- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05729282
Glycemic Effect of Diazoxide in NAFLD
Role of Hyperinsulinemia in Non-Alcoholic Fatty Liver Disease (NAFLD) Pathogenesis: Diazoxide Pilot & Feasibility Study
The goal of this clinical trial is to compare a two-week course of diazoxide (at two different doses) and placebo in people with overweight/obesity and insulin resistance (IR) with, or at high risk for, non-alcoholic fatty liver disease (NAFLD). The main questions it aims to answer are how mitigation of compensatory hyperinsulinemia with diazoxide affects parameters of glucose and lipid metabolism (how people with IR and NAFLD respond to lowering high insulin levels so that the investigators can see what happens to how the liver handles fat and sugar).
Participants will:
- Take 27 doses of diazoxide (at 1 mg per kg of body weight per dose [mpk] or 2 mpk) or of placebo, over 14 days
- Take 32 doses of heavy (deuterated) water (50 mL each) over 14 days
- Have blood drawn and saliva collected after an overnight fast on four mornings over the two-week study period
- Consume their total calculated daily caloric needs as divided into three meals per day
- Wear a continuous glucose monitor for the two-week study period
Researchers will compare fasting blood tests at intervals during the study period in participants randomized (like the flip of a coin) to diazoxide 1 mpk, diazoxide 2 mpk, or placebo, to see how the drug treatment affects plasma glucose, serum insulin, and serum lipid parameters (triglycerides, free fatty acids, and apolipoprotein B). They will also consume heavy (deuterated) water to assess de novo lipogenesis (building of new fatty acids by the liver).
Study Overview
Status
Detailed Description
Non-alcoholic fatty liver disease (NAFLD) is an under-appreciated complication of lipid dysmetabolism in type 2 diabetes (T2DM). Although it appears that insulin resistance (IR) is a mechanism common to both, the pathophysiology of its connection to unhealthy fat accumulation in the liver remains unclear. The investigators propose that the hyperinsulinemia that accompanies IR drives the excess hepatic de novo lipogenesis (DNL) that characterizes IR-associated NAFLD (IR-NAFLD). As such, despite its potential impact on glucose tolerance, lowering insulin levels might attenuate the pro-steatotic drive in patients with IR. The investigators' long-term objective, therefore, is to blunt endogenous insulin secretion using the insulin anti-secretagogue diazoxide in order to assess the impact on DNL. However, in order to optimize diazoxide treatment conditions, the investigators must first perform a pilot & feasibility study.
This is a single-center, randomized, double blinded, placebo-controlled clinical trial to provide pilot and feasibility data on the use of diazoxide oral suspension to ameliorate hyperinsulinemia in participants with overweight/obesity and insulin resistance (prediabetic state or elevated Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) score, + fasting hyperinsulinemia) who are diagnosed with, or clinically judged to be at high risk of, NAFLD. Participants will be randomized to one of three parallel arms: placebo, diazoxide at 1 mg per kg of body weight (mpk) per dose, or diazoxide at 2 mpk per dose, for a total of 27 doses over 14 days. They will also consume heavy (deuterated) water for a total of 32 doses of 50 ml over 14 days to measure de novo lipogenesis, an exploratory endpoint. They will present for outpatient blood draws and saliva collections after an overnight fast at four time points during the study course. Additionally, participants will follow a weight-maintaining diet and wear a professional continuous glucose monitor (CGM) throughout.
Study Type
Enrollment (Estimated)
Phase
- Phase 1
Contacts and Locations
Study Contact
- Name: Zachary Sone
- Phone Number: 2123059336
- Email: zds2120@cumc.columbia.edu
Study Locations
-
-
New York
-
New York, New York, United States, 10032
- Recruiting
- Columbia University Irving Medical Center
-
Contact:
- Joshua R Cook, MD, PhD
- Phone Number: 212-305-6289
- Email: jrc2175@cumc.columbia.edu
-
Principal Investigator:
- Joshua R Cook, MD, PhD
-
Sub-Investigator:
- Julia J Wattacheril, MD
-
Sub-Investigator:
- Nur Bedeir, MD
-
Sub-Investigator:
- Lindsey A Bordone, MD
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Adults aged 18-70 years (using highly effective contraception if of childbearing potential)
- Body mass index of 25.0-45.0 kg/m2
- Able to understand written and spoken English and/or Spanish
- Able to have pre-randomization screening labs drawn and study protocol initiated within 30 days of informed consent
- Diagnosed with, or clinically judged to be at high risk for, non-alcoholic fatty liver disease (NAFLD), also known as metabolic-associated fatty liver disease (MAFLD), by hepatologist or other qualified physician
Evidence of insulin resistance, represented by any or all of the following criteria:
i. Meeting either of the American Diabetes Association's definitions for prediabetes or IFG on screening labs:
- Prediabetes: Hemoglobin A1c 5.7-6.4%
- IFG: plasma glucose of 100-125 mg dL-1 after ≥ 8-h fast
and/or
ii. Homeostasis Model of Insulin Resistance (HOMA-IR) score ≥ 2.73
- Fasting hyperinsulinemia (fasting insulin level ≥ 13 µIU/mL) on screening labs
- Written informed consent (in English or Spanish) and any locally required authorization (e.g., Health Insurance Portability and Accountability Act) obtained from the participant prior to performing any protocol-related procedures, including screening evaluations.
Exclusion Criteria:
- Unable to provide informed consent in English or Spanish
Concerns arising at screening visit (any of the following):
i. Documented weight loss of ≥ 5.0% of baseline within the previous 6 months
ii. Abnormal blood pressure (including on treatment, if prescribed) • Systolic blood pressure < 95 mm Hg or > 160 mm Hg, and/or
• Diastolic blood pressure < 65 mm Hg or > 100 mm Hg
iii. Abnormal resting heart rate < 60 bpm or ≥ 100 bpm
• Sinus brady- or tachycardia that has been appropriately evaluated and considered benign by the recruit's personal physician may be permitted at PI's discretion
iv. Abnormal screening electrocardiogram (or if on file, performed within previous 90 d):
- Non-sinus rhythm
- Significant corrected QT segment (QTc) prolongation (≥ 480 ms)
New or previously unknown ischaemic changes that persist on repeat EKG:
•• ST segment elevations
•• T-wave inversions
v. Laboratory evidence of diabetes mellitus:
- Hemoglobin A1c ≥ 6.5%, and/or
- Fasting plasma glucose ≥ 126 mg/dL
vi. Positive qualitative serum β-hCG (human chorionic gonadotropin, beta subunit; i.e., pregnancy test) in women of childbearing potential
vii. Liver function abnormalities
- Transaminases (AST or ALT) > 3.0 x the upper limit of normal, and/or
- Total bilirubin > 1.25 x the upper limit of normal
viii. Abnormal screening triglycerides > 400 mg/dL
ix. Abnormal screening serum electrolytes (any of the following) • Sodium, potassium, chloride, or bicarbonate levels that are considered clinically significant according to the clinical judgment of the PI • Creatinine equating to estimated glomerular filtration rate < 60 mL/min/1.73 m2
x. Uric acid level above the upper limit of normal
xi. Glucose-6-phosphate dehydrogenase below the lower limit of normal
COVID-19 precautions
i. Unwillingness to comply with masking requirements per hospital policy
ii. Active, documented COVID-19 at any time after screening
Reproductive concerns
i. Women of childbearing potential not using highly effective contraception, defined as:
- Surgical sterilization (e.g., bilateral tubal occlusion, bilateral oophorectomy and/or salpingectomy, hysterectomy)
- Combined oral contraceptive pills taken daily, including during the study
- Intrauterine device (levonorgestrel-eluting or copper) active at the time of the study
- Medroxyprogesterone acetate (Depo-Provera®) injection active at the time of the study
- Etonogestrel implants (e.g., Implanon®, etc.) active at the time of the study
- Etonogestrel/ethinyl estradiol vaginal rings (e.g., Nuvaring®, etc.) active at the time of the study
- Norelgestromin/ethinyl estradiol transdermal system (e.g., Ortho-Evra®) active at the time of the study
ii. Women currently pregnant (tested by serum and/or urine β-hCG)
iii. Women currently breastfeeding
Concerns related to glucose metabolism
i. History of having met any of the American Diabetes Association's definitions of diabetes mellitus (i.e., overt diabetes):
- Hemoglobin A1c ≥ 6.5%, or rapid rise in documented HbA1c values causing clinical concern for evolving insulin deficiency
- Plasma glucose ≥ 126 mg/dL after 8-h fast
- Plasma glucose of ≥ 200 mg/dL at 2 h after ingestion of a 75-g glucose load
- Random plasma glucose ≥ 200 mg/dL associated with typical hyperglycemic symptoms, diabetic ketoacidosis, or hyperglycemic-hyperosmolar state
ii. History of gestational diabetes mellitus within the previous 5 years
iii. Use of most antidiabetic medications within the 90 days prior to screening
- Excluded: thiazolidinediones, sulfonylureas, meglitinides, dipeptidyl peptidase-4 (DPP4) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors, amylin mimetics, acarbose, insulin
- Metformin is acceptable provided that recruits meet all of the inclusion criteria at screening
iv. Clinical concern for absolute insulin deficiency (e.g., type 1 diabetes, pancreatic disease)
Concerns related to lipid metabolism
i. Known diagnoses of familial hypercholesterolemia, familial combined hyperlipidemia, or familial hyperchylomicronemia
ii. Use of certain lipid-lowering drugs within the 90 days prior to screening:
- Statins or PCSK9 inhibitors for secondary prevention or for treatment of familial hypercholesterolemia. Statins or PCSK9 inhibitors for primary prevention of ASCVD are acceptable.
- Fibrates (e.g., fenofibrate, clofibrate, gemfibrozil)
- High-dose niacin (>100 mg daily)
Known, documented history (i.e., not to be newly screened/tested for study purposes), at the time of screening, of any of the following medical conditions:
i. Pancreatic pathology, including but not limited to:
- Pancreatic neoplasia, unless appropriately evaluated and considered benign and not producing hormones
- Chronic pancreatitis
- Acute pancreatitis within the previous 5 years
- Autoimmune pancreatitis
- Surgical removal of any portion of the pancreas
ii. Cardiovascular disease (N.B. uncomplicated hypertension is not exclusionary)
- Atherosclerotic cardiovascular disease
- Stable or unstable angina
- Myocardial infarction
- Ischaemic or hemorrhagic stroke, or transient ischaemic attack
- Peripheral arterial disease (claudication)
- Use of dual antiplatelet therapy (aspirin + P2Y12 inhibitor)
- History of percutaneous coronary intervention
- Heart rhythm abnormalities
- Congestive heart failure of any New York Heart Association class
- Symptomatic valvular heart disease (e.g., aortic stenosis)
- Pulmonary hypertension
iii. Chronic kidney disease, Stage 3 or higher (estimated glomerular filtration rate < 60 mL/min/1.73 m2), of any cause
iv. Chronic liver disease other than uncomplicated NAFLD, including but not limited to:
- Advanced liver fibrosis, as determined by non-invasive testing
- Cirrhosis of any etiology
- Autoimmune hepatitis or other rheumatologic disorder affecting the liver
- Biliopathy (e.g., progressive sclerosing cholangitis, primary biliary cholangitis)
- Chronic liver infection (e.g., viral hepatitis, parasitic infestation)
- Hepatocellular carcinoma
Infiltrative disorders (e.g., sarcoidosis, hemochromatosis, Wilson disease)
v. Gout
vi. Chronic viral illness (N.B. diagnosis based only on medical history; the investigators will not test for any of these viruses at any point in this study)
- Hepatitis B virus (HBV), unless previously successfully eradicated with antiviral drugs that have been discontinued for at least 90 days prior to screening
- Hepatitis C virus (HCV) infection, unless previously successfully eradicated with antiviral drugs that have been discontinued for at least 90 d prior to screening
- Human immunodeficiency virus (HIV) infection
vii. Malabsorptive conditions
- Active inflammatory bowel disease (quiescent and off medication is acceptable)
- Celiac disease (in remission on gluten-free diet is acceptable)
- Surgical removal of a significant length of intestine
viii. Active seizure disorder (including controlled with antiepileptic drugs)
ix. Psychiatric diseases that:
- Are or have been decompensated within 1 year of screening, and/or
Require use of anti-dopaminergic antipsychotic drugs associated with significant weight gain/metabolic dysfunction (e.g., clozapine, olanzapine), monoamine oxidase inhibitors, tricyclic antidepressants, or lithium
x. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
- Due to presence of quinine in tonic water placebo
xi. Other endocrinopathies:
- Cushing syndrome (okay if considered in remission after treatment, provided that no exogenous corticosteroids are required)
- Adrenal insufficiency
- Primary aldosteronism
xii. Venous thromboembolic disease (deep vein thrombosis or pulmonary embolism) or any required use of therapeutic anticoagulation
xiii. Active malignancy, or hormonally active benign neoplasm, except allowances for:
- Non-melanoma skin cancer
- Differentiated thyroid cancer (AJCC Stage I only)
- Clinical concern for increased risk of volume overload or hypotension (systolic blood pressure <95 and/or diastolic blood pressure <65 mm Hg), including due to medications and/or heart/liver/kidney problems, as listed above
Use of certain medications currently or within 90 d prior to screening:
i. Prescribed medications used for any of the indications in the preceding list of excluded conditions, or their use within 90 d prior to screening, except allowances for:
- Statins for primary prevention of cardiovascular disease
- Use of drugs prescribed for indications other than the exclusionary diagnoses/purposes listed above (e.g., non-hydantoin antiepileptic drugs used for non-seizure indications, angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) used for uncomplicated hypertension rather than for congestive heart failure, etc.) •• Note, as above, that antidiabetic drugs for any indication (except metformin) within 90 d of screening are excluded
ii. Vasodilating drugs for any indication: hydralazine, nitrates, phosphodiesterase-5 inhibitors (e.g., sildenafil, tadalafil), minoxidil (oral)
iii. Phenytoin or fosphenytoin for any indication
iv. Oral or parenteral corticosteroids (at greater than prednisone 5 mg daily, or equivalent) for more than 3 days within the previous 90 days; topical and inhaled formulations are permitted
v. Fludrocortisone
vi. Opioids
History of certain weight-loss (bariatric) surgeries, including:
i. Roux-en-Y gastric bypass
ii. Biliopancreatic diversion
iii. Restrictive procedures (lap band, sleeve gastrectomy) performed within past 6 months
- Clinical concern for alcohol overuse, including based on chart review and/or by participant's report of consuming more than 14 standard drinks per week for males or more than 7 standard drinks per week for females
Positive urine drug screen, except for:
- Lawfully prescribed medication
- Marijuana/THC positivity is okay, provided that the participant agrees not to use it during the same period that they will abstain from alcohol
- History of severe infection or ongoing febrile illness within 30 days of screening
- Any other disease or condition or laboratory value that, in the opinion of the investigator, would place the participant at an unacceptable risk and/or interfere with the analysis of study data.
- Known allergy/hypersensitivity to any component of the medicinal product formulations (including sulfa drugs), other biologics, IV infusion equipment, plastics, adhesive or silicone, history of infusion site reactions with IV administration of other medicines, or ongoing clinically important allergy/hypersensitivity as judged by the investigator.
- Concurrent enrollment in another clinical study of any investigational drug therapy or use of any biologicals within 6 months prior to screening or within 5 half-lives of an investigational agent or biologic, whichever is longer.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Basic Science
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Double
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Placebo Comparator: Placebo
Participants will ingest a placebo solution (27 doses over 14 days) formulated to approximate the taste of diazoxide oral suspension.
Blinding will occur by completely covering single-dose oral syringes with labels.
|
Flavor-approximate placebo consisting of peppermint extract in diet tonic water, thickened with xanthan gum, provided in label-obscured single-use oral syringes at 2 mg per kg per dose (total of 27 doses over 14 days).
Other Names:
All participants will wear a FreeStyle Libre Pro continuous glucose monitor (CGM) to track glycemic trends in response to study treatments.
Investigators and participants will be blinded to CGM readings until after each participant has completed the trial.
All participants will consume 32 aliquots of deuterated water (2H2O/D2O) 50 mL over 14 days to assess hepatic de novo lipogenesis.
Tracer enrichment will be determined in blood and saliva.
Other Names:
|
Experimental: Diazoxide oral suspension, 1 mg per kg per dose
Participants will ingest diazoxide oral suspension at 1 mg per kg body weight per dose (27 doses over 14 days).
Blinding will occur by completely covering single-dose oral syringes with labels.
|
All participants will wear a FreeStyle Libre Pro continuous glucose monitor (CGM) to track glycemic trends in response to study treatments.
Investigators and participants will be blinded to CGM readings until after each participant has completed the trial.
Diazoxide oral suspension provided in label-obscured single-use oral syringes at 1 mg per kg per dose (total of 27 doses over 14 days).
Other Names:
All participants will consume 32 aliquots of deuterated water (2H2O/D2O) 50 mL over 14 days to assess hepatic de novo lipogenesis.
Tracer enrichment will be determined in blood and saliva.
Other Names:
|
Experimental: Diazoxide oral suspension, 2 mg per kg per dose
Participants will ingest diazoxide oral suspension at 2 mg per kg body weight per dose (27 doses over 14 days).
Blinding will occur by completely covering single-dose oral syringes with labels.
|
All participants will wear a FreeStyle Libre Pro continuous glucose monitor (CGM) to track glycemic trends in response to study treatments.
Investigators and participants will be blinded to CGM readings until after each participant has completed the trial.
Diazoxide oral suspension provided in label-obscured single-use oral syringes at 2 mg per kg per dose (total of 27 doses over 14 days).
Other Names:
All participants will consume 32 aliquots of deuterated water (2H2O/D2O) 50 mL over 14 days to assess hepatic de novo lipogenesis.
Tracer enrichment will be determined in blood and saliva.
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Fasting plasma glucose (absolute values)
Time Frame: Up to Study Day 15
|
Measurement of fasting plasma glucose levels during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: mg/dL).
|
Up to Study Day 15
|
Fasting plasma glucose (relative/change)
Time Frame: Up to Study Day 15
|
Measurement of fasting plasma glucose during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: fold difference and/or Δmg/dL versus other groups).
|
Up to Study Day 15
|
Fasting plasma/serum insulin (absolute values)
Time Frame: Up to Study Day 15
|
Measurement of fasting endogenous insulin levels during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: micro-international units [µIU] per mL).
|
Up to Study Day 15
|
Fasting plasma/serum insulin (relative change)
Time Frame: Up to Study Day 15
|
Measurement of fasting endogenous insulin levels during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: fold difference and/or ΔµIU/mL versus other groups).
|
Up to Study Day 15
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Continuous glucose monitoring (CGM) profile
Time Frame: Up to Study Day 15
|
Measurement of interstitial glucose profiles during treatment with diazoxide 1 mpk vs 2 mpk vs placebo over the 2-week study course
|
Up to Study Day 15
|
Fasting serum or plasma triglycerides (TG) (absolute values)
Time Frame: Up to Study Day 15
|
Measurement of fasting circulating TG during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: mg/dL).
|
Up to Study Day 15
|
Fasting serum/plasma triglycerides (TG) (relative/change)
Time Frame: Up to Study Day 15
|
Measurement of fasting serum TG during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: fold difference and/or Δmg/dL versus other groups).
|
Up to Study Day 15
|
Fasting serum or plasma free fatty acids (FFA) (absolute values)
Time Frame: Up to Study Day 15
|
Measurement of fasting serum FFA (units: mmol/L) during treatment with diazoxide 1 mpk vs 2 mpk vs placebo
|
Up to Study Day 15
|
Fasting serum or plasma free fatty acids (FFA) (relative/change)
Time Frame: Up to Study Day 15
|
Measurement of fasting serum FFA during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: fold difference and/or Δmmol/L versus other groups)
|
Up to Study Day 15
|
Fasting serum/plasma apolipoprotein B (ApoB) (absolute values)
Time Frame: Up to Study Day 15
|
Measurement of fasting serum/plasma ApoB during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: mg/dL)
|
Up to Study Day 15
|
Fasting serum/plasma apolipoprotein B (ApoB) (relative/change)
Time Frame: Up to Study Day 15
|
Measurement of fasting serum/plasma ApoB during treatment with diazoxide 1 mpk vs 2 mpk vs placebo (units: mg/dL)
|
Up to Study Day 15
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Hepatic de novo lipogenesis (absolute values)
Time Frame: Up to Study Day 15
|
Percent incorporation of newly synthesized fatty acids into serum or VLDL TG (units: %)
|
Up to Study Day 15
|
Hepatic de novo lipogenesis (relative/change)
Time Frame: Up to Study Day 15
|
Percent incorporation of newly synthesized fatty acids into serum or VLDL TG (units: fold difference and/or ∆% versus other groups)
|
Up to Study Day 15
|
Deuterium tracer enrichment in body water (measured in blood)
Time Frame: Up to Study Day 15
|
Enrichment of total body water with deuterated water (2H2O/D2O) (units: %)
|
Up to Study Day 15
|
Deuterium tracer enrichment in body water (measured in saliva)
Time Frame: Up to Study Day 15
|
Enrichment of total body water with deuterated water (2H2O/D2O) (units: %)
|
Up to Study Day 15
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Joshua R Cook, MD, PhD, Columbia University
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- AAAU2570
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
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