Mechanisms of Glucose Lowering Effects of Sitagliptin and Metformin Alone and in Combination in Patients With T2DM

Mechanisms of Glucose Lowering Effects of Sitagliptin and Metformin Alone and in Combination in Patients With Type 2 Diabetes Mellitus

In patients with type 2 diabetes with inadequate glycemic control on diet and exercise after 6 weeks of treatment:

Objective: To assess the effects of co-administration of sitagliptin and metformin compared to placebo on hepatic glucose production (HGP).

Hypothesis: After 6 weeks of treatment, the co-administration of sitagliptin and metformin provides greater reduction in hepatic glucose production (HGP) compared to placebo.

Study Overview

• Status: Completed
• Conditions: Diabetes
• Intervention / Treatment: Drug: Placebo; Drug: Sitagliptin; Drug: Metformin; Drug: Sitagliptin + Metformin

Detailed Description

PRIMARY:

In patients with type 2 diabetes with inadequate glycemic control on diet and exercise after 6 weeks of treatment:

Objective: To assess the effects of co-administration of sitagliptin and metformin compared to placebo on hepatic glucose production (HGP).

Hypothesis: After 6 weeks of treatment, the co-administration of sitagliptin and metformin provides greater reduction in hepatic glucose production (HGP) compared to placebo.

SECONDARY:

In patients with type 2 diabetes with inadequate glycemic control on diet and exercise after 6 weeks of treatment:

1. Objective: To assess the effects of co-administration of sitagliptin and metformin compared to placebo on post-meal glucose during meal tolerance test (MTT).

   Hypothesis: After 6 weeks of treatment the co-administration of sitagliptin and metformin provides greater reduction in the total glucose AUC (0-6 hr) during MTT compared to placebo.

2. Objective: To assess the effects of co-administration of sitagliptin and metformin compared to placebo on fasting plasma glucose (FPG).

   Hypothesis: After 6 weeks of treatment the co-administration of sitagliptin and metformin provides greater reduction in FPG compared to placebo.

3. Objective: To assess the effects sitagliptin alone compared to placebo on HGP. Hypothesis: After 6 weeks of treatment, sitagliptin alone provides greater reduction in HGP compared to placebo

EXPLORATORY OBJECTIVES:

(i) Objective: after 6 weeks of treatment, to assess the effects co-administration of sitagliptin and metformin compared to placebo on:

1. active and inactive incretin concentrations (fasting and post-meal GLP-1 and fasting and post-meal GIP).
2. glucagon concentration (fasting and post-meal).
3. parameters of insulin secretion and insulin sensitivity.

4. splanchnic glucose uptake.

   (ii) Objective: after 6 weeks of treatment, to assess the effects co-administration of sitagliptin and metformin compared to treatment with sitagliptin alone and metformin alone on:

5. glucose concentration (fasting and total glucose AUC [0-6 hr]).
6. active and inactive incretin concentrations (fasting and post-meal GLP-1 and fasting and post-meal GIP).
7. glucagon concentration (fasting and post-meal).
8. parameters of insulin secretion and insulin sensitivity.
9. HGP.
10. splanchnic glucose uptake. (iii) Objective: after 6 weeks of treatment, to assess the effects of sitagliptin alone and metformin alone compared to placebo on:
11. glucose concentration (fasting and total glucose AUC [0-6 hr]).
12. active and inactive incretin concentrations (fasting and post-meal GLP-1 and fasting and post-meal GIP).
13. glucagon concentration (fasting and post-meal).
14. parameters of insulin secretion and insulin sensitivity.
15. HGP.
16. splanchnic glucose uptake.

• Study Type: Interventional
• Enrollment (Actual): 16
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Texas
    • San Antonio, Texas, United States, 78207
      • Texas Diabetes Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 70 years (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients must meet all of the following inclusion criteria to participate in the study.
• Patients with screening values/findings outside ranges described in the protocol may have one repeat determination performed and if the repeat value satisfies the criterion, they may continue in the screening process.
• If the repeat value does not satisfy the criterion, the principal investigator will review the abnormal laboratory value and decide whether the subject may continue in the screening process.
• All screening laboratory measurements are to be performed after an overnight fast ≥10 hours in duration.
• Patients must be able to communicate meaningfully with the investigator and must be legally competent to provide written informed consent.
• Patients can be either male or female.
• Patients are ≥18 and ≤70 years of age on the day of signing informed consent.
• Patients must meet the current American Diabetes Association criteria for the diagnosis of type 2 diabetes mellitus
• Patients must be on diet or diet plus exercise therapy.
• Patients must have a HbA1c ≥ 7.5% and ≤ 9.5%
• Patients must have a BMI of 23-40 kg/m2

• Patients must have the following laboratory values:

  • Hematocrit Males ≥ 34 vol%
  • Females ≥ 33vol%
  • Serum creatinine ≤ 1.5 mg/dL in males and ≤ 1.4 mg/dL in females
  • AST (SGOT): ≤ 2.5 times upper limit of normal
  • ALT (SGPT): ≤ 2.5 times upper limit of normal
  • Alkaline phosphatase ≤ 2.5 times upper limit of normal
  • If serum creatinine is > 1.5 mg/dl in males and > 1.4 mg/dl in females, the Principal Investigator can include the patient if the measured GFR is >70 ml/min (24 hour creatinine clearance)
• Patients must have been on a stable dose of allowed chronic medications for ≥30 days prior to entering the study.
• Only patients whose body weight has been stable (±4 pounds) over the three months prior to the study will be included.

Exclusion Criteria:

• Patients are excluded from participation in the study if they meet any of the following criteria:

  • Patient has type 1 diabetes.
  • Patient has received insulin for more than one week within the previous year prior to entry.
  • Patient has been treated with exenatide or a non-TZD, oral antihyperglycemic agent within the last 2 months or with a TZD (pioglitazone or rosiglitazone) within the last 4 months.
  • Patient is receiving any medications with known adverse effects on glucose tolerance (e.g., systemic glucocorticoids, psychotropic drugs like clozapine, olanzapine, haloperidol, risperidone). Note: Patients may be taking stable doses of estrogens, other hormonal replacement therapy, or lipid and blood pressure lowering agents if the patient has been on these agents for the prior three months.
  • Patient has evidence of a significant cardiovascular disorder within 6 months of signing informed consent (e.g. acute coronary syndrome, coronary artery intervention, stroke or transient ischemic neurological disorder) or has New York Heart Association Classification greater than Class 2; or has significant findings on ECG (other than non-specific ST-T wave changes); or peripheral vascular disease (history of claudication); or has dyspnea on exertion of one flight or less, or abnormal breath sounds on auscultation.
  • Patient has a history of intolerance or hypersensitivity to a DPP-4 inhibitor or to metformin.
  • Patient is pregnant or plans to become pregnant within the projected duration of the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Placebo; Placebo to be provided for 6 weeks	Drug: Placebo; Placebo 6 weeks; Other Names: Placebo tablet
Experimental: Sitagliptin; Sitagliptin to be provided for 6 weeks	Drug: Sitagliptin; tablet, 100 mg/day, 6 weeks; Other Names: Januvia
Experimental: Metformin; Metformin to be provided for 6 weeks	Drug: Metformin; tablet, 1000 mg/ bid, 6 weeks; Other Names: Glucophage
Experimental: Sitagliptin+Metfromin; Sitagliptin + Metformin combined will be provided for 6 weeks	Drug: Sitagliptin + Metformin; tablet, Sitagliptin (100mg/day) + tablet, Metformin (1000 mg/bid), 6 weeks; Other Names: Januvia and glucophage

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Objective: Comparisons of the Effects of Co-administration of Sitagliptin and Metformin Alone or in Combination Versus Placebo on Baseline Endogenous Glucose Production (EGP).	Baseline endogenous glucose production prior to a mixed meal tolerance test (placebo) and following 6 weeks of either sitagliptin, metformin or sitagliptin plus metformin combination therapy in all 16 participants	6 weeks
Average of Plasma Glucose During Mixed Meal Tolerance Test (MTT) Compared to Baseline Plasma Glucose to Post Therapy (6-weeks).	The degree of suppression of baseline endogenous glucose production was measured in absolute values and as a percent of basal values at the end of each 6-week therapeutic period. The absolute values obtained in each sequence study group (both basal and post-meal) were compared amongst all groups.	6 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fasting Plasma Glucose 6 Weeks After Therapy	Basal pasma glucose was determined with the glucose oxidase method after each specific 6 week treatment. The absolute values obtained of basal plasma glucose at the end of each 6-week therapeutic period in each sequence study group (both basal and post-meal) were compared amongst all groups.	6 weeks
Changes in Plasma Glucose Post-MTT After Each Six Weeks of Therapy Compared to Baseline	The absolute values of mean plasma glucose post-meal (360 minutes)were determined after each specific 6 week treatment and these absolute values after each specific sequence therapy were compared amongst all groups.	360 min

Collaborators and Investigators

• Sponsor: The University of Texas Health Science Center at San Antonio
• Investigators: Principal Investigator: Eugenio Cersosimo, MD, University of TX Health Science Center

Publications and helpful links

General Publications

• Solis-Herrera C, Triplitt C, Garduno-Garcia Jde J, Adams J, DeFronzo RA, Cersosimo E. Mechanisms of glucose lowering of dipeptidyl peptidase-4 inhibitor sitagliptin when used alone or with metformin in type 2 diabetes: a double-tracer study. Diabetes Care. 2013 Sep;36(9):2756-62. doi: 10.2337/dc12-2072. Epub 2013 Apr 11.

Study record dates

Study Major Dates

• Study Start: October 1, 2009
• Primary Completion (Actual): June 1, 2012
• Study Completion (Actual): October 1, 2012

Study Registration Dates

• First Submitted: January 8, 2009
• First Submitted That Met QC Criteria: January 9, 2009
• First Posted (Estimate): January 12, 2009

Study Record Updates

• Last Update Posted (Estimate): December 13, 2013
• Last Update Submitted That Met QC Criteria: December 11, 2013
• Last Verified: December 1, 2013

More Information

Terms related to this study

• Keywords: Diabetes
• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Endocrine System Diseases; Diabetes Mellitus; Hypoglycemic Agents; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Protease Inhibitors; Incretins; Dipeptidyl-Peptidase IV Inhibitors; Metformin; Sitagliptin Phosphate
• Other Study ID Numbers: 35464