A Series of Pilot Studies to Evaluate the haemoDynamic and mEtabolic Effects oF apelIn aNd rElaxin

Phase 2Active Not RecruitingNCT03449251

Cambridge University Hospitals NHS Foundation Trust170 enrolled

Overview

Type two diabetes mellitus (T2DM) is a common, long term metabolic disorder characterised by hyperglycaemia (high blood glucose) resulting from insulin resistance and relative insulin insufficiency. The risk of developing insulin resistance and subsequently T2DM is increased by being overweight and also through a sedentary lifestyle. As the onset can be gradual, physiological damage may have occurred prior to diagnosis. Diabetes is associated with the development of microvascular complications (diabetic nephropathy, neuropathy, and retinopathy), and macrovascular complications (coronary artery disease, peripheral arterial disease, and stroke). While there are many treatments available for T2DM, these complications may still arise, leading to significant morbidity and mortality. There is therefore an urgent need to identify novel signalling pathways that may contribute to the development of diabetes related complications. The identification of these pathways may ultimately lead to the development of new therapies targeting better blood glucose control and preventing these subsequent complications. Both animal and human studies have indicated that two endogenous peptides, apelin and relaxin both act as vasodilators in the human cardiovascular system and could also have beneficial action in T2DM. Therefore, we aim to carry out experimental medicine studies to test this hypothesis, and explore the signalling pathway in the human vascular system.

An extensive body of evidence demonstrates a direct association between T2DM and cardiovascular complications and mortality. Unfortunately, current therapies for diabetes have failed to be translated into improvements in cardiovascular outcomes, highlighting an urgent need to develop novel therapeutic strategies that can ultimately achieve the dual outcome of improving glycaemic control and improving cardiovascular function. While the precise cellular mechanisms involved remain to be elucidated, we hypothesise that the apelin and relaxin pathways meet these two criteria and therefore are potential therapeutic targets in conditions of abnormal glucose metabolism and heart failure. Apelin and relaxin are safe for parenteral use as they are naturally occurring peptide hormones, have a short half-life and will be rapidly cleared. They target endogenous receptors and post-receptor signalling, and have been used in human trials without any significant side effects reported.

Study Type

INTERVENTIONAL

Allocation

Interventions

ApelinDRUG

Apelin is an endogenous peptide that activate a single G-protein couple receptor. Apelin inhibits insulin secretion, decreases glucose levels and increases insulin sensitivity.

RelaxinDRUG

Relaxin is RLN2 encoded endogenous peptide hormone, which binds to G protein coupled receptor RXFP1.

Normal salineDRUG

Vehicle

VerapamilDIAGNOSTIC_TEST

NO independent challenge agent

LN Monomethyl arginineDIAGNOSTIC_TEST

Basal NO synthase inhibitor

Eligibility

Sex: ALLMin age: 18 YearsMax age: 75 YearsHealthy volunteers:

Medical Language ↔ Plain English

Inclusion Criteria: Healthy participants * Have given written informed consent to participate * Aged 18 to 70 years inclusive * Male or female * Current non-smoker * If female, either postmenopausal or on days 2-9 of menstrual cycle and negative pregnancy test performed on the day of the of visit * BMI in range for studies 1 and 4: 18.5-24.9 kg/m2 with waist circumference lower than 88 centimetres (35 inches) for women or 102 cm (40 inches) for men, and/or body fat level less than 32 % for women or 25% for men * BMI in range for studies 2 and 3: 18.5-30.0 kg/m2 without limitations in waist circumference or body fat level Overweight/obese participants * Have given written informed consent to participate * Aged 18 to 70 years inclusive * Male or female * Current non-smoker * If female, either postmenopausal or on days 2-9 of menstrual cycle and negative pregnancy test performed on the day of the of visit * BMI in range of 25-34.9 kg/m2 (inclusive) with either waist circumference higher than 88cm (35 inches) for women or 102 cm (40 inches) for men, and/or body fat levels in excess of 32% for women or 25% for men Participants with type 2 diabetes mellitus * Have given written informed consent to participate * Aged 18 to 70 years inclusive * Male or female * Current non-smoker * If female, either postmenopausal or on days 2-9 of menstrual cycle and negative pregnancy test performed on the day of the of visit * BMI in range of 25-34.9 kg/m2 (inclusive) with either waist circumference higher than 88cm (35 inches) for women or 102 cm (40 inches) for men, and/or body fat levels in excess of 32% for women or 25% for men * Documented diagnosis of Type 2 Diabetes Mellitus, either diet controlled or treated with oral hypoglycaemic therapy Exclusion Criteria: * Hypersensitivity to any of the study drugs or excipients * Systemic Hypertension (sustained BP \>160/100mmHg) or hypotension (systolic BP below 90 mmHg) * Known heart disease * Implanted heart pace-maker or implantable cardioverter defibrillator (ICD) * Known active malignancy * Known renal failure (creatinine \>140µmol/L) * Known neurological disease * History of Scleroderma (Study 4 only) * Current pregnancy, breast feeding * Use of vasoactive medications or NSAIDS/aspirin within 24 hours of study visits * Use of caffeine within 24 hours of study visits * Current involvement in the active treatment phase of other research studies, (excluding observations/non-interventional) * Second or third-degree AV block, sino-atrial block, sick sinus syndrome or sinus bradycardia * Known HIV, hepatitis B or C * Needle phobia * Participants treated with formal anticoagulant therapy such as, but not limited to, heparin, warfarin or clopidogrel * Diagnosis of Type 1 Diabetes Mellitus or current usage of insulin or other injectable drugs for the treatment of diabetes such as but not limited to GLP1 agonists * BMI \<18.5 * Aged \<18 or \>70 years * Any other clinical reason which may preclude entry in the opinion of the investigator

Locations (1)

Addenbrooke's Hospital

Cambridge, Cambridgeshire, United Kingdom

Outcomes

Primary Outcomes

Sub-study 1a: Changes in markers of glucose homeostasis in healthy participants after infusion of apelin (Glucose)

Glucose, in mmol/l

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1a: Changes in markers of glucose homeostasis in healthy participants after infusion of apelin (C-Peptide)

C-peptide, in pmol/L

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1a: Changes in markers of glucose homeostasis in healthy participants after infusion of apelin (Glucagon)

Glucagon, in pg/ml

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1a: Changes in markers of glucose homeostasis in healthy participants after infusion of apelin (Insulin)

Insulin, in pmol/L

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1a: Changes in markers of glucose homeostasis in healthy participants after infusion of apelin (TNF-alpha)

TNF-alpha, in pg/ml

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in markers of glucose homeostasis in participants with increased weight and participants with type 2 diabetes mellitus after infusion of apelin with or without mixed meal tolerance in obese/overweight and T2DM participants

Glucose, in mmol/l

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

C-peptide, in pmol/L

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Glucagon, in pg/ml

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Insulin, in pmol/L

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

TNF-alpha, in pg/ml

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Sub-study 2a: Change in forearm blood flow parameters in healthy participants after infusion of relaxin (Absolute Flow)

Absolute flow in the infused arm, in mg/dL/min

Time frame: Within visit 2, over a period of up to 4 weeks

Sub-study 2a: Change in forearm blood flow parameters in healthy participants after infusion of relaxin (Percentage Change)

Percentage change in the infused arm, in %

Time frame: Within visit 2, over a period of up to 4 weeks

Sub-study 2a: Change in forearm blood flow parameters in healthy participants after infusion of relaxin (Ratio)

Ratio, expressed as a number (no units as this is a ratio)

Time frame: Within visit 2, over a period of up to 4 weeks

Sub-study 2b: Change in forearm blood flow parameters in healthy participants after infusion of relaxin in the presence of L-NMMA or normal saline

Ratio; absolute flow and percentage change in the infused arm

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 2b: Change in forearm blood flow parameters in health participants after infusion of verapamil in the presence of L-NMMA or normal saline (Ratio)

Ratio; expressed as a number (no units as this is a ratio)

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 2b: Change in forearm blood flow parameters in health participants after infusion of verapamil in the presence of L-NMMA or normal saline (Absolute Flow)

Absolute flow in the infused arm, in mg/dL/min

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 2b: Change in forearm blood flow parameters in health participants after infusion of verapamil in the presence of L-NMMA or normal saline (Percentage Change)

Percentage change in the infused arm, In %

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3a: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial relaxin in the presence of apelin

Ratio; absolute flow and percentage change in the infused arm

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3a: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial relaxin in the presence of apelin (Ratio)

Ratio, expressed as a number (no units as this is a ratio)

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3a: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial relaxin in the presence of apelin (Absolute Flow)

Absolute flow in the infused arm, in mg/dL/min

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3a: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial relaxin in the presence of apelin (Percentage Change)

Percentage change in the infused arm, In %

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3b: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial apelin in the presence of relaxin (Ratio)

Ratio, expressed as a number (no units as this is a ratio)

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3b: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial apelin in the presence of relaxin (Absolute Flow)

Absolute flow in the infused arm, in mg/dL/min

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-Study 3b: Change in forearm blood flow parameters in healthy participants after incremental infusions of intra-arterial apelin in the presence of relaxin (Percentage Change)

Percentage change in the infused arm, In %

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 4: Changes in markers of glucose homeostasis healthy participants, participants with increased weight and participants with type 2 diabetes mellitus after infusion of relaxin with and without apelin (Glucose)

Glucose, in each of the groups, in mmol/L

Time frame: Visit 2 to Visit 4, over a period of up to 8 weeks

C-peptide, in each of the groups, in pmol/L

Time frame: Visit 2 to Visit 4, over a period of up to 8 weeks

glucagon, in each of the groups,in pg/ml

Time frame: Visit 2 to Visit 4, over a period of up to 8 weeks

Insulin, in each of the groups, in pmol/L

Time frame: Visit 2 to Visit 4, over a period of up to 8 weeks

TNF-alpha, in each of the groups, in pg/ml

Time frame: Visit 2 to Visit 4, over a period of up to 8 weeks

Sub-study 5: Change in hand vein diameter after relaxin infusion in healthy participants

Hand vein Demeter is measured using Aellig dorsal hand vein technique

Time frame: Visit 2

Secondary Outcomes

Sub-study 1a: Changes in parameters of cardiovascular haemodynamics in healthy participants after infusion of apelin (Echocardiography)

Cardiac output measured by Echocardiography, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1a: Changes in parameters of cardiovascular haemodynamics in healthy participants after infusion of apelin (Innocor)

Cardiac output measured by Innocor, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1a: Changes in parameters of cardiovascular haemodynamics in healthy participants after infusion of apelin (Bioimpedance)

Cardiac output measured by bioimpedance, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in parameters of cardiovascular haemodynamics in obese/overweight and T2DM participants after infusion of apelin (Echocardiography)

Cardiac output measured by Echocardiography, in L/min

Time frame: VIsit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in parameters of cardiovascular haemodynamics in obese/overweight and T2DM participants after infusion of apelin (Innocor)

Cardiac output measured by Innocor, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in parameters of cardiovascular haemodynamics in obese/overweight and T2DM participants after infusion of apelin (Bioimpedance)

Cardiac output measured by bioimpedance, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in parameters of cardiovascular haemodynamics in obese/overweight and T2DM participants after infusion of apelin,after a mixed meal challenge (Echocardiography)

Data from ClinicalTrials.gov

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Cardiac output measured by Echocardiography, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in parameters of cardiovascular haemodynamics in obese/overweight and T2DM participants after infusion of apelin, after a mixed meal challenge (Innocor)

Cardiac output measured by Innocor, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in parameters of cardiovascular haemodynamics in obese/overweight and T2DM participants after infusion of apelin,after a mixed meal challenge (Bioimpedance)

Cardiac output measured by bioimpedance, in L/min

Time frame: VIsit 2 to visit 4, over a period of up to 8 weeks

Sub-study 1b: Changes in markers of glucose homeostasis after infusion of apelin in obese/overweight and T2DM, after a mixed meal challenge (Clugose)

Glucose, in mmol/L

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Sub-study 1b: Changes in markers of glucose homeostasis after infusion of apelin in obese/overweight and T2DM, after a mixed meal challenge (C-peptide)

C-peptide, in pmol/L

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Sub-study 1b: Changes in markers of glucose homeostasis after infusion of apelin in obese/overweight and T2DM, after a mixed meal challenge (Glucagon)

Glucagon, in pg/ml

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Sub-study 1b: Changes in markers of glucose homeostasis after infusion of apelin in obese/overweight and T2DM, after a mixed meal challenge (Insulin)

Insulin, in pmol/L

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Sub-study 1b: Changes in markers of glucose homeostasis after infusion of apelin in obese/overweight and T2DM, after a mixed meal challenge (TNF alpha)

TNF alpha, in pg/ml

Time frame: Visit 2 to visit 5, over a period of up to 14 weeks

Sub-study 2b: Change in forearm blood flow parameters after infusion of verapamil in the presence of L-NMMA or saline (Ratio)

Ratio,expressed as a number (no units as this is a ratio)

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 2b: Change in forearm blood flow parameters after infusion of verapamil in the presence of L-NMMA or saline (Absolute Flow)

Absolute flow in the infused arm, in mg/dL/min

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 2b: Change in forearm blood flow parameters after infusion of verapamil in the presence of L-NMMA or saline (Percentage Change)

Percentage change in the infused arm, In %

Time frame: Visit 2 to visit 3, over a period of up to 10 weeks

Sub-study 4: Change in cardiovascular haemodynamics after infusion of relaxin (Echocardiography)

Cardiac output measured by Echocardiography, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in cardiovascular haemodynamics after infusion of relaxin (Bioimpedance)

Cardiac output measured by bioimpedance, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in cardiovascular haemodynamics after infusion of relaxin (Innocor)

Cardiac output measured by Innocor, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in cardiovascular haemodynamics after combined infusion of relaxin and apelin (Echocardiography)

Cardiac output measured by Echocardiography, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in cardiovascular haemodynamics after combined infusion of relaxin and apelin (Bioimpedance)

Cardiac output measured by bioimpedance, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in cardiovascular haemodynamics after combined infusion of relaxin and apelin (Innocor)

Cardiac output measured by Innocor, in L/min

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in glucose homeostasis after combined infusion of relaxin and apelin (Glucose)

Glucose, in mmol/L

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Substudy 4: Change in glucose homeostasis after combined infusion of relaxin and apelin (C-peptide)

C-peptide, in pmol/L

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in glucose homeostasis after combined infusion of relaxin and apelin (Glucagon)

Glucagon, in pg/ml

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in glucose homeostasis after combined infusion of relaxin and apelin (Insulin)

Insulin, in pmol/L

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

Sub-study 4: Change in glucose homeostasis after combined infusion of relaxin and apelin (TNF alpha)

TNF alpha, glucose homeostasis

Time frame: Visit 2 to visit 4, over a period of up to 8 weeks

A Series of Pilot Studies to Evaluate the haemoDynamic and mEtabolic Effects oF apelIn aNd rElaxin

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes