The Role of the Adrenergic System in Hypoglycaemia Induced Inflammatory Response in People With Type 1 Diabetes and People Without Type 1 Diabetes-RAID-II (RAID-II)

The goal of this trial is to study the effect that adrenaline has on the immune reaction seen during a low blood sugar. People with type 1 diabetes do not produce their own insulin. The cells in the pancreas that produce insulin are destroyed. People with type 1 diabetes require daily insulin administration. As a consequence of this insulin therapy the blood sugar can dip too low, causing symptoms such as confusion, irritation and tiredness. This is called hypoglycaemia. Hypoglycaemia has been associated with an increased risk for cardiovascular disease such as heart attacks. During hypoglycaemia the immune system is activated. The immune system consists of white blood cells which produce cytokines, these are proteins used to kill pathogens such as bacteria. During hypoglycaemia there are no pathogens but the cytokines are still produced, leading to unwanted damage. A previous study performed by our research group showed that the immune system activation caused by hypoglycaemia is associated with the stress hormone adrenaline. Adrenaline is released by the body in moments of stress such as during running or bungee jumping. Adrenaline is also released by the body during hypoglycaemia to increase the sugar level. Our hypothesis is that adrenaline activates the immune system during hypoglycaemia. Adrenaline acts in the body through two receivers, these are called alpha and beta receptors. These are present on almost all cells in the body especially on the immune cells. With the study we want to study the situation where there is a hypoglycaemia without the adrenaline. We will achieve this by lowering the blood sugar in participants. During the low blood sugar we will administer two drugs, which will attach themselves to the adrenaline receivers, the alpha and beta receptor. With this method we hope to block the adrenaline effects and with that block the immune response caused by adrenaline.

Study Overview

• Status: Active, not recruiting
• Conditions: Inflammation; Diabetes Mellitus, Type 1
• Intervention / Treatment: Drug: hyperinsulinaemic hypoglycaemic clamp; Drug: Propranolol Hydrochloride 1 MG/ML; Drug: Phentolamine

Detailed Description

Rationale: Hypoglycaemia has shown to cause a sustained pro-inflammatory response which could promote a pro-atherogenic state and explain the association between hypoglycaemia and cardiovascular events. This pro-inflammatory response has been linked to the adrenaline response to hypoglycaemia. Adrenergic blockade with α and β adrenergic receptor antagonists (ARA) has shown to blunt the leukocyte response after hypoglycaemia induction and adrenaline administration. Whether and to what degree a combined blockade blunts the hypoglycaemia induced pro-inflammatory response is unknown.

Objective: to examine the effect of adrenergic inhibition on the hypoglycaemia induced inflammatory response (e.g. leukocyte phenotype, cytokines, inflammatory proteins) by performing a hyperinsulinaemic hypoglycaemic glucose clamp alongside infusion of α-ARA and β-ARA. Secondary objectives consist of the effect of adrenergic blockade during hypoglycaemia on atherogenic parameters and glucose metrics ( e.g. time in range).

Study design: Intervention study with a cross-over design

Study population: Potentially eligible adult ( 16 - 75 years) participants will be recruited through social media, the Radboudumc outpatient clinic and other advertisements. We will recruit a total of 24 individuals, i.e. 12 healthy participants and 12 participants with type 1 diabetes. Participants with type 1 diabetes will be twice ( as there are two investigational days) equipped with a blinded continuous glucose monitoring device (CGM) during the test, which will measure interstitial glucose levels for a total of 10 days.

Intervention: All participants will undergo a hyperinsulinaemic hypoglycaemic glucose clamp ( nadir 2.8 mmol/L). During the clamp the participants will be randomized to receive an infusion of saline or an infusion of phentolamine and propranolol. This will be done using a cross-over design. The participants will undergo both the saline and adrenergic blockade.

Main study parameters/endpoints: The main study parameter will be the monocyte count after 60 minutes hyperinsulinaemic hypoglycaemic clamp and adrenergic blockade during the clamp.

• Study Type: Interventional
• Enrollment (Estimated): 24
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Netherlands
  • Gelderland
    • Nijmegen, Gelderland, Netherlands, 6525 GA
      • Radboud University Medical Center, Nijmegen, Netherlands

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Overall inclusion criteria:

  • Ability to provide written informed consent
  • Body-Mass Index: 18,5-35 kg/m2
  • Age ≥16 years, ≤ 75 years
  • Blood pressure: <140/90 mmHg
  • Non-smoking
  • Electrocardiogram not showing any serious arrythmias (premature ventricular complexes and premature atrial complexes accepted)

Diabetes group specific criteria:

• Insulin treatment according to basal-bolus insulin regimen (injections or insulin pump)
• Duration of diabetes > 1 year
• HbA1c < 100 mmol/mol,

Exclusion Criteria:

• Any event of cardiovascular disease in the past 5 years (e.g. myocardial infarction, stroke, symptomatic peripheral arterial disease)
• Pregnancy or breastfeeding or unwillingness to undertake measures for birth control
• Active epilepsy ( with the need for treatment)
• Allergy for sulphite
• Active asthma with use of β2-bronchodilators or obstructive lung disease
• Current treatment with Alpha- or beta-blockers (e.g. doxazosin, propranolol)
• History of clinical significant Arrhythmias
• Use of immune-modifying drugs or antibiotics
• Use of antidepressants ( Including monoamine oxidase inhibitors, tricyclic antidepressants and serotonin-reuptake inhibitors)
• Use of antipsychotics
• Use of statins with the inability to stop statins >2 weeks before the investigational day.
• Proliferative retinopathy
• Nephropathy with an estimated glomerular filtration rate (by Chronic Kidney Disease Epidemiology Collaboration equation, CKD-EPI) ˂60ml/min/1.73m2

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Participants without type 1 diabetes; The participants without type 1 diabetes	Drug: hyperinsulinaemic hypoglycaemic clamp; Insulin will be infused at a continuous rate of 60 mU∙m-2 ∙min-1 and glucose 20% will be infused at a variable rate, aiming for stable plasma glucose levels of 5.0 mmol/L. The infusion rate of glucose will be adjusted by plasma glucose levels, measured at 5-minute intervals. After 30 minutes of stable euglycaemia, plasma glucose levels will be allowed to drop gradually to 2.8 mmol/L and will be maintained at this level for 60 minutes. Then, insulin infusion and adrenergic blockade infusions will be stopped. Glucose infusion will be increased and then tapered until stable euglycaemia plasma levels are reached.; Drug: Propranolol Hydrochloride 1 MG/ML; When euglycaemic level of 5.0mmol/L is achieved we will start the adrenergic blockade which will continue throughout euglycaemia and hypoglycaemia. The participants will be administered a bolus of phentolamine of 70µg/kg followed by a dose of 7.0µg/kg/min continuous infusion and a bolus of propranolol of 14µg/kg followed by a dose of 1.4µg/kg/min.; Drug: Phentolamine; When euglycaemic level of 5.0mmol/L is achieved we will start the adrenergic blockade which will continue throughout euglycaemia and hypoglycaemia. The participants will be administered a bolus of phentolamine of 70µg/kg followed by a dose of 7.0µg/kg/min continuous infusion and a bolus of propranolol of 14µg/kg followed by a dose of 1.4µg/kg/min.
Active Comparator: Participants with type 1 diabetes	Drug: hyperinsulinaemic hypoglycaemic clamp; Insulin will be infused at a continuous rate of 60 mU∙m-2 ∙min-1 and glucose 20% will be infused at a variable rate, aiming for stable plasma glucose levels of 5.0 mmol/L. The infusion rate of glucose will be adjusted by plasma glucose levels, measured at 5-minute intervals. After 30 minutes of stable euglycaemia, plasma glucose levels will be allowed to drop gradually to 2.8 mmol/L and will be maintained at this level for 60 minutes. Then, insulin infusion and adrenergic blockade infusions will be stopped. Glucose infusion will be increased and then tapered until stable euglycaemia plasma levels are reached.; Drug: Propranolol Hydrochloride 1 MG/ML; When euglycaemic level of 5.0mmol/L is achieved we will start the adrenergic blockade which will continue throughout euglycaemia and hypoglycaemia. The participants will be administered a bolus of phentolamine of 70µg/kg followed by a dose of 7.0µg/kg/min continuous infusion and a bolus of propranolol of 14µg/kg followed by a dose of 1.4µg/kg/min.; Drug: Phentolamine; When euglycaemic level of 5.0mmol/L is achieved we will start the adrenergic blockade which will continue throughout euglycaemia and hypoglycaemia. The participants will be administered a bolus of phentolamine of 70µg/kg followed by a dose of 7.0µg/kg/min continuous infusion and a bolus of propranolol of 14µg/kg followed by a dose of 1.4µg/kg/min.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Monocyte count after 60 minutes of hypoglycaemia and adrenergic blockade	The number of monocytes following 60 minutes hypoglycaemia and adrenergic blockade compared to baseline. Adrenergic blockade using Phentolamine and Propranolol intravenously. Expressed in 10^3/µl measured using a sysmex machine.	After 60 minutes of hypoglycaemia and adrenergic blockade

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Leukocyte count at the time points	Leukocyte count at the time points 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia, +1 day, +3 days and 1 week after of hypoglycaemia (e.g. Monocytes, granulocytes, lymphocytes).	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia, +1 day, +3 days and 1 week after of hypoglycaemia
Ex vivo production of pro- and anti-inflammatory cytokines and chemokines	Ex vivo production of pro- and anti-inflammatory cytokines and chemokines after ex vivo stimulation of isolated leukocytes, including Tumor necrosis factor-α, Interleukin-6, Interleukin-10 and Interleukin-1β, 1β	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia, +1 day, +3 days and 1 week after of hypoglycaemia
92 circulating inflammatory proteins	92 circulating inflammatory proteins using Olink Proteomics inflammation panel	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Inflammatory plasma protein ( e.g. high-sensitive crp)	Inflammatory plasma protein using ELISA,(e.g high sensitive-crp)	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Atherogenic parameters	Atherogenic parameters using ELISA including but not limited to, vascular endothelial cell adhesion molecule-1, vascular endothelial cell adhesion molecule-1, E-Selectin, P-selectin, Plasminogen activator inhibitor-1, Plasma Endothelin	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Plasma levels of hormones	Plasma levels of hormones ( Cortisol, insulin, glucagon, growth-hormone, adrenaline, noradrenaline)	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Amount of hypoglycaemic events measured by the blinded continuous glucose monitor	Amount of events	During the full study, 3 days before and 7 days after each investigational day
Variability measured by the blinded continuous glucose monitor	Variability of glucose expressed as a standard deviation of the mean glucose	During the full study, 3 days before and 7 days after each investigational day
Average glucose measured by the blinded continuous glucose monitor	Average glucose during the 10 days of measuring expressed as mmol/L	During the full study, 3 days before and 7 days after each investigational day
Time in range measured by the blinded continuous glucose monitor	Amount of time that glucose is between 3.8 and 10 mmol/L expressed as a percentage	During the full study, 3 days before and 7 days after each investigational day
Amount of plasma glycerol	Amount of plasma glycerol during and after hypoglycaemia	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Amount of Non-esterified fatty acids	Amount of Non-esterified fatty acids (NEFAs) during and after hypoglycaemia	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Untargeted metabolomics profiling	Measuring a panel of amino acids	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Gene expression changes in leukocytes	Gene expression changes in leukocytes (e.g. using RNA sequencing, quantitative PCR)	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Epigenetic changes in leukocytes	Epigenetic changes in leukocytes (e.g. using Assay for Transposase- Accessible Chromatin using sequencing (ATACseq), DNA methylation analysis)	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Functional changes in monocytes	Functional changes in monocytes (e.g. using adhesion assays, differentiation experiments)	0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia
Adrenergic symptoms assessed using the validated Edinburgh Hypoglycaemia Score		0, 30 minutes after euglycaemia, 30 minutes and 60 minutes during hypoglycaemia
Hypoglycaemia awareness using the modified Clarke score		At screening

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
HbA1c expressed in mmol/L		At screening
Serum creatinine for kidney function expressed in umol/L		Once at the screening at least 1 week before the hypoglycaemia
Vitals ( blood pressure and heart rate)	Measured by automatic sphygmomanometer	At both investigational days, every 15 minutes during each investigational day for a total of 8 hours.
Body mass index	Using length and weight expressed in kg/m^2	Once at the screening at least 1 week before the hypoglycaemia
Age		Once at the screening at least 1 week before the hypoglycaemia
Sex	Male or female	Once at the screening at least 1 week before the hypoglycaemia
Duration of diabetes ( years)		Once at the screening at least 1 week before the hypoglycaemia

Collaborators and Investigators

• Sponsor: Radboud University Medical Center
• Investigators: Principal Investigator: Cees Tack, MD, PhD, Radboud University Medical Center (Radboudumc)

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2025
• Primary Completion (Estimated): September 1, 2025
• Study Completion (Estimated): October 1, 2025

Study Registration Dates

• First Submitted: May 8, 2024
• First Submitted That Met QC Criteria: May 14, 2024
• First Posted (Actual): May 21, 2024

Study Record Updates

• Last Update Posted (Actual): July 24, 2025
• Last Update Submitted That Met QC Criteria: July 22, 2025
• Last Verified: July 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Endocrine System Diseases; Pathologic Processes; Metabolic Diseases; Autoimmune Diseases; Immune System Diseases; Glucose Metabolism Disorders; Hypoglycemia; Inflammation; Diabetes Mellitus; Diabetes Mellitus, Type 1; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Neurotransmitter Agents; Anti-Arrhythmia Agents; Adrenergic Agents; Vasodilator Agents; Antihypertensive Agents; Adrenergic beta-Antagonists; Adrenergic Antagonists; Adrenergic alpha-Antagonists; Hypoglycemic Agents; Propranolol; Phentolamine
• Other Study ID Numbers: 115142

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: We will share the study protocol using a data repository accessible through the research team on demand. Starting around 6 months after publication.
• IPD Sharing Time Frame: 6 months after publication
• IPD Sharing Access Criteria: The coordinating researcher will review access requests. Seeing as the data are all anonymized access will be granted for additional research in the field of inflammation or diabetes.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No