Ignite Creation Date:
2024-05-05 @ 4:58 PM
Last Modification Date:
2024-10-26 @ 9:26 AM
Study NCT ID:
NCT00353834
Status:
COMPLETED
Last Update Posted:
2018-01-09
First Post:
2006-07-18
Brief Title:
The Effect of Exenatide Compared to Lantus Insulin on Vascular Function in Type 2 Diabetes
Sponsor:
Joslin Diabetes Center
Organization:
Joslin Diabetes Center
Study Overview
Official Title:
The Effect of Exenatide Compared to Lantus Insulin on Vascular Function Before and After a Meal Tolerance Test in Patients With Type 2 Diabetes
Status:
COMPLETED
Status Verified Date:
2017-12
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
The main goals of the study are to evaluate the effect of Exenatide on endothelial-dependent vasodilation as measured by flow mediated dilation FMD to evaluate the effect on endothelial-independent vasodilation as measured by nitroglycerin TNG response and to evaluate the effect on arterial stiffness as measured by pulse wave analysis PWA We will also measure the effects on various markers of endothelial function subclinical inflammation fibrinolysis and oxidative stress The control group for the study will receive Lantus insulin with a goal of similar glycemic control between the treatment and control groups
Specific Aims
We will test the following hypotheses
1 Treatment of patients with type 2 diabetes who are inadequately controlled by monotherapy with a Sulfonylurea SU or Metformin or on combination therapy of a SU and Metformin with Exenatide GLP-1 mimetic will result in improved endothelial dependent vasodilation as measured by FMD as compared to the control group who will be treated with Lantus insulin to achieve comparable HbA1c levels
2 Treatment with Exenatide GLP-1 mimetic will result in improved arterial stiffness as measured by AI by PWA as compared to the control group who will be treated with Lantus insulin to achieve comparable HbA1c levels
3 Endothelial dependent vasodilation as measured by FMD and arterial stiffness as measured by AI measured in the postprandial state following a standard test meal will be improved following treatment with Exenatide as compared to treatment with once daily basal insulin Lantus
4 Treatment will result in no improvement in endothelial-independent vasodilation as measured by a response to TNG as compared to the control group who will be treated with Lantus insulin to achieve comparable HbA1c levels
5 Treatment with Exenatide compared with treatment with Lantus will result in a reduction in various plasma markers of inflammation CRP TNFA IL6 endothelial activation ICAM VCAM endothelin 1 fibrinolysis PAI-1 protein PAI-1 activity and oxidative stress FOX2
Specific Aims
We will test the following hypotheses
1 Treatment of patients with type 2 diabetes who are inadequately controlled by monotherapy with a Sulfonylurea SU or Metformin or on combination therapy of a SU and Metformin with Exenatide GLP-1 mimetic will result in improved endothelial dependent vasodilation as measured by FMD as compared to the control group who will be treated with Lantus insulin to achieve comparable HbA1c levels
2 Treatment with Exenatide GLP-1 mimetic will result in improved arterial stiffness as measured by AI by PWA as compared to the control group who will be treated with Lantus insulin to achieve comparable HbA1c levels
3 Endothelial dependent vasodilation as measured by FMD and arterial stiffness as measured by AI measured in the postprandial state following a standard test meal will be improved following treatment with Exenatide as compared to treatment with once daily basal insulin Lantus
4 Treatment will result in no improvement in endothelial-independent vasodilation as measured by a response to TNG as compared to the control group who will be treated with Lantus insulin to achieve comparable HbA1c levels
5 Treatment with Exenatide compared with treatment with Lantus will result in a reduction in various plasma markers of inflammation CRP TNFA IL6 endothelial activation ICAM VCAM endothelin 1 fibrinolysis PAI-1 protein PAI-1 activity and oxidative stress FOX2
Detailed Description:
The trial is a randomized controlled comparator study Subjects and investigators will not be blinded due to the nature of the treatment After providing informed consent and meeting the inclusion and exclusion criteria subjects will undergo baseline studies then be randomized to either treatment with Exenatide or Lantus insulin to achieve comparable improvement in glycemic control as measured by HbA1c A computer program randomizationcom will be utilized to randomize 72 patients to receive either Exenatide or Lantus The treatment group will receive twice daily injections of Exenatide initially of 5ug BID and increased to 10ug BID after 1 month The control group will receive daily injections of Lantus insulin each evening which will be titrated to achieve blood glucose targets based on self monitoring of blood glucose SMBG as outlined by the American Diabetes Association ADA goal fasting 90-130 peak postprandial less than180 mgdl The subjects on Lantus should achieve this goal by week 6 of the study so that they have six weeks of maximal therapy The control group will receive Lantus with the goal of similar glycemic control between the groups with a goal of HbA1c reduction of 05-15 after 3 months Based on recent data it should be feasible to accomplish similar improvements in glycemia between the groups
The trial will be preceded by a one-week screening and evaluation period during which time the patient will be informed about the trial and qualification will be determined based on the inclusionexclusion criteria as noted below The patient will also be instructed in injection technique and SMBG techniques at the screening visit Subjects will be asked to perform daily fasting blood glucose monitoring and in addition on 2 days per week 1 weekday and 1 weekend day to obtain 6 blood glucose measurements fasting 1-2hours post-breakfast pre-lunch 1-2 hours post-lunch pre-dinner and 1-2 hours post-dinner Baseline studies will then be performed at week 0 including fasting laboratory studies FMD PWA and Meal Challenge Test The subject will then be randomized to receive treatment with either Lantus or Exenatide for 12 weeks duration Repeat studies will then be performed at 12 weeks including repeat of the baseline laboratory studies FMD PWA and Meal Challenge test
ScheduleFlow Chart
Visit 1 week -1 Potential participants will be informed regarding the trial records will be reviewed and inclusionexclusion criteria will be evaluated Informed consent will be administered and a history and physical will be performed They will have baseline labs drawn including HbA1c glucose lipids CBC chemistry renal function liver function and urinalysis If they are female and of reproductive age they will also have a urine HCG performed Subjects will be fasting for this visit
Visit 2 week 0 Participants will come in fasting Interval medical history and medications will be reviewed Vital signs will be obtained PWA and FMD will be performed The patient will then have fasting labs drawn which will include glucose insulin c-peptide lipids free fatty acids FFA CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 The patient will then have a mixed meal time 0 and labs will again be drawn at 15 30 minutes 45 minutes 60 minutes 120 minutes 180 minutes and 240 minutes after the meal challenge measuring glucose insulin c-peptide lipids and FFA At time 120 minutes FWA and FMD will be performed again along with blood samples for CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 At 240 minutes PWA FMD and TNG will be performed
After completion of these tests the patients will be randomized and start treatment with either Exenatide 5ug BID or nightly Lantus beginning the following day Lantus dose will be based on clinical assessment but starting doses will likely be between 10 and 20 units Patients will be instructed in SMBG techniques as well as injection techniques for either Byetta Exenatide or Lantus
Week 1 Telephone contact Review side effects and blood glucoses BGs adjust Lantus if needed and adjust oral hypoglycemic agents OHA in Exenatide treated group if clinically indicated
Week 2 Telephone contact Review side effects and BGs adjust Lantus if needed and adjust OHA in Exenatide treated group if clinically indicated
Visit 3 week 4 Patients will come in Those in the Exenatide group will have the dose increased to 10ug sq BID The patients in the Lantus group will have their fasting BGs reviewed and their dose adjusted Side effects will be reviewed with all subjects Subjects in the Exenatide treated group will have their OHA adjusted if clinically indicated
Week 6 Telephone contact Review BGs and side effects and adjust Lantus if needed Lantus dose should be atclose to maximal dose to achieve target fasting blood glucose goal Subjects in the Exenatide treated group will have their OHA adjusted if clinically indicated
Week 8 Telephone contact Review side effects and BGs adjust Lantus if needed and adjust OHA in Exenatide treated group if clinically indicated
Week 10 Telephone contact Review side effects and BGs adjust Lantus if needed and adjust OHA in Exenatide treated group if clinically indicated At this time we will discuss with the subjects if they are interested in continuing their study medication upon completion of the study We will advise them to call their diabetes provider to then arrange for a prescription that will start upon study completion We will advise them at the beginning of the study to set up a follow up appointment with their provider around the time of study completion We will speak with their diabetes provider if the subject wishes us to do so
Visit 4 week 12 Participants will come in fasting If they are in the Exenatide group we will ask them not to take their morning dose at home but to bring it in with them so that it can be administered within 60 minutes of the meal tolerance test Subjects will also be asked to return any unused study drug at this final visit Interval medical history and medications will be reviewed Vital signs will be obtained PWA and FMD will be performed The patient will then have fasting labs drawn which will include CBC Chem 20 HbA1C urinalysis microalbumin LFTs glucose insulin c-peptide lipids FFA CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 The subjects randomized to Exenatide will then take their morning dose and all subjects will then have a mixed meal time 0 and labs will again be drawn at 15 30 minutes 45 minutes 60 minutes 120 minutes 180 minutes and 240 minutes after the meal challenge measuring glucose insulin c-peptide lipids and FFA At time 120 minutes PWA and FMD will be performed again along with labs for CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 At 240 minutes PWA FMD and TNG will be performed
Methods The Mixed Meal will consist of standard liquid meal Boost which is composed of 615g of carbohydrate 15g of protein and 6g of fat in 360ml with 360 calories The subjects will come in fasting Starting at time 0 the Boost will be consumed over a five minute time period The studies will then be performed on visits 2 and 4
Brachial artery flow mediated dilatation FMD evaluates endothelium-dependent reactivity in the macrocirculation This is carried out in temperature-controlled room 24-26 degrees C with a 30 minute acclimatization period FMD of the brachial artery is measured at rest and during reactive hyperemia using a high-resolution 100 MHz linear array transducer and an HDI Ultramark 9 system Reactive hyperemia is produced by inflating a pneumatic tourniquet distally to the brachial artery to 50 mmHg above the systolic BP for 5 minutes then deflating it Brachial artery diameter is measured before inflation of the cuff and 1-2 minutes after cuff deflation and expressed as the percentage change
Trinitroglycerin-induced vasodilation evaluates endothelium independent vasodilation The brachial artery will be scanned before and 5 minutes after sublingual administration of 400 ug of trinitroglycerin This will be performed only at 240 minutes fifteen minutes after completion of the FMD study to allow for the brachial artery to return to baseline
Pulse wave analysisPWA is another method to evaluate the function of the vasculature The shape of the arterial pressure waveform provides a measure of systemic arterial stiffness All measurements will be made in the right arm using the Sphygmocore Px Atcor Medical Blood Pressure Analysis System Australia in a temperature-controlled room With the wrist slightly extended and supported on a pillow the radial artery of the right arm is flattened with a high fidelity micro manometer using gentle pressure 20 sequential waveforms are acquired and the system software generates an average peripheral and corresponding central waveform which is then subjected to further analysis of augmentation Two pressure peaks characterize the systolic part of the central waveform The first peak results from LV ejection and the second results from the wave reflection The difference between peaks represents the degree to which central arterial pressure is augmented by wave reflection AP is the absolute increase in pressure from the reflected wave and AI is a measure of the contribution that the wave reflection makes to the arterial pressure waveform and is expressed as a percentage of pulse pressure The amplitude and timing of the reflected wave ultimately depends on the stiffness of the small vessels and large arteries and thus is a measure of systemic arterial stiffness
We will enroll 72 subjects to obtain 60 subjects who will complete the study The subjects will have Type 2 diabetes and will be randomized to one of two treatment arms
The trial will be preceded by a one-week screening and evaluation period during which time the patient will be informed about the trial and qualification will be determined based on the inclusionexclusion criteria as noted below The patient will also be instructed in injection technique and SMBG techniques at the screening visit Subjects will be asked to perform daily fasting blood glucose monitoring and in addition on 2 days per week 1 weekday and 1 weekend day to obtain 6 blood glucose measurements fasting 1-2hours post-breakfast pre-lunch 1-2 hours post-lunch pre-dinner and 1-2 hours post-dinner Baseline studies will then be performed at week 0 including fasting laboratory studies FMD PWA and Meal Challenge Test The subject will then be randomized to receive treatment with either Lantus or Exenatide for 12 weeks duration Repeat studies will then be performed at 12 weeks including repeat of the baseline laboratory studies FMD PWA and Meal Challenge test
ScheduleFlow Chart
Visit 1 week -1 Potential participants will be informed regarding the trial records will be reviewed and inclusionexclusion criteria will be evaluated Informed consent will be administered and a history and physical will be performed They will have baseline labs drawn including HbA1c glucose lipids CBC chemistry renal function liver function and urinalysis If they are female and of reproductive age they will also have a urine HCG performed Subjects will be fasting for this visit
Visit 2 week 0 Participants will come in fasting Interval medical history and medications will be reviewed Vital signs will be obtained PWA and FMD will be performed The patient will then have fasting labs drawn which will include glucose insulin c-peptide lipids free fatty acids FFA CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 The patient will then have a mixed meal time 0 and labs will again be drawn at 15 30 minutes 45 minutes 60 minutes 120 minutes 180 minutes and 240 minutes after the meal challenge measuring glucose insulin c-peptide lipids and FFA At time 120 minutes FWA and FMD will be performed again along with blood samples for CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 At 240 minutes PWA FMD and TNG will be performed
After completion of these tests the patients will be randomized and start treatment with either Exenatide 5ug BID or nightly Lantus beginning the following day Lantus dose will be based on clinical assessment but starting doses will likely be between 10 and 20 units Patients will be instructed in SMBG techniques as well as injection techniques for either Byetta Exenatide or Lantus
Week 1 Telephone contact Review side effects and blood glucoses BGs adjust Lantus if needed and adjust oral hypoglycemic agents OHA in Exenatide treated group if clinically indicated
Week 2 Telephone contact Review side effects and BGs adjust Lantus if needed and adjust OHA in Exenatide treated group if clinically indicated
Visit 3 week 4 Patients will come in Those in the Exenatide group will have the dose increased to 10ug sq BID The patients in the Lantus group will have their fasting BGs reviewed and their dose adjusted Side effects will be reviewed with all subjects Subjects in the Exenatide treated group will have their OHA adjusted if clinically indicated
Week 6 Telephone contact Review BGs and side effects and adjust Lantus if needed Lantus dose should be atclose to maximal dose to achieve target fasting blood glucose goal Subjects in the Exenatide treated group will have their OHA adjusted if clinically indicated
Week 8 Telephone contact Review side effects and BGs adjust Lantus if needed and adjust OHA in Exenatide treated group if clinically indicated
Week 10 Telephone contact Review side effects and BGs adjust Lantus if needed and adjust OHA in Exenatide treated group if clinically indicated At this time we will discuss with the subjects if they are interested in continuing their study medication upon completion of the study We will advise them to call their diabetes provider to then arrange for a prescription that will start upon study completion We will advise them at the beginning of the study to set up a follow up appointment with their provider around the time of study completion We will speak with their diabetes provider if the subject wishes us to do so
Visit 4 week 12 Participants will come in fasting If they are in the Exenatide group we will ask them not to take their morning dose at home but to bring it in with them so that it can be administered within 60 minutes of the meal tolerance test Subjects will also be asked to return any unused study drug at this final visit Interval medical history and medications will be reviewed Vital signs will be obtained PWA and FMD will be performed The patient will then have fasting labs drawn which will include CBC Chem 20 HbA1C urinalysis microalbumin LFTs glucose insulin c-peptide lipids FFA CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 The subjects randomized to Exenatide will then take their morning dose and all subjects will then have a mixed meal time 0 and labs will again be drawn at 15 30 minutes 45 minutes 60 minutes 120 minutes 180 minutes and 240 minutes after the meal challenge measuring glucose insulin c-peptide lipids and FFA At time 120 minutes PWA and FMD will be performed again along with labs for CRP TNFA IL-6 ICAM VCAM endothelin 1 PAI-1 protein PAI-1 activity and FOX2 At 240 minutes PWA FMD and TNG will be performed
Methods The Mixed Meal will consist of standard liquid meal Boost which is composed of 615g of carbohydrate 15g of protein and 6g of fat in 360ml with 360 calories The subjects will come in fasting Starting at time 0 the Boost will be consumed over a five minute time period The studies will then be performed on visits 2 and 4
Brachial artery flow mediated dilatation FMD evaluates endothelium-dependent reactivity in the macrocirculation This is carried out in temperature-controlled room 24-26 degrees C with a 30 minute acclimatization period FMD of the brachial artery is measured at rest and during reactive hyperemia using a high-resolution 100 MHz linear array transducer and an HDI Ultramark 9 system Reactive hyperemia is produced by inflating a pneumatic tourniquet distally to the brachial artery to 50 mmHg above the systolic BP for 5 minutes then deflating it Brachial artery diameter is measured before inflation of the cuff and 1-2 minutes after cuff deflation and expressed as the percentage change
Trinitroglycerin-induced vasodilation evaluates endothelium independent vasodilation The brachial artery will be scanned before and 5 minutes after sublingual administration of 400 ug of trinitroglycerin This will be performed only at 240 minutes fifteen minutes after completion of the FMD study to allow for the brachial artery to return to baseline
Pulse wave analysisPWA is another method to evaluate the function of the vasculature The shape of the arterial pressure waveform provides a measure of systemic arterial stiffness All measurements will be made in the right arm using the Sphygmocore Px Atcor Medical Blood Pressure Analysis System Australia in a temperature-controlled room With the wrist slightly extended and supported on a pillow the radial artery of the right arm is flattened with a high fidelity micro manometer using gentle pressure 20 sequential waveforms are acquired and the system software generates an average peripheral and corresponding central waveform which is then subjected to further analysis of augmentation Two pressure peaks characterize the systolic part of the central waveform The first peak results from LV ejection and the second results from the wave reflection The difference between peaks represents the degree to which central arterial pressure is augmented by wave reflection AP is the absolute increase in pressure from the reflected wave and AI is a measure of the contribution that the wave reflection makes to the arterial pressure waveform and is expressed as a percentage of pulse pressure The amplitude and timing of the reflected wave ultimately depends on the stiffness of the small vessels and large arteries and thus is a measure of systemic arterial stiffness
We will enroll 72 subjects to obtain 60 subjects who will complete the study The subjects will have Type 2 diabetes and will be randomized to one of two treatment arms
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None