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The resulting oxidative overload disrupts redox-sensitive pathways (e.g., NF-B, Nrf2), promoting inflammation, fibrosis, and cellular apoptosis (Fountoulakis et al., 2025)

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Key Highlights from REIMAGINE 13 REIMAGINE 1 (Diet & Exercise Alone) 40 Weeks HbA1c reduction: 1.8% Weight loss: 13.8% Baseline HbA1c: 7.8% REIMAGINE 2 (Metformin SGLT2 Inhibitor) 68 Weeks HbA1c reduction: 1.91% Weight loss: 14.2% Demonstrated superiority over semaglutide 2.4 mg: * HbA1c: 1.91% vs 1.75% * Weight loss: 14.2% vs 10.2% REIMAGINE 3 (Add-on to Basal Insulin) 40 Weeks HbA1c reduction: 2.33% Weight loss: 12.0% Achieved meaningful metabolic improvements despite background insulin therapy

These studies indicate an oncogenic effect of L-2-HG and the association of L-2-HG with tumorigenesis under hypoxic conditions