Such penetrants are generally known in the art. Exemplary transdermal delivery formulations that can be used in the present invention include those described in U.S. Patent Nos. 6,589,549; 6,544,548; 6,517,864; 6,512,010; 6,465,006; 6,379,696; 6,312,717; and 6,310,177, each of which is incorporated herein by reference.

[0145] In addition to the above-mentioned formulations, Compound 1 can also be formulated as a depot preparation. This long-acting formulation can be administered by implantation (e.g., subcutaneous or intramuscular) or intramuscular injection. Thus, for example, Compound 1 can be formulated with suitable polymeric or hydrophobic materials or ion exchange resins (e.g., as an emulsion in an acceptable oil), or with a sparingly soluble derivative, for example, as a sparingly soluble complex or salt.

[0146] The pharmaceutical compositions may also comprise suitable solid- or gel-phase carriers or excipients, examples of which include, but are not limited to, calcium carbonate, calcium phosphate, various sugars, starches, cellulose derivatives, gelatin, and polymers such as polyethylene glycols. V. Pharmaceutical Dosage Forms

[0147] The present disclosure includes a novel pharmaceutical dosage form of Compound 1 or its pharmaceutically acceptable form. The dosage form described herein is suitable for oral administration to a subject. The dosage form may be any form suitable for oral administration, including, but not limited to, a capsule or tablet.

[0148] In some embodiments, the present disclosure provides a single unit dosage capsule or tablet form containing 5 to 50 mg of Compound 1 (bexagliflozin) having the following formula or a crystalline form thereof: [ka]

[0149] In some embodiments, the amount of Compound 1 is about 10-20 mg. In some embodiments, the amount of Compound 1 is about 15 mg.

[0150] In some embodiments, the single unit dosage form of Compound 1 is a capsule. In some embodiments, the single unit dosage form of Compound 1 is a tablet.

[0151] In some embodiments, the single unit dosage form is a size 0, 1, 2, 3, 4, or 5 capsule. In some embodiments, the single unit dosage form is a size 4 capsule. In some embodiments, the single unit dosage form is a size 5 capsule. VI. Kit

[0152] Also provided herein are kits containing pharmaceutical compositions of Compound 1 and dosage forms thereof.

[0153] In some aspects, the invention provides kits comprising Compound 1. Some kits described herein include a label that describes a method for administering Compound 1. Some kits described herein include a label that describes a method for managing diabetes in a cat. In some embodiments, the kits described herein include a label that describes a method for lowering serum fructosamine levels and / or blood glucose or serum glucose levels in a cat.

[0154] Compositions of the invention include, but are not limited to, compositions comprising Compound 1 in a bottle, jar, vial, ampoule, tube, or other closed container system approved by the U.S. Food and Drug Administration (FDA) or other regulatory agency, which containers may provide one or more doses containing the compound. The enclosure or dispenser may have attached to it a notice associated with the container in a form prescribed by a government agency regulating the manufacture, use, or sale of pharmaceuticals, which notice indicates approval by the agency. In certain aspects, kits may include a formulation or composition described herein, a closed container system containing a dosage unit form comprising the formulation or formulation, and a notice or instructions describing the method of use described herein. [Example]

[0155] The following examples are offered for illustrative purposes and are not intended to limit the invention in any way. Those of ordinary skill in the art will readily identify a variety of noncritical parameters that can be changed or modified to yield essentially the same results. Example 1. Effect of bexagliflozin in diabetic mice

[0156] In Study 350, the effects of bexagliflozin (as a 2:1 proline:bexagliflozin cocrystal) were examined in genetically diabetic db / db mice. Blood glucose levels were measured using a blood glucose meter (One Touch Ultra Johnson & Johnson (LifeScan) Blood Glucose Monitoring System). Typically, blood was collected by tail nick. If blood glucose levels exceeded the meter's upper limit of quantitation, 33.3 mmol / L, two drops of blood were drawn from the orbital plexus and collected in an anticoagulant microcentrifuge tube containing heparin for subsequent dilution and measurement of blood glucose. The mass of bexagliflozin in Table 1 is approximately two-thirds the mass of the 2:1 composition.

[0157] The animals received daily doses of vehicle or proline:bexagliflozin cocrystals by gavage for 28 days. Animals were dosed between 10:00 AM and 12:00 PM each day. Body weights were measured every four days, and doses were adjusted according to the most recent body weight. The dose was 10 mL / kg (per kg body weight). All animals were observed daily, and any abnormal findings were recorded. Blood glucose concentrations were measured 6 hours after dosing on days -3, 0, 1, 7, 14, 21, and 28.

[0158] As shown in Table 1, nonfasting blood glucose levels in all treatment groups, except for the 0.1 mg / kg group, were significantly lower on days 1, 7, 14, 21, and 28 compared with the control group. Bexagliflozin dose-dependently reduced nonfasting blood glucose levels in db / db mice 6 hours after administration. After 28 days of bexagliflozin treatment, the blood glucose levels of animals receiving 0.067, 0.2, 0.67, and 2 mg / kg bexagliflozin were 79.74%, 56.33%, 51.81%, and 53.25% of the control, respectively. These data indicate that bexagliflozin is an effective antidiabetic drug in diabetic mice; however, none of the dose groups demonstrated normalization of blood glucose levels to the nondiabetic range. In fasting mice of the C57 / BL6 strain (a nondiabetic control strain for db / db mice), the mean fasting glucose level has been reported to be 7.3 mM (131 mg / dL; Andrikopoulos et al., 2005; J Endocrinol (2005) 187:45). Typically, a blood glucose level above 180 mg / dL is considered a sign of diabetes. However, bexagliflozin as the sole agent in db / db mice did not reduce blood glucose levels below 300 mg / dL. [Table 1] Example 2. Effect of bexagliflozin in diabetic rats

[0159] In Study 338, the effects of bexagliflozin (as a 2:1 proline:bexagliflozin cocrystal) were investigated in ZDF rats with genetic diabetes. Nonfasting plasma glucose concentrations were measured using blood collected from the saphenous vein of male ZDF rats into Capiject tubes (Lot No. HA0931; Terumo Medical Corp.) containing sodium fluoride and potassium oxalate. Plasma glucose concentrations were analyzed by a colorimetric assay based on the hexokinase method (Glucose SL assay; Diagnostic Chemicals Ltd.). Plasma samples had to be diluted 1:2 with 0.9% saline according to the manufacturer's instructions before analysis.

[0160] The animals were orally administered vehicle (10% PEG 400) or one of four dose concentrations (0.067, 0.2, 0.67, and 2.0 mg / kg) of the experimental compound by gavage once daily (9:00–11:00 AM) for 28 days. Body weight was measured three times per week, and the dose was adjusted accordingly. Food (Purina 5008; Formulab Diet) and water consumption were measured three times per week to estimate daily values. Twenty-four-hour food and water consumption was recorded during urine collection in metabolic cages. All animals were observed daily, and any abnormal findings were recorded.

[0161] On days 7, 14, and 21, blood samples were collected from the saphenous vein for determination of plasma glucose concentrations (Capiject lot no. HA0931; Terumo Medical Corp.), followed by oral administration of compound or vehicle.

[0162] Daily oral treatment with bexagliflozin resulted in significant reductions in plasma glucose concentrations after only 7 days. Because the study groups were designed to minimize between-group variability for this variable, no significant differences in plasma glucose were observed between any of the groups at the start of treatment (F(4,45) = 0.04; p = 0.99). Significantly reduced plasma glucose concentrations were observed on the 7th day of treatment (F(4,45) = 3.99; p = 0.007), and pairwise comparisons revealed that plasma glucose concentrations were lower in all groups receiving bexagliflozin compared with vehicle controls, except for the lowest dose (p < 0.05 for 0.2 and 0.67 mg / kg, and p < 0.01 for 2.0 mg / kg) (Table 2). The decline from baseline was also significant (F(4,45) = 4.05; p = 0.007), and follow-up comparisons again revealed that the declines in all but the 0.067 mg / kg bexagliflozin treatment group were significantly greater than the increases in plasma glucose concentrations observed in the vehicle controls (p < 0.05 for 0.3 and 1.0 mg / kg, and p < 0.01 for 3.0 mg / kg) (Table 2). The observed changes in plasma glucose concentrations after 7 days were as follows: +2.8%, -16.8%, -17.1%, and -25.3% for 0.067, 0.2, 0.67, and 2.0 mg / kg bexagliflozin, respectively, and +9.6% for the vehicle control.

[0163] After 2 weeks of treatment, a decrease in plasma glucose concentrations was observed (F(4,45) = 12.3; p < 0.0001), and pairwise comparisons showed that plasma glucose concentrations were significantly lower in all groups except the 0.067 mg / kg bexagliflozin group compared to vehicle controls: p < 0.01 for 0.2, 0.67, and 2.0 mg / kg bexagliflozin (Figure 1 and Table 1). Similarly, the decrease from baseline after 2 weeks of treatment was also significant (F(4,45) = 5.13; p = 0.002), with the decrease produced by 2.0 mg / kg bexagliflozin being significantly greater than vehicle controls (p < 0.01) (Table 2). The observed changes in plasma glucose concentrations after 14 days were +9.5%, -5.6%, -8.1%, and -25.1% for 0.067, 0.2, 0.67, and 2.0 mg / kg bexagliflozin, respectively, and +17.0% for the vehicle control.

[0164] Similarly, after 3 weeks of treatment, plasma glucose concentrations decreased significantly (F(4,44) = 7.77; p < 0.0001), and plasma glucose concentrations were significantly lower in the EGT0001474 groups receiving 0.3, 1.0, and 3.0 mg / kg (p < 0.05, < 0.01, and < 0.01, respectively) (Table 2). The decrease from baseline was again significant (F(4,44) = 3.36; p = 0.017), and the decrease produced by 2.0 mg / kg bexagliflozin was significantly greater than the vehicle control (p < 0.01) (Table 2). The observed changes in plasma glucose concentrations after 21 days were as follows: +15.5%, +4.3%, +1.5%, and -15.4% for 0.067, 0.2, 0.67, and 2.0 mg / kg bexagliflozin, respectively, and +25.5% for vehicle control. One rat receiving 0.67 mg / kg bexagliflozin was euthanized due to moribundity before blood collection on day 21. Necropsy results suggested that this animal may have aspirated some dosing solution several weeks before dosing. This effect was not considered related to the test drug. Data from the euthanized animal were included in the analyses on days 7 and 14 but not on day 21 (thus reducing the degrees of freedom in the denominator of the F statistic).

[0165] These data demonstrated that bexagliflozin was an effective antidiabetic agent in diabetic rats; however, none of the dose groups demonstrated normalization of blood glucose levels to the nondiabetic range. Typically, blood glucose levels above 180 mg / dL are considered a sign of diabetes. However, bexagliflozin as the sole agent in ZDF rats did not reduce blood glucose levels below 287 mg / dL (Table 2). [Table 2]

[0166] As the foregoing discussion demonstrates, administration of bexagliflozin to diabetic rodents substantially ameliorates the severity of their disease, but does not restore the animals to a normoglycemic state or result in plasma glucose concentrations within the normal range. Example 3. Effect of bexagliflozin on feline SGLT1 and SGLT2 transporters in vitro

[0167] In study 5, a DNA fragment encoding feline SGLT2 was inserted downstream of the cytomegalovirus immediate-early protein enhancer / chicken β-actin promoter, along with a rabbit β-globin intron (CAG promoter), between the SalI and HindIII sites of the mammalian expression vector pNL715 (pPB-CAG-SGLT2Cat-IRES-EGFP; Egret Pharma Shanghai, 1118 Halei Road 4F, Zhangjiang Hi-Tech Park, Shanghai China 201203). The plasmid expression cassette contained an internal ribosome entry site (IRES) and a bovine growth hormone polyadenylation signal upstream of the enhanced GFP open reading frame, flanked by PiggyBac transposon inverted terminal repeats. Plasmids containing the desired cDNA insert were identified by restriction enzyme digestion analysis. A plasmid encoding feline SGLT1 (pNL717) was similarly inserted between the SalI and HindIII sites to form pPB-CAG-SGLT1Cat-IRES-EGFP (Egret Pharma Shanghai). A C-to-T transition mutation at position 891 of the fSGLT1 coding region of the cDNA clone (forming a stop codon at amino acid residue 297) was reverted to the wild-type sequence by polymerase chain reaction. This reversion restored activity to the expression plasmid.

[0168] Feline SGLT expression plasmid DNA was transfected into Cos-7 cells using Lipofectamine 3000 (Thermo Fisher Corporation, Waltham, MA) according to the manufacturer's recommended procedure. 24 hours before transfection, the cells were cultured at approximately 3 × 10 6Cells / well were seeded in 100 mm dishes in 10 mL of medium and were >95% confluent at the time of transfection. Transfected cells were harvested 24 hours after transfection using trypsin and seeded in 100 μL per well of 96-well poly-D-lysine-coated ScintiPlates (Perkin Elmer) in DMEM supplemented with 10% FBS and 2 mM glutamine, followed by culture for 48 hours at 37°C in a 5% CO2 atmosphere. Transfected cells were either cryopreserved at -195°C in DMEM containing 10% DMSO or stored in methyl-α-D-[U- 14 Transporter activity was assessed by measuring [C] glucopyranoside (AMG) uptake.

[0169] Transfected cells expressing SGLT1 or SGLT2 (4 x 10 per well) 4 The cells were washed twice with 150 μL of either sodium buffer (137 mM NaCl, 5.4 mM KCl, 2.8 mM CaCl, 1.2 mM MgCl, 10 mM Tris / HEPES, pH 7.2) or sodium-free buffer (137 mM N-methylglucamine, 5.4 mM KCl, 2.8 mM CaCl, 1.2 mM MgCl, 10 mM Tris / HEPES, pH 7.2). Either 50 μL of sodium-free buffer containing 40 μCi / mL α-methyl-D-glucopyranoside (AMG; Perkin Elmer) or 50 μL of sodium buffer containing 8 μCi / mL AMG, 10% feline plasma, and bexagliflozin at the desired concentration was added to each well of the plate and incubated at 37°C for 1 hour with shaking. Cells were washed twice with 150 μL of phosphate-buffered saline, plates were covered with TopSeal (PerkinElmer), and AMG uptake was quantified using a Model 1450 MicroBeta Trilux microplate scintillation counter (PerkinElmer Corporation). AMG uptake results were analyzed using GraphPad Prism (Intuitive Software for Science). IC 50The calculation of was performed using nonlinear regression with variable slope.

[0170] Bexagliflozin showed high efficacy against SGLT1 and SGLT2 in cats, and IC 50 The values ​​were 23.8 nM and 412 pM, respectively, in the presence of 10% feline plasma. Compared to its activity against the cognate human transporters (Zhang et al., Pharmacological Research 63:284 2011), bexagliflozin was more than 5-fold more active against feline SGLT2 and more than 235-fold more active against feline SGLT1. Example 4. Effect of bexagliflozin in non-diabetic cats

[0171] In Studies 1 and 2, bexagliflozin formulated in gelatin capsules was administered to cats bred for health purposes, and urinary glucose excretion was recorded for 24 hours after administration. Cats were administered either once (qd) or twice (bid) (at 0 and 12 h for the latter). As shown in Figure 5, maximum glycosuria was observed at a dose of approximately 3 mg / kg, with twice-daily administration being slightly more effective than once-daily administration. Cats exposed to high doses of bexagliflozin exhibited a dose-dependent increase in the severity of loose stools and / or diarrhea, an effect consistent with (and attributed to) the drug's inhibition of intestinal SGLT1. Given the drug's poor in vitro selectivity for feline SGLT2, it appears likely that the pharmacological effects of bexagliflozin in cats are the result of inhibition of both SGLT1 and SGLT2.

[0172] Because undesirable effects due to SGLT1 inhibition were detected at doses 5-10 times higher than the dose producing the maximal pharmacodynamic effect, the efficacy of bexagliflozin against feline SGLT1 appears to be near-optimal. Higher efficacy against SGLT1 may result in an overlap between the maximal pharmacodynamic effect and undesirable side effects.

[0173] Further evidence of the favorable efficacy of bexagliflozin against feline SGLT1 was found in Study 3, in which healthy cats were administered bexagliflozin at 15 mg / kg twice daily (30 mg / kg per day) for 21 days. As shown in Figure 6, cats lost weight throughout the study due to calorie wasting caused by the combination of diabetes and diarrhea. All cats regained weight after treatment was terminated. Because diabetic cats often present with weight loss, the degree of diarrhea is clearly regressive and incompatible with treatment. Therefore, a dose 10 times higher than the dose producing the maximal pharmacodynamic effect cannot be maintained. Fortunately, the effect of bexagliflozin on SGLT1 is not large enough to cause diarrhea at the dose producing the maximal pharmacodynamic effect, but the results are nonetheless substantial enough to provide clear evidence of resulting intestinal inhibition at relatively low multiples of the maximally effective dose. Example 5. Effect of bexagliflozin in diabetic cats

[0174] The on-site efficacy study enrolled client-owned cats diagnosed with diabetes based on i) two separate (≥6-hour) fasting blood glucose measurements >250 mg / dL; ii) the presence of glycosuria; iii) fructosamine >450 μmol / L (subsequently changed to >360 μmol / L due to a change in the testing laboratory's methodology); and iv) one or more of the following (documented in the cat's medical record): polyuria / polydipsia, polyphagia, and / or weight loss. Cats suspected of having diabetes were screened during Visit 1 (within 7 days prior to Day 0). Eligible cats were enrolled during Visit 2 (Day 0), and management was initiated with bexagliflozin administered orally once daily. Cats were placed on a diabetic diet (Purina DM, either dry or wet varieties). Cats returned to the clinic for evaluation of glycemic control during Visit 3 (Day 14 ± 3), Visit 4 (Day 28 ± 3), and Visit 5 (Day 56 ± 3). The treatment period ran from Visit 2 (Day 0) to Visit 5 (Day 56 ± 3). If the owner or investigator deemed an unscheduled visit necessary, the cat could return to the clinic at any time for that visit. An 8-hour blood glucose curve (blood samples collected every 2 hours ± 15 minutes over 8 hours) was performed at each visit, beginning with Visit 2 (Day 0), and blood glucose was measured using an AlphaTRAK 2 blood glucose meter (Abbott Laboratories). Blood samples for hematology and serology were collected at prescreening and during each scheduled visit after medication initiation. A central laboratory was used to evaluate all clinical pathology samples (blood, serum, and urine) not analyzed in the clinic for blood glucose curves. Serum testing included fructosamine assessment. Due to a change in measurement methodology at the central laboratory, the upper limit of normal (ULN) changed from 356 μmol / L to 275 μmol / L during the study. To account for the change in reference range, data were matched by the formula as a percentage of the upper limit of normal, and the log-transformed percentages were analyzed by repeated measures analysis of covariance (ANCOVA) with unstructured covariance and visit as a fixed effect. The test laboratory's upper limit of normal for fasting serum glucose was 155 mg / dL. The following data were compiled after 32 cats completed the 56-day visit.

[0175] In this study, cats exposed to bexagliflozin showed improvement in polydipsia, polyphagia, and polyuria as observed by their owners. Of the three owner-rated symptoms, polyphagia was the least likely to be judged as an improvement. Weight gain was also frequently observed despite bexagliflozin-induced calorie depletion.

[0176] Surprisingly good glycemic control was evident as measured by normalization of serum fructosamine. Of the 32 cats that completed the study, 26 achieved fructosamine concentrations below the upper limit of normal for the controlled laboratory test range. None of the cats exhibited symptoms of hypoglycemia, consistent with studies in healthy animals showing that bexagliflozin at high multiples of the intended clinical dose does not cause hypoglycemia. Freedom from hypoglycemia is also predicted by the observation that mice and humans genetically deficient in SGLT2 are normoglycemic.

[0177] Three cats had elevated serum insulin-like growth factor-1 (IGF-1), which, given the known association between acromegaly and insulin-resistant and insulin-refractory diabetes, suggested that acromegaly may contribute to the pathogenesis of these diseases. All three cats with elevated IGF-1 achieved normal fructosamine concentrations and completed the study, as well as the 4-month safety extension period. Acromegaly was subsequently confirmed in the cat with the highest IGF-1 concentration. After completion of the study, the cat required 11 units of insulin daily and did not progress clinically well.

[0178] Improvements in owner- and veterinarian-assessed measures of cat health or condition were recorded, and many of these changes met statistical significance. Ketonia, if evident at initial presentation, was usually treated during the study. A validated survey instrument designed to measure the impact of feline diabetes on owners' quality of life was administered to detect statistically significant improvements in owners' quality of life. Detailed study results

[0179] Each cat was classified as achieving (or not achieving) glycemic control (i.e., success / failure) on Day 56 ± 3. Treatment success was defined as improvement in at least one glycemic variable (mean BG <250 mg / dL; or fructosamine <450 μmol / L or <360 μmol / L, depending on the measurement reference range at the time of analysis) and veterinarian judgment of adequate glycemic control at final evaluation. As shown in Table 3, 32 of 40 enrolled cats were considered treatment successful (80%). All cats that continued in the V5 study were considered treatment successful. Of the eight cats considered treatment failures, six were removed from the study after an SAE, one was removed at the request of the sponsor, and one was removed because the AE was treated with a prohibited drug. Table 3 also tabulates cats that achieved fructosamine concentrations below the upper limit of normal (initially 356 μmol / L and subsequently 275 μmol / L). [Table 3-1] [Table 3-2]

[0180] Clinical signs of acute diabetes in cats include weight loss, polyuria, polydipsia, and polyphagia. All of these are thought to be secondary to the caloric wasting caused by glycosuria, which occurs after plasma glucose concentrations exceed the renal threshold for glycosuria. Because bexagliflozin lowers the renal threshold for glycosuria, it would be expected to worsen clinical signs of hyperglycemia. However, if bexagliflozin can increase glycosuria to a level where a significant reduction in plasma glucose concentrations is achieved, the net effect would be to reduce overall glomerular glucose flux once plasma glucose concentrations normalize. Following normalization, the severity of clinical signs of hyperglycemia may be reduced. Data collected from the study group indicate that the latter effect may exist.

[0181] Responsibility for assessing clinical signs of diabetes was assigned between the owner and the treating veterinarian. Body weight was recorded by the veterinarian at each visit, and signs of polydipsia, polyuria, and polyphagia were recorded by the owner at each visit using a 4-point integer score (0-3), with lower scores representing more favorable evaluations.

[0182] In addition to providing a measure of the cat's condition as a function of time, quantitative assessments were used to provide a binary outcome of success or failure at study completion. To be scored as successful for weight, the weight at Visit 5 had to be greater than the weight at Visit 2 (treatment initiation). To be scored as successful for other indicators, the owner's score at Visit 5 had to be lower than the owner's score at Visit 2.

[0183] Table 4 shows the binary results for each cat from the quantitative assessments. Any cat that withdrew from the study was recorded as a failure (0) for all criteria. The last row of Table 4 shows the total for each column, or the total number of successes for each criterion. Improvement in at least one clinical sign (the "Any Success" column) was observed in 31 cats, one fewer than the cats found to have achieved glycemic control. Case 5 was a success for glycemia but a failure for clinical signs. For this cat, owner scores were the same for each category at all visits, and weight decreased from 5.4 kg to 5.1 kg. When weight was excluded as a criterion (the "Success Other Than Weight" column), 30 cats were recorded as successes. The additional cat that failed for criteria other than weight was Example 4. For this cat, the final and initial scores for each category were the same. However, as explained in the following paragraphs, both cats in Cases 4 and 5 were assessed by their owners as showing improvement in polydipsia, polyuria, or polyphagia when qualitatively compared to the start of the study. [Table 4-1] [Table 4-2]

[0184] Glucose curves were constructed from blood glucose measurements taken at 0, 2, 4, 6, and 8 hours post-dose. Log-transformed data were analyzed by mixed-model repeated measures ANCOVA with a first-order autoregressive covariance structure and with visit, time, and visit per hour as fixed effects and time as a random effect. Figure 7 below shows the model-adjusted least squares means for the five measurements for each curve per visit, with 95% confidence intervals. Individual visit mean data (quadratic plot below) were analyzed by repeated measures ANCOVA with time as a fixed effect and a first-order autoregressive covariance structure. Data from 40 enrolled cats are shown in Figure 8. At week 8, the mean of the five glucose measurements was 114.9 mg / dL (95% CI: 102.8, 128.4).

[0185] Serum fructosamine concentrations were measured by a central laboratory at prescreening (V1) and at each post-enrollment visit (V3, V4, and V5). A change in central laboratory measurement methodology resulted in a change in the upper limit of normal (ULN) from 356 μmol / L to 275 μmol / L. Data were harmonized by the formula as a percentage of the upper limit of normal, and the log-transformed percentages were analyzed by repeated measures ANCOVA with unstructured covariance and visit as a fixed effect. Figure 9 displays model-adjusted least-squares means with 95% confidence intervals. The inset Δ indicates the least-squares mean difference from initial values ​​to week 8, expressed as a percentage of the ULN with the corresponding 95% confidence interval. At week 8, the population mean serum fructosamine value was 86.7% of the upper limit of normal (95% CI: 80.0%, 93.9%).

[0186] Serum glucose concentrations were measured by a central laboratory at prescreening (V1) and at each post-enrollment visit (V3, V4, and V5). Log-transformed data were analyzed by repeated measures ANCOVA with unstructured covariance and visit as a fixed effect. Figure 10 displays model-adjusted least-squares means with 95% confidence intervals. Insets indicate least-squares mean differences from initial values ​​to week 8 with corresponding 95% confidence intervals. At week 8, the mean serum glucose value was 144 (95% CI: 127, 163).

[0187] Owners often enrolled their cats in the study when they noticed a weight loss despite the cat consuming more food than normal. As shown in Figure 11, the average weight of the cats increased over the course of the study. By day 56, 82% of the cats had maintained or gained weight, and no cats had lost more than 5% of their weight since study entry.

[0188] Body weights were measured at each study visit. Log-transformed data were analyzed as described above. Figure 11 shows model-adjusted least-squares means with 95% confidence intervals. Inserted values ​​represent least-squares mean differences from baseline to week 8 as a percentage of initial body weight with 95% confidence intervals. Although the confidence intervals are wide due to heterogeneity of the population with respect to baseline weight, the treatment effect on weight gain per cat was highly significant (p<0.0001). The effect on weight gain was striking and contradicts the expectation that caloric depletion due to bexagliflozin-induced diabetes would lead to weight loss in cats.

[0189] Throughout the study, owners were asked to rate their cats' hyperglycemia-related clinical signs according to a 4-point qualitative scale, with 0 representing excellent and 3 representing poor. Ratings for polyphagia, polydipsia, and polyuria were recorded separately. Significant differences were detected for all three measures (Figures 12, 13, and 14), with the smallest effect evident for owner-assessed polyphagia. Despite owners' perceptions that their cats' polyphagic signs were worsening, the cats' objective weight gain was significant. Thus, despite the mechanism of action of bexagliflozin involving calorie consumption through glycosuria, its impact on hyperglycemia-related clinical signs was more pronounced than the impact of bexagliflozin-induced calorie loss.

[0190] Diabetes associated with acromegaly in cats is a distinct etiology that presents particular challenges for management. Extremely high insulin doses are often required to overcome the severe insulin resistance that typically develops in these cases. In addition to the morphological changes associated with long-term disease, elevated IGF-1 concentrations are a hallmark symptom of feline acromegaly. Three cats with IGF-1 concentrations above the upper limit of normal (92 nmol / L) were included in this study: Case 7 (172 nmol / L), Case 28 (100 nmol / L), and Case 30 (120 nmol / L). All three cats were considered successfully treated at V5 and completed an extended safety study for a total of 6 months of treatment.

[0191] Ketosis and ketoacidosis are two manifestations of severe deficiencies in glycemic control. Ketosis results from the inability of adipocytes to fully absorb a glucose load because available insulin does not adequately lower plasma glucose. The most reliable analyte for measuring ketonemia is β-hydroxybutyrate. Serum β-hydroxybutyrate (β-OHB) concentrations were measured by a central laboratory at prescreening (V1) and at each post-enrollment visit (V3, V4, and V5). Log-transformed data were analyzed by mixed-model repeated measures ANCOVA with unstructured covariance and visit as a fixed effect. Figure 15 shows the model-adjusted least-squares means with 95% confidence intervals. Insets indicate the least-squares mean difference from baseline to week 8 with the corresponding 95% confidence intervals. At week 8, the mean serum β-hydroxybutyrate concentration was 1.76 mg / dL (95% CI: 1.40, 2.20), lower than the upper limit of normal for the study laboratory (1.9 mg / dL). The very large confidence interval for the value at the first visit reflects the extreme variability observed in the degree of ketonemia exhibited by cats at the start of the study.

[0192] Although the invention hereinbefore set forth has been described in some detail by way of illustration and example for purposes of clarity of understanding, it will be understood by those skilled in the art that certain changes and modifications may be practiced within the scope of the appended claims. Furthermore, each reference provided herein is incorporated by reference in its entirety to the same extent as if each reference were individually incorporated by reference. In the event of a conflict between this application and a reference provided herein, this application shall control.

Claims

1. 1. A method for managing diabetes in a cat, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1 having the following formula: 【Chemical 1】

2. 1. A method for reducing clinical signs associated with hyperglycemia in a diabetic cat, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

3. 1. A method for ameliorating clinical signs associated with hyperglycemia in a diabetic cat, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

4. 1. A method for inducing clinical remission of diabetes in a cat, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

5. A method for reducing serum fructosamine concentrations in a diabetic cat to below the upper normal limit of a laboratory reference range, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1 or a pharmaceutically acceptable form thereof.

6. 1. A method for improving glycemic control in a diabetic cat such that the cat has a blood glucose curve in which all blood glucose measurements fall within a range of a maximum of 10 mmol / L (180 mg / dL) and a minimum of 4.5 mmol / L (80 mg / dL), comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

7. 1. A method for preventing weight loss in a diabetic cat, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

8. A method for managing diabetes in a cat exhibiting IGF-1 concentrations above the upper normal limit of a testing laboratory reference range, comprising administering to a cat in need thereof a total daily dose of about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof.

9. 9. The method of claim 8, wherein the upper normal limit of the laboratory reference range for IGF-1 is 92 nmol / L.

10. 10. The method of any one of claims 1 to 9, comprising administering to a cat in need thereof a low carbohydrate diet and a total daily dose comprising about 5 to 50 mg of Compound 1.

11. 11. The method of claim 10, wherein the low carbohydrate diet is a canned diet.

12. 11. The method of claim 10, wherein the low carbohydrate diet is a diabetic diet.

13. 11. The method of claim 10, wherein the low carbohydrate diet is a ketogenic diet.

14. 11. The method of claim 10, wherein the low carbohydrate diet is a grain-free diet.

15. 11. The method of claim 10, wherein the low carbohydrate diet contains less than 40% of calories in the form of carbohydrates.

16. 11. The method of claim 10, wherein the low carbohydrate diet contains less than 35% of calories in the form of carbohydrates.

17. 11. The method of claim 10, wherein the low carbohydrate diet contains less than 26% of calories in the form of carbohydrates.

18. 11. The method of claim 10, wherein the low carbohydrate diet contains less than 12% of calories in the form of carbohydrates.

19. 1. A method for managing diabetes in a cat, comprising administering to a cat in need thereof a total daily dose comprising about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof; wherein Compound 1 or a pharmaceutically acceptable form thereof is in the form of a tablet, capsule, or solid dosage form.

20. 1. A method for managing diabetes in a cat, comprising administering to a cat in need thereof a total daily dose comprising about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof; The method, wherein Compound 1 or a pharmaceutically acceptable form thereof is in the form of an oral solution.

21. 1. A method for managing diabetes in a cat, comprising administering to a cat in need thereof a total daily dose comprising about 5 to 50 mg of Compound 1, or a pharmaceutically acceptable form thereof; The method, wherein Compound 1 or a pharmaceutically acceptable form thereof is in the form of a medicated feed.

22. 22. The method of any one of claims 1 to 21, wherein compound 1 is a bisproline conjugate of (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol having the following formula: 【Chemistry 2】

23. 22. The method of any one of claims 1 to 21, wherein compound 1 is a crystalline form of (2S,3R,4R,5S,6R)-2-(4-chloro-3-(4-(2-cyclopropoxyethoxy)benzyl)phenyl)-6-(hydroxymethyl)tetrahydro-2H-pyran-3,4,5-triol having the formula: 【Chemistry 3】

24. 24. The method of any one of claims 1 to 23, wherein the total daily dose is about 10 to 20 mg.

25. 24. The method of any one of claims 1 to 23, wherein the total daily dose is about 15 mg.

26. 26. The method of any one of claims 1 to 25, wherein Compound 1 is administered orally.

27. 27. The method of any one of claims 1 to 26, wherein Compound 1 is administered once daily.

28. 28. The method of any one of claims 1 to 27, wherein Compound 1 is administered according to a regimen, said regimen lasting at least one day.

29. 28. The method of any one of claims 1 to 27, wherein Compound 1 is administered according to a regimen, said regimen lasting at least 3 days.

30. 28. The method of any one of claims 1 to 27, wherein Compound 1 is administered according to a regimen, said regimen lasting at least 7 days.

31. 28. The method of any one of claims 1 to 27, wherein Compound 1 is administered according to a regimen, said regimen lasting at least 14 days.

32. 28. The method of any one of claims 1 to 27, wherein Compound 1 is administered according to a regimen, said regimen lasting at least 28 days.

33. 28. The method of any one of claims 1 to 27, wherein Compound 1 is administered according to a regimen, said regimen lasting from 1 day to 2 months.

34. 34. The method of any one of claims 1 to 33, wherein Compound 1 is the only antidiabetic agent administered to the cat.

35. 35. The method of any one of claims 1 to 34, wherein administration of Compound 1 results in clinical remission in the cat.

36. The method of any one of claims 1 to 35, wherein compound 1 is administered to the cat having a serum fructosamine concentration higher than the upper limit of normal of the test laboratory's reference range prior to initiation of treatment.

37. 37. The method of claim 36, wherein the upper limit of normal for the testing laboratory is about 356 μmol / L or about 275 μmol / L.

38. The method of any one of claims 1 to 35, wherein compound 1 is administered to the cat having a serum fructosamine concentration of 450 μmol / L or greater prior to the initiation of treatment.

39. 36. The method of any one of claims 1 to 35, wherein Compound 1 is administered to the cat having a blood glucose or serum glucose concentration of 170 mg / dL or greater prior to initiation of treatment.

40. The method of any one of claims 28 to 39, wherein serum fructosamine concentrations measured after completion of the management regimen are reduced in the cat.

41. 41. The method of claim 40, wherein the cat's serum fructosamine concentration is reduced by at least about 20% after completion of the management plan.

42. 41. The method of claim 40, wherein the cat's serum fructosamine concentration is reduced by at least about 30% after completion of the management plan.

43. 41. The method of claim 40, wherein the cat's serum fructosamine concentration is reduced by at least about 40% after completion of the management plan.

44. 41. The method of claim 40, wherein the cat's serum fructosamine concentration is reduced by at least about 50% after completion of the management plan.

45. The method of claim 40, wherein the cat's serum fructosamine concentration is less than 450 μmol / L after completion of the management plan.

46. The method of claim 40, wherein the cat's serum fructosamine concentration is less than 400 μmol / L after completion of the management plan.

47. The method of claim 40, wherein the cat's serum fructosamine concentration is less than 350 μmol / L after completion of the management plan.

48. The method of claim 40, wherein the cat's serum fructosamine concentration is lower than the upper normal limit of the test laboratory's reference range after completion of the management plan.

49. 49. The method of claim 48, wherein the upper limit of normal for the testing laboratory standard is about 356 μmol / L or about 275 μmol / L.

50. 50. The method of any one of claims 30 to 49, wherein blood glucose or serum glucose levels measured after completion of the management regimen are reduced in the cat.

51. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is reduced by at least about 20% after completion of the management regimen.

52. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is reduced by at least about 30% after completion of the management regimen.

53. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is reduced by at least about 40% after completion of the management regimen.

54. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is reduced by at least about 50% after completion of the management regimen.

55. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is less than 250 mg / dL after completion of the management plan.

56. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is less than 200 mg / dL after completion of the management plan.

57. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is less than 170 mg / dL after completion of the management plan.

58. 51. The method of claim 50, wherein the cat's blood glucose or serum glucose concentration is less than 150 mg / dL after completion of the management plan.

59. 59. The method of any one of claims 1 to 58, wherein the feline diabetes is type 1 diabetes.

60. 59. The method of any one of claims 1 to 58, wherein the feline diabetes is type 2 diabetes.

61. The method of any one of claims 35 to 60, wherein the cat in clinical remission maintains a serum fructosamine concentration of 450 μmol / L or less.

62. The method of any one of claims 35 to 60, wherein the cat in clinical remission maintains a serum fructosamine concentration of 350 μmol / L or less.

63. 63. The method of any one of claims 35 to 62, wherein the cat remains in clinical remission for at least one month.

64. 63. The method of any one of claims 35 to 62, wherein the cat remains in clinical remission for at least 3 months.

65. 1. A method for managing diabetes in a cat, comprising administering to a cat in need thereof an effective amount of an SGLT inhibitor or a pharmaceutically acceptable form thereof; wherein the effective amount is 10% to 30% or less of the dose required to cause an increase in the frequency of diarrhea or loose stools in healthy cats.

66. 66. The method of claim 65, wherein the effective amount is no more than 30% of the dose required to cause an increase in the frequency of diarrhea or loose stools in healthy cats.

67. 66. The method of claim 65, wherein the effective amount is no more than 20% of the dose required to cause an increase in the frequency of diarrhea or loose stools in healthy cats.

68. 66. The method of claim 65, wherein the effective amount is 10% or less of the dose required to cause an increase in the frequency of diarrhea or loose stools in healthy cats.

69. 70. The method of any one of claims 65 to 69, wherein the healthy cat is on a diet of commercially available dry food.

70. 70. The method according to any one of claims 65 to 69, wherein said effective amount is a dose that produces about 90% of the maximum pharmacodynamic effect of said SGLT inhibitor.

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