Diabetes Mellitus, Type 2, Diabetes Mellitus With Hypoglycemia, Hypoglycemia, Hypoglycemic Episode
Conditions
Keywords
Hypoglycaemia, Platelet activity, Type 2 diabetes mellitus
Brief summary
This experimental study is planned to investigate the impact of hypoglycaemia on platelet activation parameters (PAP) during a hyperinsulinaemic hypoglycaemic clamp study. The hypothesis that hypoglycaemia in patients with Diabetes Mellitus, Type 2 (T2DM) leads to increased platelet activation will be tested.
Detailed description
Increased platelet activation is significantly involved in the pathophysiology of micro- and macrovascular diabetic complications. Previously performed studies suggested platelet activation in both, hyper- and hypoglycaemic states, leading to a potentially increased risk for thromboembolic complications. Hypoglycaemia, in particular severe hypoglycaemic episodes, has been associated with increased cardiovascular or overall mortality in previous studies. Potential mechanisms include arrhythmias or increased risk for thromboembolism, based on platelet activation and/or hypercoagulability. The aim of this experimental study is to investigate the impact of hypoglycaemia on platelet activation parameters (PAP) during a hyperinsulinaemic hypoglycaemic clamp study. We hypothesize that Hypoglycaemia in patients with T2DM leads to increased platelet activation. The primary objective is to investigate platelet activation during different levels of hypoglycaemia induced by a stepwise hyperinsulinaemic, hypoglycemic clamp experiment in patients with T2DM. Active study duration will be 5 days for each study participant. 14 subjects with T2DM without history of cardiovascular events or manifest atherosclerosis will be enrolled. During this monocentric, single arm, open, mechanistic trial platelet activation and recovery at one week after the clamp experiment, changes of pro-atherothrombotic markers during the hypoglycaemic clamp as well as counter regulatory hormone response during the clamp will be investigated.
Interventions
OTHEREuglycaemic Clamp
All 14 subjects will undergo an euglycaemic clamp at Visit 2 with a plasma Glucose target of 5.5 mmol/L +/- 10% (4 timepoints for platelet activity parameter blood sampling)
OTHERHyperinsulinaemic/Hypoglycaemic Clamp
All 14 subjects will undergo a hypoglycaemic/hyperinsulinaemic clamp at Visit 3 with 4 timepoints for platelet activity Parameter blood sampling 30 minutes after reaching certain plasma glucose plateaus (5.5 mmol/L; 3.5 mmol/L; 2.5 mmol/L; after recovery again at 5.5 mmol/L)
Sponsors
Merck Sharp & Dohme LLC
Medical University of Graz
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
BASIC_SCIENCE
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 64 Years
Healthy volunteers
No
Inclusion criteria
* Male or female aged 18-64 years (both inclusive) at the time of signing informed consent * Subjects diagnosed with type 2 diabetes (diagnosed regarding world health organization \[WHO\] criteria) and on stable treatment for a period of 90 days prior to screening with metformin as monotherapy or diet only. Stable is defined as unchanged dose * Body mass index (BMI) between 20.0 and 35.0 kg/m2 (both inclusive) * HbA1c between 43 and 64 mmol/mol (6.0% - 8.0%) (both inclusive) * No use of platelet inhibiting therapy (e.g. aspirin, clopidogrel, ticagrelor, prasugrel)
Exclusion criteria
* All other forms of diabetes (type 1 diabetes, gestational diabetes) than type 2 diabetes mellitus * Treatment with any glucose lowering agent(s) other than metformin in a period of 60 days before screening. An exception is short-term treatment (≤ 7 days in total) with insulin due to intercurrent illness * Impaired hypoglycaemic awareness determined at the discretion of the investigator * Medical history of arrhythmia as atrial fibrillation, atrial flutter, atrioventricular dissociation disorders or ventricular arrhythmias * Previously known cardiovascular disease and / or past cardiovascular events, or past episodes of a congestive heart failure syndrome (NYHA II - NYHA IV) * Severe hypoglycaemic event requiring third party help in the last 6 months * Known allergy to human insulin or dextrose solution * Clinically significant abnormal haematology, biochemistry, lipids, hormones, coagulation or urinalysis * Uncontrolled hypertension defined as resting blood pressure at screening (after resting for 5 min, measured in sitting position) outside the range of 90-160 mmHg for systolic or 50-100 mmHg for diastolic * Chronic liver failure with severe liver dysfunction as assessed by the investigator * Alanine Aminotransferase (ALT) or Aspartate Aminotransferase (AST) levels \> 3x upper Limit of normal (ULN) * estimated Glomerular Filtration Rate (eGFR) \<45 ml/min/1,73 m2 * Any musculoskeletal disorders holding back from stay in bed in a lying position during the time of the clamp experiments * Treatment with beta-blockers, antiarrhythmic agents or neuroleptic drugs * Active smoker or intake of illicit substances * Regular intake of nonsteroidal anti-inflammatory drugs (NSAIDs) * Any mental disorders or psychiatric conditions which may interfere with understanding or conduction of study related procedures * Females of child bearing potential without adequate contraceptive methods (i.e. sterilisation, intrauterine device, vasectomised partner; or medical history of hysterectomy)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment | Changes in platelet activation measured by light transmittance aggregometry (LTA) on a Chronolog 700 Lumi-Aggregometer based on Adenosin Diphosphate (ADP %) activation. Visit 3, Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = Plasma Glucose 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = Plasma Glucose 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = Plasma Glucose 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = Plasma Glucose 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment | Quantification of platelet activation markers by flow cytometry in unstimulated blood samples (CD62P, CD63 and binding of PAC-1) using a BD LSRFortessa flow cytometer. Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = Plasma Glucose 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = Plasma Glucose 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = Plasma Glucose 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = Plasma Glucose 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment) |
| Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment | Effects on coagulation parameter plasminogen activator Inhibitor-1 (PAI-1) measured by Enzyme-linked immunosorbent assays. Visit 3, Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = PG 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = PG 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = PG 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = PG 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment) |
| Changes in Coagulation Marker Fibrinogen (g/L) | Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment | Changes in coagulation marker Fibrinogen, measured on a Behring Coagulation System BCS XP Analyzer. Visit 3, Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = PG 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = PG 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = PG 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = PG 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment) |
Countries
Austria
Participant flow
Recruitment details
Recruitment period: Approximately 3 Months (End of February until beginning of May 2018) Recruitmet process: Subjects were recruited by using a local recruitment registry.
Participants by arm
| Arm | Count |
|---|---|
| Clamp Arm All 14 subjects will undergo an Euglycaemic Clamp at Visit 2 as well as a Hyperinsulinaemic/Hypoglycaemic Clamp at Visit 3 with the Intervention of reaching certain plasma glucose levels for blood sampling regarding platelet activity parameters. Infusion of Dextrose and human soluble insuline (Actrapid) will be used to reach certain plasma glucose levels.
Euglycaemic Clamp: All 14 subjects will undergo an euglycaemic clamp at Visit 2 with a plasma Glucose target of 5.5 mmol/L +/- 10% (4 timepoints for platelet activity parameter blood sampling)
Hyperinsulinaemic/Hypoglycaemic Clamp: All 14 subjects will undergo a hypoglycaemic/hyperinsulinaemic clamp at Visit 3 with 4 timepoints for platelet activity Parameter blood sampling 30 minutes after reaching certain plasma glucose plateaus (5.5 mmol/L; 3.5 mmol/L; 2.5 mmol/L; after recovery again at 5.5 mmol/L) | 14 |
| Total | 14 |
Baseline characteristics
| Characteristic | Clamp Arm | — |
|---|---|---|
| Age, Continuous | 55 years STANDARD_DEVIATION 7 | — |
| Angiotensin-converting-enzyme inhibitors | 4 Participants | — |
| Angiotensin-II receptor antagonists | 5 Participants | — |
| Body Mass Index (BMI) | 28.9 kg/m² STANDARD_DEVIATION 3.3 | — |
| Calcium antagonists | 3 Participants | — |
| Cholesterol | 5.22 mmol/L STANDARD_DEVIATION 1.19 | — |
| Daily metformin dose | 1336 mg STANDARD_DEVIATION 599 | — |
| Diabetes duration | 5 years STANDARD_DEVIATION 4 | — |
| Diastolic Blood Pressure (DBP) | 83 mmHg STANDARD_DEVIATION 8 | — |
| Diuretics | 1 Participants | — |
| Fasting plasma glucose | 7.2 mmol/L STANDARD_DEVIATION 0.9 | — |
| HbA1c | 51 mmol/mol STANDARD_DEVIATION 7 | — |
| High-density lipoprotein-cholesterol (HDL-C) | 1.19 mmol/L STANDARD_DEVIATION 0.36 | — |
| Low-density lipoprotein-cholesterol (LDL-C) | 3.13 mmol/L STANDARD_DEVIATION 1.01 | — |
| Race and Ethnicity Not Collected | — | — Participants |
| Sex: Female, Male Female | 10 Participants | — |
| Sex: Female, Male Male | 4 Participants | — |
| Statins | 4 Participants | — |
| Systolic Blood Pressure (SBP) | 133 mmHg STANDARD_DEVIATION 13 | — |
| Triglycerides | 2.02 mmol/L STANDARD_DEVIATION 1.33 | — |
| Weight | 86.4 kg STANDARD_DEVIATION 15.1 | — |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 14 |
| other Total, other adverse events | 0 / 14 |
| serious Total, serious adverse events | 1 / 14 |
Outcome results
Primary
Changes in Platelet Activation Marker Adenosin Diphosphate (%)
Changes in platelet activation measured by light transmittance aggregometry (LTA) on a Chronolog 700 Lumi-Aggregometer based on Adenosin Diphosphate (ADP %) activation. Visit 3, Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = Plasma Glucose 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = Plasma Glucose 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = Plasma Glucose 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = Plasma Glucose 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment)
Time frame: Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Clamp Arm | Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Timepoint 0 | 63 percentage of ADP | Standard Deviation 14.3 |
| Clamp Arm | Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Timepoint 1 | 64.4 percentage of ADP | Standard Deviation 16.7 |
| Clamp Arm | Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Timepoint 2 | 64.4 percentage of ADP | Standard Deviation 13.4 |
| Clamp Arm | Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Timepoint 3 | 61.1 percentage of ADP | Standard Deviation 15.1 |
| Clamp Arm | Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Follow up 1 | 67.7 percentage of ADP | Standard Deviation 11.3 |
| Clamp Arm | Changes in Platelet Activation Marker Adenosin Diphosphate (%) | Follow up 2 | 70.4 percentage of ADP | Standard Deviation 7.3 |
Secondary
Changes in Coagulation Marker Fibrinogen (g/L)
Changes in coagulation marker Fibrinogen, measured on a Behring Coagulation System BCS XP Analyzer. Visit 3, Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = PG 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = PG 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = PG 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = PG 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment)
Time frame: Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Clamp Arm | Changes in Coagulation Marker Fibrinogen (g/L) | Timepoint 0 | 2.49 g/L | Standard Deviation 0.4 |
| Clamp Arm | Changes in Coagulation Marker Fibrinogen (g/L) | Timepoint 1 | 2.54 g/L | Standard Deviation 0.43 |
| Clamp Arm | Changes in Coagulation Marker Fibrinogen (g/L) | Timepoint 2 | 2.64 g/L | Standard Deviation 0.45 |
| Clamp Arm | Changes in Coagulation Marker Fibrinogen (g/L) | Timepoint 3 | 2.49 g/L | Standard Deviation 0.41 |
| Clamp Arm | Changes in Coagulation Marker Fibrinogen (g/L) | Follow up 1 | 2.90 g/L | Standard Deviation 0.5 |
| Clamp Arm | Changes in Coagulation Marker Fibrinogen (g/L) | Follow up 2 | 2.93 g/L | Standard Deviation 0.53 |
Secondary
Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL)
Effects on coagulation parameter plasminogen activator Inhibitor-1 (PAI-1) measured by Enzyme-linked immunosorbent assays. Visit 3, Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = PG 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = PG 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = PG 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = PG 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment)
Time frame: Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Clamp Arm | Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Timepoint 0 | 14.14 ng/mL | Standard Deviation 9.06 |
| Clamp Arm | Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Timepoint 1 | 11.32 ng/mL | Standard Deviation 7.69 |
| Clamp Arm | Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Timepoint 2 | 12.08 ng/mL | Standard Deviation 8.5 |
| Clamp Arm | Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Timepoin 3 | 13.50 ng/mL | Standard Deviation 9.87 |
| Clamp Arm | Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Follow up 1 | 26.26 ng/mL | Standard Deviation 15.14 |
| Clamp Arm | Markers of Coagulation Plasminogen Activator Inhibitor-1 (ng/mL) | Follow up 2 | 25.35 ng/mL | Standard Deviation 14.38 |
Secondary
Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%)
Quantification of platelet activation markers by flow cytometry in unstimulated blood samples (CD62P, CD63 and binding of PAC-1) using a BD LSRFortessa flow cytometer. Hyperinsulinaemic/Hypoglycaemic clamp Experiment: Timepoint 0 (Baseline = Plasma Glucose 100mg/dL \[5.5mmol/L\]) Timepoint 1 (Hypoglycaemia Plateau 1 = Plasma Glucose 63mg/dL \[3.5mmol/L\]) Timepoint 2 (Hypoglycaemia Plateau 2 = Plasma Glucose 45mg/dL \[2.5mmol/L\]) Timepoint 3 (Recovery = Plasma Glucose 100mg/dL \[5.5mmol/L\] Follow up 1 (1 Day after the Clamp Experiment) Follow up 2 (7 +/- 1 day after the Clamp Experiment)
Time frame: Measurement during different levels of hypoglycaemia as well as 1 and 7 days after the clamp experiment
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Clamp Arm | Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Timepoint 0 | 0.023 percentage of PAC1CD62PCD63POS | Standard Deviation 0.019 |
| Clamp Arm | Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Timepoint 1 | 0.027 percentage of PAC1CD62PCD63POS | Standard Deviation 0.028 |
| Clamp Arm | Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Timepoint 2 | 0.032 percentage of PAC1CD62PCD63POS | Standard Deviation 0.032 |
| Clamp Arm | Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Timepoint 3 | 0.031 percentage of PAC1CD62PCD63POS | Standard Deviation 0.033 |
| Clamp Arm | Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Follow up 1 | 0.085 percentage of PAC1CD62PCD63POS | Standard Deviation 0.071 |
| Clamp Arm | Quantification of Platelet Function and Activation PAC1CD62PCD63POS (%) | Follow up 2 | 0.094 percentage of PAC1CD62PCD63POS | Standard Deviation 0.087 |