Role of Linagliptin in Improving Renal Failure by Improving CD34+ Stem Cell Number, Function and Gene Expression in Renal Function Impaired Type 2 Diabetes Patients.
Phase: PHASE4
Conditions: Type 2 Diabetes, Impaired Renal Function
Sponsor: George Washington University

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
1 
Date: 06/27/2017 
TITLE PAGE 
 
Role of Linagliptin in improving renal failure by improving 
CD34+ stem cell number, function and gene expression in renal 
function impaired type 2 diabetes patients 
 
Sabyasachi Sen, MD, MRCP (UK), PhD, FACP, FACE 
 
George Washington University Medical Faculty Associates 
2150 Pennsylvania Ave NW, Suite 4-403 
Washington, D.C.  20037 
Phone - (202) 994-8560 
 
 
Protocol Version/Date: Version 6.9 / June 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
2 
Date: 06/27/2017 
PROTOCOL SYNOPSIS 
Protocol Title: 
Role of Linagliptin in improving renal failure by improving CD34+ stem 
cell number, function and gene expression in renal function impaired 
type 2 diabetes patients 
Site Numbers & 
Names: 
GWU Medical Faculty Associates 
Research 
Hypothesis: 
Both type 2 diabetes and CKD are associated with poor stem cell 
number and function. Poor viability and function of EPCs in CKD and 
diabetes affects the repair and regeneration of the endothelium and 
renal tubules. We hypothesize that use of Linagliptin (along with 
Insulin, metformin, or both) may help reduce cardiovascular risk by 
improving EPC survival and function above and beyond adequate 
glucose metabolism control.   
Study Schema: 
Drugs / Doses / 
Length of Treatment) 
We propose a 2-arm randomized, parallel group, longitudinal study of 
12-week intervention duration. The 12-week time interval has been 
previously shown adequate to observe changes in biochemistry, EPCs 
and, importantly, pulse wave velocity (PWV) changes. Patients will be 
randomized to 2 groups:  
Control, (n=20), Insulin/Metformin + Lifestyle + Placebo.  
Treatment, (n=20) Insulin/Metformin + Lifestyle + Linagliptin 5mg.  
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
3 
Date: 06/27/2017 
Study Objectives: 
• 
Primary: 
• 
Secondary: 
The primary objective is to ascertain if addition of Linagliptin improves CD34+ 
cell function and gene expression in early type 2 diabetes patients with CKD 
stage 1-3, which will be correlated to improvement in 24hr urinary protein 
estimation and creatinine clearance (obtained via micro-albumin/creatinine ratio 
from a spot urine sample). 
The secondary objective is to correlate the cellular outcome measures with other 
measures of endothelial function such as: 
1. Arterial stiffness measures with pulse wave analysis and pulse wave velocity 
measurements  
2. Serum biochemistry looking at surrogates of endothelial health, endothelial 
inflammation, appetite controlling hormone levels and fasting glucose, insulin 
and lipid profile.  
3. Resting Metabolic Rate measurement 
 
Study Outcome Measures 
Primary:  
To investigate the effect of Linagliptin on Endothelial function in patients 
inadequately controlled (HbA1C ≥6.5 % to ≤10%) while being treated 
with stable Insulin, Metformin, or both.  
• 
Cellular markers. We will study pre and post Linagliptin treatment 
changes in number, function and gene expression of patients’ peripheral 
blood-derived CD34+ cells.  
• 
24hr urinary protein estimation and creatinine clearance. 
 
Secondary:  
• 
To investigate the effect of Linagliptin treatment on serum endothelial 
inflammatory markers including high sensitivity C-reactive protein (hs-
CRP), IL-6, TNF-alpha, and fasting lipid profile including ApoA1 and 
ApoB.  
 Glycemic control will be evaluated by measuring fasting blood glucose, 
insulin, and HbA1c levels and assessing insulin resistance using HOMA-
IR 
• 
Adiposity, measured using the Tanita Body Composition Analyzer scale, 
measured as percentage body fat. 
• 
Estimation of Creatinine clearance and Protenuria estimation. 
• 
Vessel health will be assessed by systolic and diastolic blood pressure 
and Arterial stiffness assessed using vascular flow and wave 
measurement equipment, SphygmoCor CP system from ATCOR.  
• 
The sphygmocor system also allows us to estimate central and aortic 
blood pressure. 
• 
Resting Metabolic Rate (RMR, similar to Resting Energy expenditure 
measurement) at baseline, midway point (week 6) and post therapy. 
 
 
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
4 
Date: 06/27/2017 
Study Design: 
Prospective, double-masked, randomized placebo-controlled trial  
Accrual Goal: 
(Total number of 
subjects) 
N=40 
Accrual Rate: 
(Number of subjects 
expected per month) 
Recruit 40 patients in approximately 36 months. 
 
Estimated: 
FPFV: 
LPFV:  
Follow Up: 
(dd-mm-yy) 
FPFV: 09-15-2015.    
LPFV: 09-15-2018 
Co-relative Studies:  
(PK/PD, etc.) 
N/A 
Inclusion Criteria: 
1. Adults aged 40-70 years.  
2. Diagnosis of type 2 diabetes within the previous 15 years using 
criteria of the American Diabetes Association 
3. Currently treated with a stable dose of Insulin, Metformin (1-2 
grams/day), or a stable combination of the two as therapy. 
4. HbA1C between 6.5 to 10% (both inclusive)  
5. BMI 25 to 39.9 kg/m2 (both inclusive)  
6. CKD stages 1-3  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
5 
Date: 06/27/2017 
Exclusion Criteria: 
Patients with: 
1. Implanted devices (e.g., pacemakers) that may interact with 
Tanita scale 
2. Previous coronary or cerebrovascular event within 6 months of 
screening or active or clinically significant coronary and/or 
peripheral vascular disease 
3. Low hematocrit (<28 UNITS).   
4. Pre-existing  liver disease and/or ALT and AST >2.5X’s UNL 
5. CKD stage 4 and  
6. History of pancreatitis, or cancer (except basal cell carcinoma 
and cancer that is cured or not active or being treated in the 
past five years) 
7. Statin use started or dose change in the last 3 months  
8. Use of oral anti-diabetic medication other than Metformin, or 
Insulin.  
9. Use of consistent long-term steroid medication in the last 3 
months (oral, inhaled, injected). 
10. Systolic BP> 140 mmHg and Diastolic BP> 90 mmHg  
11. Active wounds or recent surgery within 3 months.  
12. Inflammatory disease, or chronic current use of anti-
inflammatory drugs within the last 3 months 
13. triglycerides >450 mg/dL 
14. untreated hyper/hypothyroidism 
15. Auto antibody confirmed type 1 diabetes 
Additionally, patients who are active smokers, patients who are 
pregnant, nursing women, and post-menopausal women who are on 
hormone replacement therapy will be excluded. 
Patients on low dose oral contraceptives will be allowed to participate 
as these formulations contain lesser amount of estrogens. 
  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
6 
Date: 06/27/2017 
 
Criteria for 
Evaluation:  
(Efficacy, safety,  
stopping rules, etc.) 
 
Subjects will be screened at week -4, then evaluated for end points at 
weeks 0, 6 and 12. Follow up phone call will be done 30 days after last 
dose of study drug to assess for adverse effects.  
Study participation will be stopped for adverse effects at the discretion 
of the study investigator. Subjects may stop study participation at any 
time and for any reason. 
Statistics: 
The total sample size is requested, after accounting for attrition over 
the 12-week period, is 20 subjects per group or 40 subjects total. 
Sample size estimates were based on the effects of exercise on 
CD34+/KDR+ cells as described in the literature.  The effect of a 
single session, as well as extended training, on healthy subjects or 
those with existing cardiovascular conditions appears to increase the 
CD34+/KDR+ cells.    
This is a pilot study as a result appropriate power calculation is not 
feasible. W however did conduct power analysis, which provided us 
with 73% power (see statistics section).  A p-value of less than 0.05 
will be considered statistically significant. 
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
7 
Date: 06/27/2017 
1 
INTRODUCTION 
Type 2 diabetes is a national epidemic (1, 2) with significant macro and microvascular 
complications (3). Insulin resistance in pre-diabetes and overt diabetes are associated 
with endothelial dysfunction (4).  
A few studies indicate that stem cells particularly EPCs can act as a suitable bio-marker 
(5-7, 9) for monitoring cardiovascular morbidity. In this proposal we suggest that EPCs 
or CD34 positive cells (defined as CD34/VEGFR2+ cells) can act as a suitable cellular 
biomarker for estimating and following endothelial dysfunction in early type 2 diabetes 
patients with CKD. EPCs have been shown to be dysfunctional in both CKD patients and 
type 2 DM patients. (5, 7, 31, 35)  
Linagliptin (TRADJENTA) tablets are indicated as an adjunct to diet and exercise to 
improve glycemic control in adults with type 2 diabetes mellitus. No dose adjustment is 
recommended for patients with renal impairment. (29) 
EPCs have been used as a regenerative tool in ischemic myocardium and diabetic 
wound healing (8, 10-13). Endothelial dysfunction with associated inflammation may be 
a consequence of excess intra-cellular super-oxide presence in a setting of diabetes 
which is a pro-oxidative stress condition ultimately leading to poor EPC function and 
senescence (14).  
Though lifestyle modification has been proposed as a main stay for prevention and 
treatment of early type 2 diabetes, (2, 15-19) several new therapies for diabetes have 
been developed in recent years (2). Incretins and incretin mimetics appear to hold 
promise. Mechanism of positive effect of exercise and oral hypoglycemic agents can be 
very different. (44-50) 
DPP-4 inhibitors have been shown to increase EPCs in patients with type 2 diabetes 
(20) reportedly via SDF-1 alpha up-regulation. Interestingly, up-regulation of SDF-1 
alpha and vascular endothelial growth factor (VEGF), both chemotactic factors increase 
mobilization and recruitment of EPCs in the face of acute ischemic injury for repair and 
regeneration. (21-24).  
Several studies have shown positive effect of incretins (Glucagon like peptide, GLP-1) 
and incretin receptor agonists (GLP-1 receptor agonists) on cardiovascular risk factors in 
type 2 diabetes patients (20, 25) and even in patients with chronic heart failure and left 
ventricular dysfunction who do not have diabetes (26, 27).  
DPP-4 Inhibitors may have cardio-protective effects of their own, as they increase bio-
availability of endogenous GLP-1. They improve blood flow and nitric oxide production in 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
8 
Date: 06/27/2017 
endothelium (28, 29). These are unique properties not demonstrated by other oral 
diabetes medications (29). The mechanism underlying these effects may be mediated by 
increased nitric oxide bioavailability but is not completely known. However these 
beneficial effects appear to be independent of glycemia reduction.  
It is however unknown whether Linagliptin will have any positive effect on human EPC 
function where two prominent cardiovascular risk factors co-exist such as CKD and type 
2 diabetes.  
Therefore we plan to investigate if Linagliptin can alter function and gene expression of 
CD34+ cells in a setting of CKD and type 2 diabetes. We choose to look at non geriatric 
adult population with early type 2 diabetes (≤15 years of duration) at an early phase of 
renal impairment (stages 1-3). 
We specifically choose to exclude known CVD disease patients and early type 2 DM 
patients with early CKD as this cohort may be still retain capability to reverse or halt 
persistent endothelial damage seen in type 2 diabetes and CKD (3,30,35).   
Our preliminary study results , which just finished, looked at effect of 150min/week of 
aerobic physical activity on EPCs in pre-diabetes population show that interventions 
even though non pharmaceutical can lead to quick (within 4 weeks) improvement in 
gene expression and function of CD34+ cells. These cellular changes are reproducible 
and consistent with other outcome measures such as serum biochemistry and vessel 
wall dilation measures such as flow mediated dilatation. (34)    
Research Hypothesis: 
We hypothesize that Linagliptin, a member of DPP-4 inhibitor group of drugs may be 
able to improve number and function of CD34+  endothelial progenitor cells by up-
regulating chemotactic agent SDF1 alpha (DPP-4 degrades SDF-1) and its receptor 
CXCR4 (7, 20, 21) and thereby improving EPC migration and overall endothelial 
function. We also propose that this expected cardiovascular benefit is independent of 
HbA1C reduction. (30, 31)  
In this proposed study we plan to recruit patients with type 2 diabetes of ≤15 years 
duration (in early phase of diagnosis), who are on a stable dose of insulin, Metformin, or 
both for at least 3 months either short or long acting but still remain inadequately 
controlled with HbA1C between 6.5% and 10% (both values inclusive), but not overtly 
out of control (> 10% of HbA1C).  
The patient will adjust insulin levels so as to keep their HbA1C levels under 10.0%, for 
health measures. If the HbA1c rises above 10.0% then the PI will speak with the patient 
and provide a documented form indicating the insulin dose adjustment that should be 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
9 
Date: 06/27/2017 
made. Initially life-style intervention with diet and regular aerobic activity (as per 
Standards of Diabetes Care: Diabetes Care Supplement: Jan 2014) along with insulin 
titration will be undertaken for initial 4 weeks (time between screening visit and 1st visit). 
Subjects will begin taking 5.0 mg of Linagliptin or placebo after initial 4 weeks. Subjects 
will be withdrawn from the study if the medication or placebo is not tolerated.  
2 
STUDY OBJECTIVES 
2.1 
Primary Objective 
To investigate the effect of Linagliptin on Endothelial progenitor cells (CD34 
positive cells) in patients whose HbA1C is between 6.5 to 10% (both inclusive) 
while being on treatment with a stable dose of insulin, Metformin, or both for the 
preceding 3 months before enrollment.  
 
Cellular markers: We will use patient’s peripheral blood derived CD34+ cells looking at 
number, function and gene expression changes pre and post Linagliptin over 12 weeks 
of therapy.  
Urinary Function Marker in CKD: We will estimate 24hr urinary protein estimation and 
creatinine clearance (This is measured via the micro-albumin/Creatinine ratio provided 
from a random spot urine sample). 
 
 
2.2 
Secondary Objectives 
To investigate the effect of Linagliptin treatment on serum endothelium inflammatory 
markers including: C-reactive protein (hs-CRP), IL-6, TNF-alpha, and fasting lipid profile 
including ApoA1 and ApoB (5, 6, 30, 36).  
 
Glycemic control will be evaluated by measuring fasting blood glucose, insulin levels and 
HbA1c. Fasting blood glucose, insulin and lipid profile will be used to assess insulin 
resistance (32, 37)  
 
Adiposity will be measured using the Tanita Body Composition Analyzer scale, 
measured as percentage body fat (33). Serum will be used to estimate levels of SDF1-
Alpha, VEGF, and GLP1 levels by ELISA (25, 28, 29, and 30). 
We also intend to follow resting Metabolic Rate at baseline, midway, and post DPP4 
inhibitor therapy to ascertain if Linagliptin has any effect on RMR (56).  
 
Kidney health will be monitored by creatinine clearance and microalbumin/ creatinine 
levels, which will be obtained from the spot urine sample. 
a. Subjects will have the option of opting into a sub-study that is being 
where 10-20 mL of the excess fresh spot urine that has been 
collected will be used for exosome analysis. This is optional, and is 
not required of subjects. For details of urine-exosome study please 
see the appendix.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
10 
Date: 06/27/2017 
 
The biochemical or bio-inflammatory markers are an important marker of endothelial 
inflammation and dysfunction along with glycemic markers and markers of arterial 
stiffness (36-43, 55, 57). Literature suggests that DPP4 inhibitors and GLP1modifies and 
modulates hemopoetic stem cells and vaso dilatation (37, 44, 45).  
Vessel health will be assessed by degree of arterial stiffness, using arterial tonometry. 
The central and the aortic pressure is assessed by pulse wave analysis (PWA) and 
pulse wave velocity (PWV) . Arterial stiffness will be assessed using vascular flow and 
wave form analysis equipment, SphygmoCor CP system from ATCOR. (56) 
    
3 
INVESTIGATIONAL PLAN 
3.1 
Study Design and Duration 
Study Schema, 40 Type 2 diabetic Subjects Aged 40-70 on stable dose of Insulin, 
Metformin, or both 
 
 
+/- 3 day window for visits 
 
*Assessed at week 0, 6 and 12: Biochemical and cellular markers of endothelial function 
and Pulse wave analysis and velocity (PWA and PWV), REE and Adiposity. 
 
Week 16 - A telephone call to subjects will be made 30 days after last dose of study 
medication to determine if there have been any adverse events.  
                         
Available related studies and Expected Results: Studies measuring changes 
to EPCs in type 2 diabetes patients are very limited. To the best of our knowledge there 
are no studies examining the effect of Linagliptin in type 2 diabetes patients with CKD. 
Group A: Insulin/Metformin/Both + Placebo, 
n=20 
Wk 6* 
Wk 16 
Follow up 
          Screening 
Group B: Insulin/Metformin/Both + 
Linagliptin 5mg, n=20 
Wk-0* 
Randomization 
Wk 12* 
Wk -4 
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
11 
Date: 06/27/2017 
Use of CD34 positive cells as a cardiovascular risk surrogate has been reported in the 
past. Various studies (11, 34), have shown that various disease states, including those 
seen in diabetes, can deplete and damage EPC, thereby diminishing their regenerative 
potential.  The inability to maintain or repair damaged endothelial tissue leads to 
cumulative vascular dysfunction and cardiovascular disease.  
 
We hypothesize that monitoring number, function and gene expression of 
endothelial progenitors will allow us to quantify cardiovascular disease risk at the 
onset and regenerative potential post intervention at a cellular level. It will also 
help us to identify and correlate the best endothelial function bio-chemical 
inflammatory marker as an early indicator of cardiovascular disease progression 
in early type 2 diabetes with CKD and identify patients that are responders. 
   
Linagliptin along with other gliptins can increase SDF1 alpha levels and possibly CXCR4 
receptor expression which will help EPC mobilization and gene expression of 
hemopoetic CD34 positive stem cells.  
  
Linagliptin 5 mg or placebo will be added to patients who have type 2 diabetes 
diagnosed ≤15 years with HbA1C of 6.5 to 10 % (both inclusive) while being on Insulin, 
metformin, or both. 
Insulin will be titrated upwards if HbA1C is above 10% with minimal dose adjustments so 
as to keep the adjusted HbA1C below overtly uncontrolled levels (above 10%).  
 
Our study population will include equal numbers of adult male and female Type 2 
diabetes (T2DM) patients aged 40-70 years, enrolled in both arms of the study. 
Patients will be treated with 5 mg of Linagliptin or placebo for 12 weeks and with 
adequate lifestyle modification for 16 weeks (as per American Diabetes Association 
guidelines).  This time interval has been previously shown to be adequate to observe 
changes to Endothelial Progenitor Cells (EPCs), (5, 6). 
 
3.2 
Study Population 
For entry into the study, the following criteria MUST be met. 
3.2.1 
Inclusion Criteria 
1) Signed Written Informed Consent 
• 
Before any study procedures are performed, subjects will have the details of 
the study described to them, and they will be given a written informed 
consent document to read. Then, if subjects consent to participate in the 
study, they will indicate that consent by signing and dating the informed 
consent document in the presence of study personnel. 
2) Target Population 
• 
Subjects with a diagnosis of Type 2 diabetes mellitus within the previous 15 
years using criteria of the American Diabetes Association. 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
12 
Date: 06/27/2017 
• 
Currently treated with Insulin (long or short acting or combination), Metformin 
(stable dose of 1-2 grams/day), or a stable dose of both. 
• 
HbA1C between 6.5% and 10% (both inclusive)   
• 
BMI 25-39.9 kg/m2 both inclusive. 
• 
History of Stage 1-3 CKD shown by a laboratory test taken within the past 2 
years 
CKD Staging: 
Estimated Glomerular Filtration Rate Serum Cr should be used to estimate 
glomerular filtration rate (GFR). Estimated GFR (eGFR) is commonly reported by 
laboratories or can be estimated using formulae such as the Modification of Diet in 
Renal Disease (MDRD) study equation or the Chronic Kidney Disease Epidemiology 
Collaboration (CKD-EPI) equation. The latter is the preferred GFR estimating 
equation. GFR calculators are available at http:// www.nkdep.nih.gov.  
Abnormal urinary albumin excretion and eGFR may be used to stage chronic kidney 
disease (CKD). The National Kidney Foundation classification (Table below) is based 
on both kidney damage (UACR at or above 30 mg/g Cr) and eGFR. 
Normal UACR is defined as less than 30 mg/g Cr, and increased urinary albumin 
excretion is defined as at or above 30 mg/g Cr. Because of variability in urinary 
albumin excretion, ideally two (at least one) specimens of UACR should have been 
collected within a 3- to 6-month period before considering a patient to have 
albuminuria. 
 
Stage -- Description  -- GFR (mL/min/1.73 m2 )  
Stage 1 Kidney damage* with normal or increased GFR >=90  
          2 Kidney damage* with mildly decreased eGFR 60–89  
          3 Moderately decreased eGFR 30–59  
          4 Severely decreased eGFR 15–29  
          5 Kidney failure ,15 or dialysis  
*Kidney damage is defined as abnormalities on pathological, urine, blood, or imaging 
tests.1 
 
 
3) Age and Reproductive Status 
Men and women, 40 to 70 years of age.  
• 
Enrolled women must not be pregnant, should not be breast-feeding and 
should not be taking hormone replacement therapy (HRT) during 
randomization. 
The following women are WOCBP: 
• 
Women using the following methods to prevent pregnancy: Oral contraceptives, 
other hormonal contraceptives (vaginal products, skin patches, or implanted or 
injectable products), or mechanical products such as intrauterine devices or 
barrier methods (diaphragm, condoms, spermicides). 
• 
Women who are practicing abstinence. 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
13 
Date: 06/27/2017 
• 
Women who have a partner who is sterile (e.g., due to vasectomy).WOCBP must 
be using an acceptable method of contraception to avoid pregnancy throughout 
the study and for up to 4 weeks after the last dose of study drug in such a 
manner that the risk of pregnancy is minimized.  
• 
WOCBP must have a negative serum or urine pregnancy test result (minimum 
sensitivity 25 IU/L or equivalent units of HCG) within 0 to 72 hours before the first 
dose of study drug.  
• 
Women must not be breast-feeding. 
Post-menopause is defined as:  
• 
Women who have had amenorrhea for  12 consecutive months (without 
another cause) and/or who have a documented serum follicle-stimulating 
hormone (FSH) level > 35 mIU/mL. 
• 
Women who have irregular menstrual periods and a documented serum FSH 
level > 35 mIU/mL. 
• 
Women who are taking hormone replacement therapy (HRT). 
 
 
3.2.2 
Exclusion Criteria 
• 
Type 1 diabetes mellitus 
• 
History of diabetic ketoacidosis or hyperosmolar non-ketotic coma 
• 
Low hematocrit (< 28 Units) 
• 
History of pancreatitis, or cancer (except basal cell carcinoma and cancer that is 
cured or not active or being treated in the past five years) 
• 
Previous coronary event or history of cerebrovascular event within 6 months of 
screening or active or clinically significant coronary and/or peripheral vascular 
disease 
• 
CKD Stages 4 and 5 (estimated CrCl <30 mL/min) 
• 
Beginning Statin medications or of change of Statin dose in the last 3 months,  
• 
Use of oral or injectable anti-diabetic medication other than Insulin and 
Metformin. We did not want to bring in too many variables in the control arm and 
wanted to avoid a combination of insulin and other OHAs as the results might be 
difficult to interpret. 
• 
Patients will be off other OHA (other than Metformin) before randomization and 
inclusion in the study. 
• 
Use of consistent long-term steroid medication (oral, inhaled, injected) within the 
last 3 months 
• 
Untreated Systolic BP> 140 mmHg and Diastolic BP> 90mmHg  
• 
Active wounds or recent surgery within 3 months  
• 
Inflammatory disease, or current chronic use of anti-inflammatory drugs in the 
last 3 months.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
14 
Date: 06/27/2017 
• 
Untreated hyper/hypothyroidism 
• 
Contraindications for moderate exercise 
• 
Implanted devices (e.g., pacemakers) that may interact with Tanita scale 
 
Physical and Laboratory Test Findings 
• 
Pre-existing  liver disease and/or ALT and AST >2.5X’s UNL, 
• 
serum creatinine levels ≥2.0 with estimated CrCl < 30 mL/min) 
• 
Triglycerides >450 mg/dL  
Allergies and Adverse Drug Reactions 
• 
Subjects with a history of any serious hypersensitivity reaction to Linagliptin 
or another DPP-4 inhibitor.  
Sex and Reproductive Status 
• 
Women in reproductive age group will be included in the study but 
encouraged to use contraceptive method to avoid pregnancy within 16 weeks 
of study duration. 
• 
Women who are pregnant or breast-feeding will be excluded. 
Prohibited Treatments and/or Therapies 
Treatment with a strong cytochrome P450 3A4 (CYP3A4) or P-gp inducer (i.e. rifampin) 
Other Exclusion Criteria 
• 
Prisoners or subjects who are involuntarily incarcerated. 
• 
Subjects who are compulsorily detained for treatment of either a psychiatric 
or physical (e.g., infectious disease) illness.  
 
Additionally, patients who are active smokers, patients who are pregnant, nursing 
women, and women who are on hormone replacement therapy will be excluded.  
Patients on low dose oral contraceptives will be allowed to participate as these 
formulations contain very low amounts of estrogens. 
Eligibility criteria for this study have been carefully considered to ensure the safety of the 
study subjects and to ensure that the results of the study can be used. It is imperative 
that subjects fully meet all eligibility criteria. 
3.2.3 
Discontinuation of Subjects from Treatment 
Subjects MUST discontinue investigational product (and non-investigational product at 
the discretion of the investigator) for any of the following reasons: 
• 
Withdrawal of informed consent (subject’s decision to withdraw for any reason). 
• 
Any clinical adverse event, laboratory abnormality, or inter-current illness which, 
in the opinion of the investigator, indicates that continued participation in the study 
is not in the best interest of the subject. 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
15 
Date: 06/27/2017 
• 
Patients in CKD stages 1-3 who progress to stages 4 and beyond, post 
screening, will be excluded also. 
• 
Concomitant treatment with a strong systemic cytochrome P450 3A4 (CYP 3A4) 
or P-gp inducer such as rifampicin. Use of alternative treatments to Linagliptin is 
recommended. 
• 
Pregnancy 
− 
Pregnant patients will be advised to contact the investigator or study staff 
immediately if they suspect they might be pregnant (e.g., missed or late 
menstrual period) at any time during study participation.  
• 
Loss of ability to freely provide consent through imprisonment or involuntary 
incarceration for treatment of either a psychiatric or physical (e.g., infectious 
disease) illness. 
• 
If pancreatitis is suspected, promptly discontinue treatment with Linagliptin 
All subjects who discontinue should comply with protocol-specified follow-up 
procedures outlined before. The only exception to this requirement is when a subject 
withdraws consent for all study procedures or loses the ability to consent freely (i.e., is 
imprisoned or involuntarily incarcerated for the treatment of either a psychiatric or 
physical illness). If a subject withdraws before completing the study, the reason for 
withdrawal must be documented appropriately. 
4 
TREATMENTS 
4.1 
Study Treatment: Linagliptin 
Definition of Investigational Product: A pharmaceutical form of an active substance or 
placebo being tested or used as a reference in a clinical study, including products 
already with a marketing authorization but used or assembled (formulated or packaged) 
in a way different from the authorized form, or used for an unauthorized indication, or 
when used to gain further information about the authorized form. In this protocol, the 
investigational product is Linagliptin. 
Definition of Non-Investigational Product: Other medications used in the study as 
support or escape medication for preventative, diagnostic, or therapeutic reasons as 
components of a given standard of care. In this protocol, the non-investigational product 
is Insulin, Metformin, or both.  Patients will continue on Insulin, Metformin, or both as per 
their study entry dose added to Linagliptin or placebo. As mentioned before, patients on 
oral hypoglycemic agents other than Metformin will not be invited to join the study as 
OHA plus DPP4 inhibitor could have a different effect on vasculature or hemopoetic 
CD34+ stem cells compared to insulin and DPP4 inhibitor.   

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
16 
Date: 06/27/2017 
This study is being conducted under FDA mandated guideline for use in type 2 diabetes. 
Though in this particular study Linagliptin is referred to as the investigational drug, it is 
not a novel drug and we should not need a separate IND for execution of this study. 
4.2 
Method of Assigning Subjects to a Treatment 
Subjects, as per selection criteria below will be randomized to treatments using a 
permuted block design, developed by the Epidemiology & Biostatistics Research Core. 
This approach ensures groups will be approximately balanced at any time during the 
study and at study completion.  
4.3 
Selection and Timing of Dose for Each Subject 
The recommended dose of Linagliptin is 5 mg PO will be given once daily. Linagliptin 
can be taken with or without food. 
4.3.1 
Dose Modifications 
No dose modification is necessary in CKD stage 1-3 
4.4 
Blinding/ Unblinding 
Blinding is critical to the integrity of this clinical study. However, in the event of a medical 
emergency or pregnancy in a subject, in which knowledge of the investigational 
product is critical to the subject's management, the blind for that subject may be 
broken.  
Before breaking the blind of an individual subject’s treatment, the investigator 
should have determined that the information is necessary, i.e., that it will alter the 
subject’s immediate management. In many cases, particularly when the emergency is 
not investigational product-related, the problem may be properly managed by assuming 
that the subject is receiving active product without the need for un-blinding.  
End of Study Unblinding Protocol 
Upon completion of the research study, we will undergo the following protocol in order to 
unblind the research data. 
Unblinding is the process by which the allocation code is broken so that the investigator, 
clinical staff and the trial statistician becomes aware of which intervention each subject 
enrolled in the research study was taking.  
Unblinding at the end of the study is required in order to make unmasked analysis in 
accordance with the study analysis plan. It is also conducted in order to inform the 
participants of which investigational product they were assigned to.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
17 
Date: 06/27/2017 
 
Time to unblind: 
Unblinding shall be conducted when all subjects enrolled in the research study have 
finished treatment, and all follow up visits. There must be no plan to recruit any more 
subjects in the research study. Additionally, all data points and outcome measures for 
each research subject must have been collected, and ideally compiled. Prior to 
unblinding there will be a data lock on clinical outcome measures and basic side 
outcome measures and associated  research data collected for the study.  
 
Procedure to unblind 
Once data (from both the clinical and the basic science side) and has been compiled 
and is data locked, the investigator can choose to unblind. The Principal Investigator 
must contact the study sponsor, and receive permission to un-blind. If, for unforeseen 
reasons, at the pre-determined date for full study unblinding the data analysis on the 
cellular or basic aspects of the study is lagging behind the clinical data outcome 
measures (though the data has been acquired) the Principal Investigator in consultation 
with the study sponsor may choose to un-blind the clinical outcome measures before the 
basic side data has been analyzed but compiled. Upon confirmation from the study 
sponsor, the principle investigator must make a written request to the designated party 
to unblind, hereto referred at the “unblinder”. The unblinder is the bio-statistician of the 
MFA, Dr. Richard Amdur. Upon receipt of an instruction to unblind, the unblinder will 
sign the request form, indicating their agreement to unblind. This form will then be taken 
to the pharmacy, MFA’s IDS, where a member of the IDS staff will take the form, and 
will give the unblinding study binder to the unblinder. The pharmacy will sign to indicate 
their release of the binder, and the unblinder will sign to indicate receipt of the binder. At 
this point in time the chain of custody of the pharmacy unblended binder has been 
transferred to the designated party to unblind. The form with all of the signatures will be 
provided to the study coordinator to be kept in the regulatory binder.  
 
Possible Adverse Events, Definitions of Adverse Events and Management 
Adverse event 
An adverse event (AE) is defined as any untoward medical occurrence, including an 
exacerbation of a pre-existing condition, in a patient in a clinical investigation who 
received a pharmaceutical product. The event does not necessarily have to have a 
causal relationship with this treatment. 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
18 
Date: 06/27/2017 
Serious adverse event 
A serious adverse event (SAE) is defined as any AE which results in death, is 
immediately life-threatening, results in persistent or significant disability / incapacity, 
requires or prolongs patient hospitalisation, is a congenital anomaly / birth defect, or is to 
be deemed serious for any other reason if it is an important medical event when based 
upon appropriate medical judgement which may jeopardise the patient and may require 
medical or surgical intervention to prevent one of the other outcomes listed in the above 
definitions. Patients may be hospitalised for administrative or social reasons during the 
study (e.g. days on which infusion takes place, long distance from home to site,). These 
and other hospitalisations planned at the beginning of the study do not need to be 
reported as a SAE in case they have been reported at screening visit in the source data 
and have been performed as planned. 
 “Adverse Events of Special Interests” or “AEs of Special Interest” shall include: 
 
1. Severe Allergic Reactions 
2. Skin changes 
3. Angio-edema 
4. Heart attack or cerebral attack 
5. Neurological manifestations 
6. Acute Pancreatitis or acute hepatic failure 
7. Acute worsening of renal function 
8. Development of malignancy, occult or overt 
9. Severe Documented Hypoglycemia (lab blood sugar less 
than 40mg%) 
AEs of special interest are a list of medical topics that are under close surveillance. AE 
should be reported in an expedited manner similar to Serious Adverse Events even if 
they do not meet the seriousness criteria.  
Please refer to the site master file for the complete list of AESIs (27-30).  
 
Intensity of adverse event 
The intensity of the AE should be judged based on the following: 
• Mild: Awareness of sign(s) or symptom(s) which is/are easily tolerated 
• Moderate: Enough discomfort to cause interference with usual activity 
• Severe: Incapacitating or causing inability to work or to perform usual activities 
Causal relationship of adverse event 
Medical judgment should be used to determine the relationship, considering all relevant 
factors, including pattern of reaction, temporal relationship, de-challenge or re-challenge, 
confounding factors such as concomitant medication, concomitant diseases and relevant 
history. Assessment of causal relationship should be recorded in the case report forms.  
Yes: 
There is a reasonable causal relationship between the investigational product 
 
administered and the AE.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
19 
Date: 06/27/2017 
No: 
There is no reasonable causal relationship between the investigational product 
 
administered and the AE.  
Worsening of the underlying disease or other pre-existing conditions 
Worsening of the underlying disease or of other pre-existing conditions will be recorded 
as an (S)AE in the (e)CRF. 
Changes in vital signs, ECG, physical examination, and laboratory test results 
Changes in vital signs, ECG, physical examination and laboratory test results will be 
recorded as an (S)AE in the (e)CRF , if they are judged clinically relevant by the 
investigator. 
Responsibilities for SAE reporting: The Sponsor shall report (i.e., from signing the 
informed consent onwards through the trial defined follow-up period) all SAEs and non-
serious AEs which are relevant for a reported SAE and Adverse Events of Special 
Interest (AESI) by fax or other secure method using BI IIS SAE form to the BI Unique 
Entry Print in accordance with timeline specified below. 
 
• within five (5) calendar days upon receipt of initial and follow-up SAEs 
containing at least one fatal or immediately life-threatening event;  
 
• Within ten (10) calendar days upon receipt of any other initial and follow-up 
SAEs.  
 
Address for contact: 
BIPI Unique Entry Point:  
 
Boehringer Ingelheim Pharmaceuticals, Inc.  
 
900 Ridgebury Road Ridgefield, CT  
 
Fax: 1-203-837-4329  
 
E-mail: PV_global_casemanagement@boehringer-ingelheim.com.  
For each adverse event, the investigator will determine the expectedness of the 
investigational drug to the AEs as defined in the Listed Adverse Events section of 
the Boehringer Ingelheim’s (BI’s Summary of Product Characteristics (SmPC) or 
Product Information (PI) for the authorised Study Drug provided by BI.  
 
 
 
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
20 
Date: 06/27/2017 
4.5 
Study Schematic. Time and Events Schedule 
Time and Events Schedule for Protocol  
Procedure 
Screening 
Visit 
(Week -4) 
Baseline/ 
Randomization  
Visit 1 
(Week 0) 
During 
Treatment 
Visit 2 
(Week 6) 
End-of-
Treatment 
Visit 3 
(Week 12) 
Follow up 
phone 
call 
(week 16) 
Eligibility Assessments 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
Medical History 
X 
 
 
 
 
Safety Assessments 
 
 
 
 
 
Physical Examination 
X 
 
 
X 
 
Targeted Physical Examination 
(as needed) 
 
X 
X 
X 
 
Vital Signs 
X 
X 
X 
X 
 
Assessment of Signs and 
Symptoms 
 
X 
X 
X 
 
Adverse Events Assessment 
X 
X 
X 
X 
X 
Laboratory Tests (Biochemical) 
screening 
X 
X 
X 
 
Urine Pregnancy (If needed) 
X 
X 
X 
X 
 
Spot Urine Sample 
X 
X 
X 
X 
 
Tanita Scale Body Composition 
 
X 
X 
X 
 
Waist / Hip 
 
X 
X 
X 
 
Efficacy Assessments 
 
 
 
 
 
Peripheral blood draw for 
CD34+cell harvest 
 
X 
X 
X 
 
Pulse wave analysis and Pulse 
wave velocity assessment 
RMR                                             
 
X 
X 
X 
X 
X 
X 
 
Clinical Drug Supplies 
 
 
 
 
 
Randomize 
 
X 
 
 
 
Dispense Study Treatment 
 
X 
X 
 
 
 
Screening visit= week-4; Visit 1= week 0, Visit 2= week 6 and Visit 3= week 12.
 
 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
21 
Date: 06/27/2017 
Research Study Design and Methods: 
 
Patient Definition and Selection: Adults aged 40-70 years will be recruited from the 
GWU MFA research patient database provided by MFA Information Technology, and 
then contacted via email and phone, from the endocrinology and other provider clinics at 
GWU and through referrals from the Veterans Affairs (VA) clinics. Suitable 
advertisements for the study patient enrollment will be posted. Patients will be included 
in the study if they have been diagnosed with type 2 diabetes within the previous 15 
years using criteria of the American Diabetes Association (2), and are currently treated 
with a stable dose of Insulin, Metformin, or both. We plan to enroll subjects with HbA1C 
between 6.5% and 10% (both inclusive) and with BMI 25-39.9 kg/m2 (both inclusive). 
Post enrollment, patients will be randomized to Linagliptin 5 mg or placebo as detailed in 
Study Design for direct comparison between the two regimens.  
Before any study procedures are performed, subjects will have the details of the study 
described to them, and they will be given a written informed consent document to read. 
Then, if subjects consent to participate in the study, they will indicate that consent by 
signing and dating the informed consent document in the presence of study personnel. 
Recruitment: Subjects will be recruited from the physician clinics at GWU, Medical 
Faculty Associates, where Dr. Sen is a clinician, as well as through referral from the VA. 
All patients will receive counseling regarding the study aims and methods.  
Study Design Overview: We propose a 2-arm randomized, double-masked, placebo-
controlled, parallel group, longitudinal study of 12-weeks duration. (See study design 
below), recruited over 3 years.  The 12 week time interval has been previously shown 
adequate to observe changes in endothelial progenitor stem cells, biochemistry and 
importantly, PWV changes [20, 36]. Patients will be randomized to 2 groups: 
Control, (n=20), Insulin/Metformin/Both + Lifestyle + Placebo 
Treatment, (n=20) Insulin/Metformin/Both + Lifestyle + Linagliptin 5mg 
This proposed study is based on patients with type 2 diabetes of ≤15 years duration, 
who are on stable dose of insulin, Metformin, or both for at least 3 months but still 
remain poorly controlled with HbA1C between 6.5% and 10% (both inclusive),  but not 
overtly out of control (> 10% of HbA1C). Our study design is similar to that of Fadini et al 
[20] where Sitagliptin was compared to placebo with endothelial progenitor cells as an 
outcome measure in patients with type 2 diabetes over 4 weeks.  
Though our study is over 12 weeks we do not anticipate significant drop in HbA1C in 
between the two groups in this relatively short time period to act as a confounding factor 
on CD34+ cell number, function and gene expression.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
22 
Date: 06/27/2017 
Most clinical studies looking at HbA1C reduction were of a much longer duration of 6 
months or above and most DPP-4 inhibitor studies are with animal EPCs where 
comparison with human CD34+ population is difficult to make. In one study (58) where 
saxagliptin was used for 12 weeks in drug-naïve type 2 diabetes patients there was 
placebo-subtracted HbA1c reduction noted of 0.45-0.63%. It showed mean placebo-
subtracted reductions in fasting serum glucose of 20 mg/dL. From our laboratory studies 
of in vitro human EPC studies we do not think glucose level change of 20 mg/dL is 
significant enough to account for changes in EPC number, function and gene 
expression. However we will take the possibility of glycemia change/ reduction in 
experimental arm into account during statistical analysis of the results between the 
Linagliptin and placebo groups. 
As per recent clinical guidelines (2), all patients at entry will receive dietary advice by 
study coordinator, diabetes educator, or registered dietician specifically geared towards 
type 2 diabetes patients. They will be advised to adhere to 150 minutes of weekly 
aerobic exercise (50-70% of maximal heart rate). Patient’s activity will be monitored 
using accelerometers and will be downloaded at visit 2 and visit 3 by the study staff. 
Subjects will be taking 5.0 mg of Linagliptin or placebo. Dose titration of insulin will be 
allowed so that the HbA1C is maintained below 10%. 
Visits with outcome measurements will be scheduled for the morning while overnight 
fasting (except water) to reduce diurnal variability, and clinical parameters will be 
obtained at scheduled office visits as depicted in the study schema and will be measured 
at each outcome visit as follows: 
Week -4: Subjects will be screened and eligibility will be verified based on physical and 
laboratory tests. Equal numbers of male and female patients will be recruited. All 
patients will be educated on the recommended lifestyle changes of maintaining a level of 
aerobic activity of 150 minutes/ week (non-supervised) and adherence to a healthy diet 
as advised by the study coordinator, a diabetes educator, or a dietitian as part of the 
type 2 diabetes patient management plan [2].  We will allow 4 weeks for the patients to 
reach a steady state while implementing diet and exercise changes. 
Week 0: At this stage patients will be randomized into the study. Subjects will have the 
first set of measurements. We will make sure that patients still meet the inclusion criteria. 
They will be started on medication or placebo and will be encouraged to continue 150 
minutes/week of moderate physical exercise and dietary management for the remainder 
of the study. 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
23 
Date: 06/27/2017 
Weeks 0, 6 and 12: Subjects will all have the same measurements and will continue on 
study medication or placebo. All primary and secondary measures as outlined before will 
be carried out. 
The cellular outcome measures are as follows: 
 
From MNC population (pre magnetic column sorting): 
A. FACS Analysis, 1 million cells in each tube/assay column. 12 tubes-- total 12 million. 
(All labelling antibodies are obtained from Miltenyi Biotec except Sytox blue-Invitrogen 
and anti-VEGEFR2/KDR-R&D systems)  
1. Unlabelled 
2. CD34 
3. CD309 (VEGFR2-KDR)  
4. CD184 (CXCR4), receptor substrate for SDF1 alpha 
5. CD31 (PECAM-1, a mature circulating endothelial cell marker) 
6. CD133 (a progenitor marker) 
7. CD144 (Vascular Endothelial cadherin) 
8. Sytox Blue OR Propidium Iodide staining (to detect apoptotic cells)  
9. Combinations of 2+3+4+8, to assay percentage of double or triple positive cells 
10. (3+4+5+8), to assay percentage of double or triple positive cells 
11. 500,000 CD34+ cells, post column will be stained with – PE labelled + Sytox Blue (as a 
quality control measure, post column) 
  
B. Plate 5 million cells in each well of a 6 well or 12 well plates (2 million) BD 
Biosciences Human Fibronectin coated plate, total 2 wells, total 10 million mononuclear 
cells (prior to CD34 magnetic bead sorting) using CFU Hill Colony forming unit (Stem 
Cell Technologies- Cat#05900) media for Colony Forming unit (CFU) Assay.  
2 days post plating, harvest non-adherent cells from each well, counted and will be re-
plated at 1.0 x 106 cells/well in 12-well fibronectin coated plate. It is important than cell 
number of 1.0 x10e6 is maintained in each well.  
CFU needs to be counted on Day 7 post plating (from initial plating).  
 
From CD 34+ cell population (Post Sorting): 
A. Migration Assay using SDF1 Alpha concentrations of 0, 10, 100ng/ml using 100,000 
cells in 300ul serum free cell suspension media per insert. If sufficient cells are available 
we will note migration in response to VEGF-A (0, 20, 50 ng/mL).  
SDF1 Assay alone will need 100,000*9 = 0.9 million cells. Use triplicates. 
We will use 24 well plate using 3 micron pore migration membrane inserts from BD or 
Corning (354575). 
 
Genes to be assessed on CD34 positive, CD34 negative cells: 
 
Endothelial lineage cell surface markers: CD34, VEGFR2 (KDR), CD31, CD144 
For Anti-oxidant gene expression: Superoxide dismutase (SOD) 1, 2 and 3, catalase, 
glutathione- peroxidase. 
Apoptosis pathway: p53, p21, Bcl2, caspase-3 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
24 
Date: 06/27/2017 
Endothelial Function Assay Gene: eNOS 
Genes associated with progenitor cell chemotaxis: VEGF-A, SDF1 alpha, CXCR4 
  
Secondary Measures:  
• 
Highly selective C-reactive protein (hs-CRP), IL-6, IL-10, TNF-alpha, and fasting 
lipid profile including ApoA1 and ApoB (3, 6) 
• 
Serum SOD activity and SDF1 alpha (ELISA), VEGF-A (ELISA) and GLP-1 
(ELISA) levels will also be assessed (14, 20, 24, 39). 
• 
Assessment of insulin sensitivity using the HOMA-IR (32), calculated from 
individual serum measures (fasting glucose (mg/dl)* insulin (µU/mL)/405) [37].  
• 
Adiposity will be measured using the Tanita Body Composition Analyzer scale, 
measured as percentage body fat, BMI, waist-hip measurements (5, 55) 
• 
Fasting lipid profile will be checked as a marker of insulin resistance and lipo-
toxicity at weeks 0, 6 and 12.  
• 
We also intend to acquire Pulse wave analysis and Vascular Flow using 
SphygmoCor CP system from ATCOR to measure central arterial pressure and 
arterial stiffness (38-42). The secondary measures are indirect measures of 
endothelial inflammation in early type 2 diabetes patients. (30, 31, 55, 56, 57).  
• 
Obtain indirect calometric measurements of basal metabolic rate using machine 
obtained from Korrs Medical. This is a non invasive procedure. We plan to 
measure the oxygen that the body consumes.  It will help us calculate a patient’s 
Resting Energy Expenditure (REE), commonly referred to as a Resting Metabolic 
Rate (RMR).   As our protocol is directed to overweight and obese individuals 
using incretin therapy, it will be beneficial to note if the treatment modifies RMR. 
Description: The machine ReeVue by KORR directly measures the concentration 
of oxygen breathed out by each patient.  The patient breathes through a simple 
mouthpiece as all the exhaled air is collected and analyzed.  Because there is a 
direct correlation between oxygen consumed and calories burned (4.813 calories 
for every milliliter of oxygen consumed), an accurate measurement of oxygen 
consumption is an effective measurement of calorie consumption. The machine 
uses a one-way valve in the disposable (MetaBreather) mouthpiece.  This draws 
in fresh room air with each inspiratory breath and eliminates concerns about 
cross contamination.  The disposable mouthpiece is thrown away. It is un-
necessary to clean the equipment or the tubing between each patient. This 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
25 
Date: 06/27/2017 
equipment is FDA approved and has been used in physician offices as an 
oxygen uptake test with associated CPT code #94690. (58) 
• 
Urine pregnancy testing for women of child bearing potential 
• 
Creatinine Clearance and proteinuria estimation via random spot urine. 
We will obtain a total of 85 mL of peripheral blood per visit. Of these 85 mL, 60 mL 
will be used to obtain CD34+ cells from MNC population and 25 mL for 
biochemistry and serum ELISA assays.  
We may obtain 95mL of peripheral blood at visits 2 and 3 if necessary, and the 
patient agrees. Of this 95mL, 75mL will be used to obtain CD34+ cells from MNC 
population and 20mL for biochemistry and serum ELISA assays.  
 
 
4.7 
Study Materials 
BI, manufacturers of Linagliptin are expected to provide Linagliptin and matching 
placebo at no cost for this study.  
4.8 
Safety Assessments 
Study drug toxicities will be assessed continuously. Adverse events will be evaluated on 
a continuous basis while the patient is on study and until 30 days after the last dose of 
study drug. Patients should be followed until all treatment-related adverse events have 
recovered to baseline or are deemed irreversible by the principal investigator.  
5 
STATISTICAL CONSIDERATIONS 
Statistical Analysis:  
Sample Size Estimation:  
The total sample size requested, accounting for attrition over the 12-week period, is 20 
subjects per group or 40 subjects total. We plan to allow for 25% attrition (drop out), 
therefore plan to screen 55 patients over three years. 
 
Sample size estimates were based on the effects of exercise on CD34+/KDR+ cells and 
VEGF, as described in the literature (47-50).   
 
This is a pilot study and accurate power calculation is not feasible. 
 
The effect of a single session, as well as extended training, on healthy subjects or those 
with existing cardiovascular conditions appears to increase the CD34+/KDR+ cells and 
VEGF.   

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
26 
Date: 06/27/2017 
 
To compute sample size we used the approach suggested by Diggle, Liang, & Zeger 
(1994)(51) which compares the rates of change in the two study groups over time.  This 
approach incorporates the number and interval of time points and the correlation among 
repeated measures.  For this study, we will employ one baseline and two follow-up 
measures at 6 and 12 weeks.  Further, we will assume a correlation 0.60 among 
repeated measures of the outcome. We consider this a conservative estimate since 
Frison and Pocock (1992) (52) suggest a correlation of 0.65 as reasonable in the 
absence of an existing estimate. We also note that as this correlation increases, 
statistical power also increases.  
 
The results in the table below show the expected mean difference in study groups at the 
end of follow-up, as well as the average rate of change in the two groups at 80% power 
and 90% power.  To estimate the effect of Linagliptin on the CD34+/KDR+ cells, we 
expect that the effect would be at least 25% greater than the effect seen for exercise 
alone.  Using the results from Sandri et al. (2005)49 for the rate of change and the 
variability, the CD34+/KDR+ cells increased an average rate of about 4/wk with a 
standard deviation of about 15.  Thus, for a 25% increase in the rate of change for the 
CD34+/KDR+ cells due to Linagliptin, a sample size of 18 subjects per group would 
provide about 84% power, assuming measures taken at baseline and 2 equally-spaced 
time points over 12 weeks. At the conclusion of follow-up, we would expect study groups 
to differ by an average of 12 cells.  If the effect of Linagliptin is only 20%, a sample of 18 
would provide about 70% power, whereas a sample of 20 would provide about 73% 
power. 
 
For VEGF, the results from Sandri et al. (2005)(49) were mixed with one study group 
showing a .6 pg/mL per week increase and another showing a 0.5 pg/mL per week 
decrease after 4 weeks of training.  If we assume that Linagliptin will increase VEGF 
consistently at 0.3 pg/mL per week difference in slopes compared with exercise alone, 
then assuming a standard deviation of 5 and correlation or 0.60 among repeated 
measures, a sample size of 18 per group would provide about 77% power to detect a 
difference in slopes of 0.3 pg/mL per week or a mean difference in the groups at the end 
of the study of 3.6 pg/mL.  A sample size of 27 would provide about 90% power to detect 
the same effects. 
 
Thus, we feel that a sample size of at least 18 subjects per group with complete data 
would provide sufficient power for the study outcomes.  In order to insure that we will 
have 18 per group who complete the study, we will enroll 20 subjects per group in order 
to account for attrition over the 12-week intervention period. 
 
 
Biochemical 
Measure 
Mean difference  
at end of 12 weeks 
Sample 
Size per 
group 
Power 
CD34+/KDR+ 
12 cells 
18 
0.84 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
27 
Date: 06/27/2017 
cells 
(25% increase;  
4/wk vs. 5/wk) 
22 
0.90 
VEGF, pg/mL 
3.6 pg/mL 
(50% increase;  
(0.6/wk vs. 0.9/wk) 
18 
0.77 
27 
0.90 
 
Sub-Group Subject Number Breakdown: 
To estimate the effect of linagliptin on CD34+/KDR+ cells, we originally proposed 
a sample size of 20 per group in 2 groups, giving us power = .73, assuming 
alpha=.05, between time points of .60 and equal allocation between groups. 
Thus, the group x time interaction effect size we were modeling was an 
interaction that explained 3% of total variance, or a partial eta-square = .0291.  
Using 3 groups (Insulin only, metformin only, metformin + insulin), with the same 
effect size, we would achieve this same level of power using a total sample size 
of 51 (17 per group). However, given the relatively small numbers of potential 
participants with insulin-only (n=21) and insulin+metformin (n=54), and the 
relative large number with Metformin only (260), we will need to change the 
allocation ratio between groups. Maintaining the same total sample size as 
originally proposed (40), we will allocate patients from each group in the following 
numbers: Metformin only (22), Metformin+insulin (12), Insulin only (6). We 
recognize that we will be underpowered for comparisons between the Metformin 
+ insulin versus Insulin groups. However, comparisons with the Metformin-only 
group will still have reasonable power.  Given the small number of potential 
patients with Insulin-only, this is a feasible strategy for including this group in the 
analysis.  
 
 
Data Analysis.   
 
The distributional assumptions of all measures will be examined. Means and standard 
deviations will be computed for continuous measures and proportions for categorical 
variables. Graphical representations of the mean group slopes and individual slopes will 
be generated and inspected.  Study groups will be compared to determine whether any 
imbalance between the groups on patient characteristics remain after randomization.  If 
imbalance is evident, by inspection, all models will be adjusted for the unbalanced 
covariates.  Change in outcome over time will be examined using a multilevel approach 
with linear mixed models (LMM) (53, 54).  The longitudinal multilevel modeling approach 
will enable us to examine characteristics of within-person change, as well as between-
group differences that may influence change.  LMMs handle missing data more 
efficiently than traditional ANOVA designs. In the linear mixed models, the patient is 
considered a random effect and the outcome measured at specific time points is nested 
within patient.   In an initial model containing only the variable TIME, we will use a 
likelihood ratio test to determine whether a random effect for time should be modeled.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
28 
Date: 06/27/2017 
ij
ij
i
i
i
ij
i
ij
ij
Time
u
u
Group
Time
Group
Time
Y





+
+
+

+
+
+
=
1
0
3
2
1
0
)
(
ij
ij
i
i
ij
ij
Time
u
u
Time
Y



+
+
+
+
=
1
0
1
0
The model below represents a random intercept for patient and a random coefficient for 
TIME. 
 
 
We will examine whether TIME may be modeled linearly by testing the added 
contribution of TIME (represented with two indicator variables) to a model with TIME as 
a single continuous variable.  Assuming time may be modeled as a continuous variable, 
subsequent analyses will add study group and other patient characteristics as 
covariates. We are particularly interested in whether there is a significant interaction 
between study group and time, adjusting for other patient level covariates.  A significant 
interaction would indicate that the slopes in outcome over time differ by study group.  If 
the global test of interaction is significant, subsequent significance testing of the pair 
wise comparisons of group slopes group will be adjusted for multiple comparisons.  The 
model also includes coefficients for the group-by-time interactions and random effects 
for patient and time. 
 
 
In the event that TIME is modeled using indicator variables, two indicator variables will 
be used to represent the three time points, with baseline serving as the reference 
category.  The interaction between GROUP and TIME will be modeled in a similar 
fashion using two additional indicator variables.   The above multivariable model enables 
us to adjust for time-varying covariates, such as glucose.  Since glucose will be 
measured contemporaneously with the outcomes at each visit, however, causal 
interpretations of glucose and any outcome are suspect.  As such, we will consider 
glucose as a nuisance covariate, and consider any relationship between glucose and an 
outcome as merely associative.   
 
APPENDIX A: OPTIONAL URINE EXOSOME STUDY 
A urine sample is already required as a part of Dr. Sen’s Linagliptin protocol. This urine 
will be used for urine pregnancy tests (if applicable), and labcorp tests for 
microalbumin/creatinine ratio. There will likely be excess urine.  
 
 
Subjects will have the option to opt in or out of a research study in which the urine will 
undergo a urine exosome analysis.  
 
Purpose of this Study: Exosomes are cell-derived vesicles that are present in many and 
perhaps all biological fluids, including blood, urine, and cultured medium of cell cultures. 
The reported diameter of exosomes is between 30 and 100 nm, which is larger than LDL, 
but much smaller than for example, red blood cells. Exosomes are either released from 
the cell when multivesicular bodies fuse with the plasma membrane or they are released 
directly from the plasma membrane.[3] Evidence is accumulating that exosomes have 
specialized functions and play a key role in, for example, coagulation, intercellular 
signaling, and waste management.[1] Consequently, there is a growing interest in the 
clinical applications of exosomes. Exosomes can potentially be used for prognosis, 
therapy, and biomarkers for health and disease. In this study we are particularly interested 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
29 
Date: 06/27/2017 
in exosomes released from podocytes as a marker of podocyte function and podocyte 
inflammation. Podocytes are often considered a modified endothelium and one of its 
more commonly used parameter is microalbuminuria. 
In this study we are using urine exosomes as an added parameter of kidney function other 
than microalbuminuria and GFR calculation. 
 
The procedure for this study is as follows: 
From this sample, 10-20 mL of the fresh spot urine (or as much as possible) is placed into 
a urine cup containing 1 tab of cOmplete Ultra - protease inhibitor cocktail (Roche) for 
exosome analysis. The specimen can be refrigerated at 4ºC for ~ 1 week or frozen at -
80ºC until assay, or will be processed for exosomes as follows;  
 
Spot urine for exosomes isolation has been successfully employed in our laboratories 
from ~15 ml urine using a differential centrifugation method2,3. The supernatant will be 
subjected to ultracentrifugation, with final centrifugation at 200,000g for 2 hr at 4ºC to 
obtain the urinary exosome pellet. The pellet will be tested for exosomes markers, 
namely CD63, CD9, CD81, Hsp70, and WT-1, nephrin and podocalyxin, using one of 
two methods. Preferably mRNA will be extracted and then RT-PCR will be run. 
Alternative analysis will be done using gel electrophoresis followed by Western blot 
techniques.   
 
Method 1: Urine exosome mRNA extraction 
mRNA extraction from exosomes will be accomplished by using commercial kits 
(Norgen Biotek Corp., Catalog # 47200). Thereafter, a pre-amplification step will take 
place, this is a necessary step to measure mRNA in exosomes and will be followed by 
quantification of specific endothelium and podocyte proteins such as CD9, WT-1, 
nephrin and podocalyxin by RT-PCR. 
 
Total urinary protein content, albumin and creatinine will be measured via Lapcorp for 
the same urine samples that have been collected.  
 
Method 2: Gel electrophoresis and Western blot  
 Exosome pellet will be dissolved in Laemli buffer and proteins will be resolved by gel 
electrophoresis (4-12% polyacrylamide gel) under denaturing conditions. Subsequently, 
proteins will be transferred to a PVDF membrane by Western blotting using a dry 
blotting method (iBlot). The blot will be incubated with blocking solution for 1h, and 
subsequently exposed to a solution with the first antibody overnight, at 4ºC. After 
washing (5 x 5 min), the membrane will be exposed to a secondary antibody (horseradish 
peroxidase [HRP]-conjugated) for 1h at room temperature. Finally, the membrane will be 
incubated with an HRP substrate reagent to reveal the proteins bound to the antibodies 
tested. Quantitative analysis will be performed by densitometry readings of the positive 
signals corrected to creatinine concentration of the urine aliquot equivalent to each 
exosome sample.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
30 
Date: 06/27/2017 
 
End-point: Exploratory but in conjunction with urine albumin/creatinine ratio will help 
to establish impact of Linagliptin on renal function in diabetes related CKD population. 
 
 
 
Guidance document for Adverse Events of Special Interest 
 
Adverse events of special interest are events that we are keeping under close 
surveillance and we would be very grateful if non-serious adverse events relating 
to the following medical topics can be reported using the SAE form so that the 
Global Pharmacovigilance Team receives it as soon as possible: 
 
Hepatic adverse events 
Renal adverse events 
Hypersensitivity reactions 
Skin lesions 
Pancreatitis 
Pancreatic cancer 
 
Thyroid neoplasia or cancer 
Cardiac failure 
 
 
The following information is key in assisting case evaluation. If possible please 
provide the following when reporting an Adverse Event of Special Interest: 
 
Hepatic adverse events 
-     Alcohol intake (e.g. grams or units per week) present and past 
-     Jaundice (personal or family history) 
-     Hepatobiliary gallstone disease 
-  Known hepatic disease- eg metabolic, autoimmmune, malignancy or -
metastatic disease 
-     Metabolic-induced liver disease, non-alcoholic steatohepatitis (NASH) 
-     Recent administration of other drugs with known hepatic toxicity- please 
state reason if these are not recorded as co-suspect drugs 
-     Environmental exposure to liver toxins (e.g. CCL4, death cap mushroom, 
vinyl chloride) 
-     Substance abuse/Intoxications/Intravenous drug use 
-     History of drug allergy/hypersensitivity reaction 
-     Infectious diseases: 
-     Bacterial, Protozoic/parasitic hepatic infection 
-     Viral hepatic serology 
-     Travel history 
-     Blood transfusions history 
-     Site, radiation and character of pain 
-     Biopsy results &/or hepatology consult reports 
-     Radiological investigations eg sonography 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
31 
Date: 06/27/2017 
 
Renal adverse events 
-     Clarity on whether the patient has pre-renal, renal-renal or post-renal failure 
and the cause of this, eg hypovolaemia due to diarrhoea, glomerulonephritis or 
bladder obstruction  
-     Fluid balance if possible 
-     Baseline renal function and past history of renal insufficiency 
-     Renal and bladder stone disease- if possible with type of stone (eg Ca 
oxalate, etc) 
-     Site, radiation and character of pain 
-     Biopsy results &/or nephrology consult reports 
-     Known renal or urinary tract disease 
-     All BUN / U&Es results 
-     All urine investigation results including microscopy and culture 
-     Creatinine clearance 
-     Radiological investigation reports, eg Kidney-Ureter-Bladder X-ray, 
Intravenous pyelogram 
Hypersensitivity reactions 
-     Clarity on whether the patient has a diagnosed condition- eg angioedema or 
anaphylaxis as opposed to reporting symptom of tongue swelling 
-     For systemic hypersensitivity syndromes, all laboratory and radiological 
investigations and differential diagnoses 
-     Clear description of clinical presentation, time course and treatments 
-     If there are consults from other specialities, please include a copy of the 
report if possible 
Skin lesions 
-     Clarity on whether the patient has a diagnosed condition as opposed to 
reporting symptoms 
-     If a dermatology consult has occurred, please send a copy of the report 
-     Results of any biopsies 
-     Estimate of the percentage of the total body surface area that is involved 
-     Clearly state whether or not there is mouth ulceration 
-     Clearly state whether or not the rash has blisters 
-     Please provide any evidence of systemic reaction, laboratory abnormalities 
 
Pancreatitis 
-     Pancreatic enzymes and liver enzyme values, if possible on presentation and 
during course of the event 
-     Baseline and current lipid investigations 
-     Report of Radiological diagnostic procedures, eg sonography, CT, ERCP 
-     Clinical symptoms with description of site radiation and character of pain 
-     Clarity on the diagnosis in the verbatim reported term- eg whether the patient 
had clinical pancreatitis or assymptomatic enzyme rise 
-     Permission to contact treating physician for follow up information 
-     All relevant abnormalities in the pancreaticobiliary tree, eg gallstones, stenosis, 
CBD thickening 
-     Alcohol intake 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
32 
Date: 06/27/2017 
-     Clarity on whether the patient has chronic pancreatitis with a known aetiology 
 
Pancreatic cancer 
-     Please clearly state the start date of the study drug, the start date of the 
presenting symptoms and the date of diagnosis of cancer 
-     Please state method of diagnosis, staging, grading and (if available) histology 
-     Family history of cancer or pancreatitis 
-     BMI of the patient 
-     If previous radiology had not shown abnormalities, please confirm if vascular 
imaging techniques had been requested 
-     Please state all previous diabetic medication 
-     Has the patient had previous chemo/radiotherapy? If so please provide details 
-     Please provide permission to contact pancreatic oncologist 
 
Thyroid neoplasia or cancer 
 
-     Please clearly state the start date of the study drug, the start date of the 
presenting symptoms and the date of diagnosis of cancer 
-     Please state method of diagnosis, staging, grading and (if available) histology 
-     Family history of cancer 
-     Please state all previous diabetic medication 
-     Has the patient had previous chemo/radiotherapy? If so please provide details 
-     Please provide permission to contact oncologist 
-     Please clarify whether the lesion is benign or not 
-     Please list previous medications used to treat thyroid disease 
 
 
Cardiac failure 
-     Please clearly state the start date of the study drug, the start date of the 
presenting symptoms and the date of diagnosis of heart failure 
-     Did the patient have a history of heart failure, coronary artery disease, renal 
failure, arrhythmia, of heart valve abnormality? 
-     If EchoCG was done, please provide the report 
-     Provide NYHA class of CHF 
 
 
 
 
 
 
 
 
References- Linagliptin Study 
1. NIDDK. National diabetes statistics: 2007 and 2011 fact sheet. Bethesda, MD, 
USA. Department of Health and Human Services, NIH, 2008 and National Center 
for Chronic Disease Prevention and Health Promotion, 2011. 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
33 
Date: 06/27/2017 
2. Standards of medical care in diabetes-2014; American Diabetes Association. Diabetes 
Care January 2014 37:S14-S80 
3. Sheetz MJ, King GL. Molecular understanding of hyperglycemia’s adverse 
effects for diabetic complications.  JAMA. 2002;288(20):2579–2588. 
4.  Rask-Madsen C, King GL: Mechanisms of disease: Endothelial dysfunction in 
insulin resistance and diabetes. Nat Clin Pract Endocrinol Metab. 2007;3(1):46-
56.  
5. Werner N, Kosiol S, Nickenig G, et al:. Circulating endothelial progenitor cells 
and 
cardiovascular 
outcomes. 
2005;353:999-1007. 
N 
Engl 
J 
Med. 
2005;353(10):999-1007. 
6. Jialal I, Devaraj S, Singh U, Huet BA. Decreased number and impaired 
functionality of endothelial progenitor cells in subjects with metabolic syndrome: 
implications 
for 
increased 
cardiovascular 
risk 
Atherosclerosis. 
2010 
Jul;211(1):297-302.  
7. Hill JM, Quyyumi AA, Finkel T et al. Circulating endothelial progenitor cells, 
vascular function, and cardiovascular risk. N Eng J Med. 2003;348(7):593-600.  
8. Losordo DW, Schatz RA, White C et al. Intramyocardial transplantation of 
autologous CD34+ stem cells for intractable angina: a phase I/IIa double-blind, 
randomized controlled trial . Circulation.2007, 26;115(25):3165-72.   
9. Sen S, Young M, Kim YC, Silva JE. Role of Antioxidants Manganese Superoxide 
Dismutase (MnSOD) and Catalase (CAT) in Preventing Adipogenic and 
Promoting Osteogenic Differentiation of Human Bone Marrow Derived 
Mesenchymal Stem Cells (hMSC) in Hyperglycemia. Endocrine Society, June 
2010. Endocrine Reviews, Suppl. 1, June 2010, 31[3]: S2127.  
10. Sen S, Merchan JA, Dean J, et al. Autologous transplantation of endothelial 
progenitor cells genetically modified by adeno-associated viral vector delivering 
IGF-1 gene following myocardial infarction. Human Gene Therapy Oct 2010: 21: 
1327-1334.  
11. Mary Young, Cyril Chou, Sabyasachi Sen. P53 Silenced, Apoptosis Resistant, 
Human Endothelial Progenitor Stem Cells (hEPCs) Improve collateral circulation 
post femoral artery occlusion in Diabetic Mice. Circulation. 2012; Supplement. 
Abstracts at Annual Am Heart Association Scientific Sessions-2012, Oral 
Presentation Circulation. 2012; 124:   
12. Marrotte EJ, Chen DD, Hakim JS, Chen AF. Manganese superoxide dismutase 
expression in endothelial progenitor cells accelerates wound healing in diabetic 
mice. J Clin Invest. 2010 Dec;120(12):4207-19.  
13. Elsharawy MA, Naim M, Greish S. Human CD34+ stem cells promote healing of 
diabetic foot ulcers in rats. Interact Cardiovasc Thorac Surg. 2011 Dec 1. 
14. Imanishi T, Tsujioka H, Akasaka T: Endothelial progenitor cells dysfunction and 
senescence: contribution to oxidative stress. Curr Cardiol Rev 2008; 4:275-286 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
34 
Date: 06/27/2017 
15. Knowler WC, Barrett-Connor E, Fowler SE et al. Reduction in the incidence of 
type 2 diabetes with lifestyle intervention or metformin. NEJM 2002 Feb 
7;346(6):393-403.  
16. Ratner R, Goldberg R, Haffner S et al. Impact of intensive lifestyle and metformin 
therapy on cardiovascular disease risk factors in the diabetes prevention 
program. Diabetes Care; 2005 Apr;28(4):888-94.  
17. Knowler WC, Fowler SE, Hamman RF et al. 10-year follow-up of diabetes 
incidence and weight loss in the Diabetes Prevention Program Outcomes Study. 
Lancet. 2009 Nov 14;374(9702):1677-86.  
18. Padilla J, Simmons GH, Bender SB, Arce-Esquivel AA, White JJ, Laughlin MH. 
Vascular effects of exercise: endothelial adaptations beyond active muscle beds. 
Physiology. 2011 26: 132-145.  
19. Exercise and Type 2 Diabetes: American College of Sports Medicine and the 
American Diabetes Association: Joint Position Statement  Medicine & Science in 
Sports & Exercise. 42(12):2282-2303, December 2010. 
20. Fadini GP, Boscaro E, Albiero M, et al: The oral dipeptidyl peptidase-4 inhibitor 
sitagliptin increases circulating endothelial progenitor cells in patients with type 2 
diabetes: possible role of stromal-derived factor-1alpha. Diabetes Care 2010; 
33:1607-1609).  
21. Herrera C, Morimoto C, Blanco J, et al: Comodulation of CXCR4 and CD26 in 
human lymphocytes. J Biol Chem 2001; 276:19532-19539 
22. Zheng H, Fu G, Dai T, et al: Migration of endothelial progenitor cells mediated by 
stromal cell-derived factor-1alpha/CXCR4 via PI3K/Akt/eNOS signal transduction 
pathway. J Cardiovasc Pharmacol 2007; 50:274-280 
23. Yin Y, Zhao X, Fang Y, et al: SDF-1alpha involved in mobilization and 
recruitment of endothelial progenitor cells after arterial injury in mice. Cardiovasc 
Pathol 2010; 19:218-227 
24. Moore MA, Hattori K, Heissig B, et al: Mobilization of endothelial and 
hematopoietic stem and progenitor cells by adenovector-mediated elevation of 
serum levels of SDF-1, VEGF, and angiopoietin-1. Ann N Y Acad Sci 2001; 
938:36-45;  
25. Verge D, López X., Impact of GLP-1 and GLP-1 Receptor Agonists on 
Cardiovascular Risk Factors in Type 2 Diabetes, Curr Diabetes Rev. 2010 Apr 
12. Review. 
26. Sokos GG, Nikolaidis LA, Mankad S, Elahi D, Shannon RP. Glucagon-like 
peptide-1 infusion improves left ventricular ejection fraction and functional status 
in patients with chronic heart failure. J Card Fail. 2006 Dec;12(9):694-699.  
27. Nikolaidis LA, Mankad S, Sokos GG, Miske G, Shah A, Elahi D, Shannon RP. 
Effects of glucagon-like peptide-1 in patients with acute myocardial infarction and 

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
35 
Date: 06/27/2017 
left ventricular dysfunction after successful reperfusion. Circ. 2004 Mar 
2;109(8):962-5.  
28. Muniyappa R., Iantorno M., Quon M.J. An integrated view of insulin resistance 
and endothelial dysfunction. Endocrinol Metab Clin North Am. 2008 
Sep;37(3):685-711, ix-x. 
29. Lovshin JA, Drucker DJ. Incretin based therapies for type 2 diabetes mellitus. Nat 
Rev Endocrinol. 2009 May;5(5):262-9. Review.  
30. Sen S, Strappe P, O'Brien T. Gene transfer in endothelial dysfunction and 
hypertension. Methods in Molecular Medicine. 2005;108:299-314.  
31. Krenning G, Dankers PY, Drouven JW, Waanders F, Franssen CF, van Luyn MJ, 
Harmsen MC, Popa ER. Endothelial progenitor cell dysfunction in patients with 
progressive chronic kidney disease. Am J Physiol Renal Physiol. 2009 
Jun;296(6):F1314-22 
32. Matthews DR, Hosker JP, Rudenski AS, et al. Homeostasis model assessment: 
Insulin resistance and beta-cell function from fasting plasma glucose and insulin 
concentrations in man. Diabetologia. 1985;28(7):412-419. 
33. Tanita Corporation of America, Inc. Tanita body composition analyzer scale. 
Arlington Heights, IL 60005. 
34. Sen S, Chou C, Islam A: Effect of aerobic exercise on Endothelial Progenitor 
Cells (EPCs) in patients with prediabetes following aerobic exercise, Volume 33, 
Issue 5 Supplement; May 2013 / Abstracts From the American Heart 
Association's Arteriosclerosis, Thrombosis and Vascular Biology 2013 Scientific 
SessionsL. 
35. Jie KE, Zaikova MA, Bergevoet MW, Westerweel PE, Rastmanesh M, Blankestijn 
PJ, Boer WH, Braam B, Verhaar MC. Progenitor cells and vascular function are 
impaired in patients with chronic kidney disease. Nephrol Dial Transplant. 2010 
Jun; 25(6):1875-82.  
36. Hattori Y, Jojima T, Tomizawa A, Satoh H, Hattori S, Kasai K, Hayashi T. A 
glucagon-like peptide-1 (GLP-1) analogue, liraglutide, upregulates nitric oxide 
production and exerts anti-inflammatory action in endothelial cells. Diabetologia. 
2010 Oct;53(10):2256-63.  
37. Cabou C, Campistron G, Marsollier N, Leloup C, Cruciani-Guglielmacci C, 
Pénicaud L, Drucker DJ, Magnan C, Burcelin R. Brain glucagon-like peptide-1 
regulates arterial blood flow, heart rate, and insulin sensitivity. Diabetes. 2008 
Oct;57(10):2577-87.  
38. Delp MD. Effects of exercise training on endothelium-dependent peripheral 
vascular responsiveness. Med Sci Sports Exerc 27: 1152-1157, 1995.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
36 
Date: 06/27/2017 
39. Scheen AJ: Dipeptidylpeptidase-4 inhibitors (gliptins): focus on drug-drug 
interactions. Clin Pharmacokinet 2010; 49:573-588 
40. Tepper OM, Galiano RD, Capla JM, Kalka C, Gagne PJ, Jacobowitz GR, Levine 
JP, Gurtner GC. Human endothelial progenitor cells from type II diabetics exhibit 
impaired proliferation, adhesion, and incorporation into vascular structures. 
Circulation. 2002 Nov 26;106(22):2781-6. 
41. Werner N, Wassmann S, Ahlers P, Kosiol S, Nickenig G. Circulating 
CD31+/annexin V+ apoptotic microparticles correlate with coronary endothelial 
function in patients with coronary artery disease. Arterioscl Thromb Vasc Biol. 
2006 Jan;26(1):112-6.  
42. Hambrecht R, Wolf A, Gielen S, Linke A, Hofer J, Erbs S, Schoene N and 
Schuler G. Effect of exercise on coronary endothelial function in patients with 
coronary artery disease. N Engl J Med 342: 454-460, 2000.  
43. Behme MT, Dupré J, McDonald TJ (April 2003)." Glucagon-like peptide 1 
improved glycemic control in type 1 diabetes". BMC Endocr Disord 3 (1): 3.  
44. De Falco E, Porcelli D, Torella AR, et al: SDF-1 involvement in endothelial 
phenotype and ischemia-induced recruitment of bone marrow progenitor cells. 
Blood 2004; 104:3472-3482 
45. Barnett A., DPP-4 inhibitors and their potential role in the management of type 2  
diabetes. Int J Clin Practice 2006; 60:1454–1470. 
46. Witkowski S, Lockard MM, Jenkins NT, Obisesan TO, Spangenburg EE, 
Hagberg JM. Relation of circulating progenitor cells to endothelial function and 
oxidative stress with long term training and short term detraining in older men.  
Clin Sci (Lond). 2010 Feb;118(4):303-11. 
47. Van Craenenbroeck EMF, Vrints CJ, Haine SE, Vermeulen K, Goovaerts I, Van 
Tendeloo VFI Hoyman VY, Conraads VMA. A maximal exercise bout increases 
the number of circulating CD34+/KDR+ endothelial progenitor cells in health 
subjects.  Relation with lipid profile. J Appl Physiol, 2008; 104: 1006-1013  
48. Van Craenenbroeck EMF, Beckers PJ, Possemiers NM, Wuyts K, Frederix G, 
Hoyman VY, Wuyts F, Paelinck BP, Vrints CJ, Conraads VMA. Exercise acutely 
reverses dysfunction of circulating antiogenic cells in chronic heart failure. 
European Heart Journal, 2010; 31: 1924-1934.  
49. Sandri M, Adams V, Cielen S, Linke A, Lenk K, Krankel N, Lenz D, Erbs S, 
Scheinert D, Mohr FW, Schuler G, Hambrecht R. Effects of exercise and 
ischemia on mobilization and function activation of blood-derived progenitor cells 
in patients with ischemic syndromes: results of 3 randomized studies. Circulation, 
2005; 111:3391-3399.  
50. Lenk K, Uhlemann M, Schuler G, Adams V. Role of endothelial progenitor cells in 
the beneficial effects of physical exercise on atherosclerosis and coronary artery 
disease. J Appl Physiol, 2011; 111: 321-328.  

 
Linagliptin-Sen IIS  
Protocol Version: 6.9 
37 
Date: 06/27/2017 
51. Diggle PJ, Liang K-Y, Zeger SL (1994). Analysis of Longitudinal Data. New York: 
Oxford University Press. 
52. Frison L, Pocock SJ. Repeated measures in clinical trials: Analysis using mean 
summary statistics and its implications for design. Statistics in Medicine. 
1992;11:1685-1704.  
53. Fitzmaurice GM, Laird NM, Ware JH. Applied Longitudinal Analysis. John Wiley 
& Sons: West Sussex, England, 2004; pp. 401-424.  
54. Singer JD, Willett JB. Applied Longitudinal Data Analysis. New York: Oxford 
University Press; 2003 
55. Sumner AE, Sen S, Ricks M, Frempong B, Sebring N, Kushner H: Determining 
the waist circumference in African Americans which best predicts insulin 
resistance. Obesity (Nature Publications). 2008; 16(4):841-845. 
56. Wadwa RP, Urbina EM, Anderson AM, Hamman RF, Dolan LM, Rodriguez BL, 
Daniels SR, Dabelea D; SEARCH Study Group. Measures of arterial stiffness in 
youth with type 1 and type 2 diabetes: the SEARCH for diabetes in youth study. 
Diabetes Care. 2010 Apr;33(4):881-6. Epub 2010 Jan 12.  
57. Malin SK, Gerber R, Chipkin SR, Braun B. Independent and combined effects of 
exercise training and metformin on insulin sensitivity in individuals with 
prediabetes. Diabetes Care. 2012 Jan;35(1):131-6. Epub 2011 Oct 31.  
58. Fernanda Cristina Esteves de Oliveira, Raquel Duarte Moreira Alves, Carolina 
Pereira Zuconi, Andréia Queiroz Ribeiro, Josefina Bressan. Agreement between 
Different Methods and Predictive Equations for Resting Energy Expenditure in 
Overweight and Obese Brazilian Men. J Acad Nutr Diet. 2012;112: 1415-1420.  
 
 
 
1 Standards of Medical Care  in Diabetes-2016. American Diabetes Association. Diabetes 
Care January 2016 39:Supplement 1  
2 Zhou H, Yuen PS, Pisitkun T, Gonzales PA, Yasuda H, Dear JW, Gross P, Knepper 
MA, Star RA: Collection, storage, preservation, and normalization of human urinary 
exosomes for biomarker discovery. Kidney international 2006, 69(8):1471-1476. 
 
3 Fernandez-Llama P, Khositseth S, Gonzales PA, Star RA, Pisitkun T, Knepper MA: 
Tamm-Horsfall protein and urinary exosome isolation. Kidney international 2010, 
77(8):736-742.