Systematic comparison of gliflozins identifies a selective anti-calcifying effect of canagliflozin beyond canonical SGLT2 inhibition

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) provide important cardiorenal benefits in chronic kidney disease (CKD), but their effects on vascular calcification remain conflicting. Whether potential anti-calcifying effects are shared across gliflozins or involve mechanisms beyond canonical SGLT2 inhibition is unknown. Methods: We systematically compared canagliflozin, dapagliflozin and empagliflozin in a high-phosphate diet-induced mouse model of vascular calcification and complementary ex vivo and in vitro models, including rodent and human vascular tissues and vascular smooth muscle cells (VSMCs). Aortic transcriptional response was investigated by RNA sequencing. VSMC calcification, proliferation, migration, viability, glucose uptake and bioenergetics were investigated using complementary cellular assays, including OsteoSense staining, Annexin V/propidium iodide staining, radiolabeled 2-deoxyglucose uptake and Seahorse ATP rate analysis. SGLT2/1 expression was examined by RT-qPCR, Western blotting and immunofluorescence. We also evaluated sotagliflozin, a dual SGLT1/2 inhibitor, and mizagliflozin, a selective SGLT1 inhibitor. Results: Among the three gliflozins, only canagliflozin significantly reduced aortic calcification in vivo. Its anti-calcifying effect was also observed in rodent aortic rings, human vascular explants, cultured VSMCs and aortic rings from diabetic db/db mice. Aortic RNA-seq revealed that canagliflozin partially reversed HPD-induced transcriptional alterations, including changes in pro-calcific signaling and cellular metabolism, while some endothelial and inflammatory responses were shared among gliflozins. In mouse VSMCs, canagliflozin reduced calcification across all tested concentrations, dose-dependently decreased osteogenic marker expression, and reduced proliferation and migration. Increased apoptotic and damaged cell fractions were observed at higher concentrations, but not at lower concentrations. Canagliflozin also reduced glucose uptake and mitochondrial ATP production, without significantly affecting glycolytic ATP production. Neither dapagliflozin nor empagliflozin reproduced these cellular and metabolic effects at any of the concentrations tested. SGLT2 and SGLT1 expression was low or undetectable in vascular tissues and cells, and neither sotagliflozin nor mizagliflozin reproduced the anti-calcifying effect of canagliflozin in vivo or in vitro. Conclusions: Canagliflozin exhibits a selective anti-calcifying profile among the gliflozins tested, associated with changes in VSMC responses and cellular metabolism. These findings suggest that its vascular protective effects may involve mechanisms beyond canonical SGLT2 inhibition.