Tailoring Obesity Treatment Trial (TOTT)

The Impact of Pramlintide on Top of Semaglutide in Obese People With Prediabetes

The two main aims of this clinical study is;

1. To investigate if the results from a series of physiological tests and questionnaires prior to treatment, can be used to predict the treatment response to obesity medication
2. To investigate the effect of combining semaglutide and pramlintide on various aspects of appetite, food preference and eating habits.

The study is planed as a 26 week, double blinded, randomized, placebo controlled trial. The goal is to include N=40. They will all receive weekly semaglutide injections. After 24 weeks they will be randomized to receive either an amylin analog (pramlintide) or placebo as a continuous infusion for two weeks, in addition to weekly semaglutide.

The results from this study will contribute to identifying possible predictors of treatment response, enabling optimal individualized medical weight loss treatment. As well as providing knowledge on the complex interplay between incretin hormones and their effects on appetite and eating habits.

Study Overview

• Status: Withdrawn
• Conditions: Obesity; PreDiabetes; Appetite Regulation
• Intervention / Treatment: Drug: Semaglutide Pen Injector; Drug: Sodium Chloride 0.9% Inj; Drug: Pramlintide Acetate 1 MG/ML

Detailed Description

Obesity is a major global health challenge and the prevalence of obesity is increasing. Presence of obesity increases the risk of several diseases, physical limitations and an increased mortality. When weightloss is wanted in order to avoid or treat some of these diseases, medical weight loss treatment is one of the options. Among these modified gut hormones, such as Glucagon Like Peptide -1 Receptor agonists (GLP-1RA). However, the individual response to GLP-1RA treatments varies considerably. Currently the best predictor of total weight loss is achieved weight loss after three months of treatment. With more pharmaceutical options to come, a trial and error approach is not appropriate. There is a need to identify possible pre-treatment predictors to treatment response.

This is one of the project's main aims. By being able to predict the treatment response, one can tailor the obesity treatment to the individual improving the treatment outcome.

Amylin is co-secreted with insulin from the pancreas in response to meals. It is found to have many similar effects in the body as GLP-1. However their combination, especially on appetite, food preferences and eating pattern is sparsely investigated. This is the other main aim of the project.

This clinical study will be a 26 week, randomized, double-blinded, placebo-controlled trial. Forty overweight (BMI ≥30kg/m2) individuals with pre-diabetes (HbA1c 39-47 mmol/mol) will all receive once-weekly semaglutide for 26 weeks. Semaglutide will be given in escalating doses aiming to reach the maximal dose of 2.4 mg (maximum dosage approved for treatment of overweight), but accepting lower maximal tolerable dosage.

After 24 weeks of treatment, they will be stratified according to their weight loss (<15% or ≧15%) and based on this stratification, block randomized 1:1 to receive either pramlintide or placebo(normal isotonic 0.9% saline solution) in addition to weekly semaglutide. Pramlintide will be continuously infused, starting at a dosage of 7,5 mcg/hour for three days, and if tolerated, the dosage will be increased to 15 mcg/hour for the remaining eleven days. Previous studies have found measurable changes in appetite after a single dosage of pramlintide, and measurable weight loss after two weeks of treatment. For the continuous infusion a commercially available insulin pump will be used.

At study start and, prior to semaglutide treatment, body composition, REE and gastric emptying rate will be measured. Various aspects of appetite will be assessed by the results from the meal tests, the "taste test", appetite assessment and eating related questionnaires. An appetite Visual Analog Scale (VAS) will be measured prior to, and following the standardized meal test and the ad libitum meal test. Satiety will be assessed by a VAS following the standardized meal test. Appetite related sensory specific desire will be assessed by the participants rating of a "taste test" consisting of a variety of small food samples representing the sensory profiles of sweet, sour, salt, bitter, fat, umami/savory and spicy, respectively. The "taste test" will be performed prior to the ad libitum test and as previously described. And satiation will be assessed by measuring calories consumed to reach fullness and terminate the meal at the ad libitum meal test. While the Food pleasure scale, Yale Food Addiction Scale 2.0, Dutch Eating Behavior Questionnaire and The Eating Disorder Quality of Life Scale questionnaires will assess hedonic, emotional and binge- eating patterns and eating related quality of life. The combined results of these physical measurements, questionnaires, appetite and hunger assessments will be used to identify the participants' main obesity driver or obesity "phenotype" similarly as previously described.

These tests will be repeated at the end of the study and the results compared. The "taste test" and ad libitum meal test will also be performed after 24 weeks, prior to the addition of either pramlintide or placebo.

Additionally blood samples will be taken at baseline, after 24 weeks and at the end of the study, measuring biomarkers related to metabolism, bone metabolism and organ specific biomarkers.

• Study Type: Interventional
• Phase: Phase 2; Phase 3

Contacts and Locations

Study Locations

• Denmark
  • Esbjerg, Denmark, 6700
    • University Hospital of Southern Denmark

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

• BMI ≧ 30kg/m2
• HbA1c 39-47 mmol/mol (pre-diabetes)
• Male or female
• Aged >18 years of age and <70 years
• Negative pregnancy test, and willing to use contraceptives during the study period

Exclusion Criteria:

• Presence of diabetes with or without treatment
• Current or recent (<6 months) treatment with GLP1 RA's
• Previous gastrointestinal surgery that might affect gastric emptying, nutritional absorption and postprandial GI peptide production
• History of acute or chronic pancreatitis
• Chronic kidney disease
• Use of any antipsychotic drugs
• Use of any antiresorptive or bone-anabolic drugs or fractures within < 6 months
• Use of systemic oral glucocorticoids within < 6 months
• Newly (< 3 months) initiated hormonal contraceptive or other hormone therapy
• Recent (<3 months) weight loss ≧ 1% of body weight
• Presence of Binge eating disorder

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Semaglutide and placebo; All subjects will receive weekly semaglutide inj. for 26 weeks. After 24 weeks of treatment, this group will be randomized to receive placebo, in addition to semaglutide for the last two weeks of the study.	Drug: Semaglutide Pen Injector; Semaglutide from 0,25mg/week to 2,4mg/week; Other Names: Wegovy; Drug: Sodium Chloride 0.9% Inj; Placebo; Other Names: isotonic saline solution
Experimental: Semaglutide and pramlintide; All subjects will receive weekly semaglutide inj. for 26 weeks. After 24 weeks of treatment, this group will be randomized to receive pramlintide, in addition to semaglutide for the last two weeks of the study.	Drug: Semaglutide Pen Injector; Semaglutide from 0,25mg/week to 2,4mg/week; Other Names: Wegovy; Drug: Pramlintide Acetate 1 MG/ML; Symlin (R) (Pramlintide acetate) 1000mcg/ml, will be administered as a continuous infusion at a rate of 15mcg/hour, equivalent to the daily recommended maximum dosage of 360mcg/day.; Other Names: Symlin

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Change in kilocalorie (kCal) consumption at ad libitum meal test, from baseline, to after 26 weeks of semaglutide of which the last two weeks is with the addition of either pramlintide or placebo	From baseline at the start of the study(week 0), to the end of the study after 26 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Difference in total weight loss between the subgroups (Obesity phenotypes)		From baseline (week 0) to end of study (week 26)
Change in appetite and satiety sensations as measured by Visual Analog Scale (VAS) prior to and following the meal tests	The meal test will be performed at baseline, after 24 weeks and at the end of the study(week 26). Prior to and following the meal tests a VAS measuring appetite and satiety sensation will be answered.	From baseline(week 0) to after 24 weeks, and to the end of the study(week 26)
Change in gastric emptying rate assessed by paracetamol (acetaminophen) test	The gastric emptying test will be performed at baseline (week 0) and at the end of the study (week26).	From baseline (week 0) to end of study(week 26)
Total weight loss	Total weight loss from baseline, after 24 weeks, and at the end of the study( week 26) The results will be repoted as percentage (%) weight loss.	From baseline(week 0) to after 24 weeks, and to the end of the study(week 26)
Total weight loss	Total weight loss from baseline, after 24 weeks, and at the end of the study( week 26) The results will be repoted as total weight loss in Kg	From baseline(week 0) to after 24 weeks, and to the end of the study(week 26)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in sensory specific desires as measured by a taste test	The taste test will be performed at baseline, after 24 weeks, and at the end of the study (week 26)	From baseline (week 0) to after 24 weeks, and to the end of the study (week 26)
Change in hedonic eating behavior as measured by questionnaires	The questionnaires; Food pleasure scale, Yale Food Addiction Scale 2.0, Dutch Eating Behavior Questionnaire and The Eating Disorder Quality of Life Scale questionnaires will assess hedonic, emotional and binge- eating patterns and eating related quality of life. The questionnaires will be answered at baseline(weeks 0) , after 24 weeks and at the end of the study (week 26)	From baseline (week 0) to after 24 weeks, and to the end of the study (week 26)

Collaborators and Investigators

• Sponsor: Esbjerg Hospital - University Hospital of Southern Denmark
• Investigators: Principal Investigator: Claus Bogh Juhl, MD, phd, professor, Head of endocrinology dept.

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2025
• Primary Completion (Actual): April 1, 2025
• Study Completion (Actual): April 1, 2025

Study Registration Dates

• First Submitted: August 28, 2024
• First Submitted That Met QC Criteria: September 25, 2024
• First Posted (Actual): October 1, 2024

Study Record Updates

• Last Update Posted (Actual): April 17, 2026
• Last Update Submitted That Met QC Criteria: April 14, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: obesity; semaglutide; placebo; PreDiabetes; Appetite Regulation; pramlintide; individualized medicine; tailoring treatment; symlin; Anti-Obesity Drugs; Treatment Effect Heterogeneity
• Additional Relevant MeSH Terms: Endocrine System Diseases; Nutrition Disorders; Metabolic Diseases; Overnutrition; Body Weight; Glucose Metabolism Disorders; Diabetes Mellitus; Overweight; Pathological Conditions, Signs and Symptoms; Nutritional and Metabolic Diseases; Signs and Symptoms; Obesity; Prediabetic State; Inorganic Chemicals; Chlorine Compounds; Sodium Compounds; Chlorides; Hydrochloric Acid; semaglutide; Sodium Chloride; pramlintide
• Other Study ID Numbers: 24/39715; 2024-510802-10-00 (Ctis)

Drug and device information, study documents

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