Pathophysiological crosstalk between chronic obstructive pulmonary disease and type 2 diabetes mellitus: implications for SGLT2 inhibitor–based intervention

The intertwined global epidemics of chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2DM) pose an increasing challenge in chronic disease management, constituting a clinically significant bidirectional threat. This review integrates current evidence to propose a pathological interactive axis underlying this comorbidity, driven by shared risk factors such as smoking, obesity, and physical inactivity, and mediated through interconnected inflammatory signaling (e.g. IL-6/NF-κB and NLRP3/IL-1β), metabolic dysregulation, and oxidative stress. Within this framework, pulmonary inflammation in COPD may exacerbate systemic metabolic abnormalities, whereas chronic hyperglycemia and insulin resistance in T2DM may, in turn, aggravate lung injury, sustaining a self-perpetuating cycle of multi-organ dysfunction. Against this background, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a pharmacological class of interest due to their pleiotropic metabolic and anti-inflammatory properties. Experimental and indirect clinical evidence suggests that SGLT2i may modulate key inflammatory and oxidative stress pathways, including macrophage polarization, AMPK/NF-κB/NLRP3 signaling, mitochondrial protection, and Nrf2-SIRT1 activation. In addition, SGLT2i-associated improvements in body weight, metabolic efficiency, and cardiopulmonary loading may indirectly influence pulmonary-metabolic interactions. However, evidence for direct benefits on COPD-specific clinical outcomes remains limited and largely hypothesis-generating. Despite these mechanistic insights, substantial gaps remain regarding cross-organ molecular interactions, the role of hypoxia, and translational limitations of current models. Future research should prioritize dedicated randomized controlled trials, advanced single-cell and spatial omics approaches, and integrated digital health strategies to refine individualized SGLT2i-based interventions and advance multi-organ protective therapies in this complex patient population.