Evaluating the Benefits of Physiologic Insulin Delivery
Phase: PHASE1
Conditions: Type 1 Diabetes
Sponsor: Stanford University

 
 
 
 
 
 
 
 
 
 
Evaluating the Benefits of Physiologic Insulin Delivery   
Study Protocol and Statistical Analysis Plan 
NCT04416737 
June 14, 2022 
 
 

 
SPECIFIC AIMS 
As of 2015, 30 million Americans (9.4% of the US population) had diabetes and it was the seventh 
leading cause of death based on 79,535 death certificate [131]. In addition to the American Diabetes 
Association (ADA) reported 1.25 million people in the United States with type 1 diabetes, about 29% of the 29 
million individuals with type 2 diabetes use insulin [132]. Long-term complications of hyperglycemia include 
retinopathy, nephropathy, neuropathy, and cardiovascular disease [133, 134]. The latest position statement by 
the ADA recommends a hemoglobin A1c goal of <7% in adults and <7.5% in pediatric age-groups [55, 135]. 
This goal challenges even the most motivated, knowledgeable and socioeconomically privileged patient. 
Despite a $327 billion investment in diabetes healthcare in 2017, nearly half of those with diabetes have a 
hemoglobin A1c above goal [136] and 31% have a hemoglobin A1c >9% [131]. 
Insulin replacement treatment is a significant burden with a narrow therapeutic margin, too much insulin 
results in acutely debilitating hypoglycemia and too little causes hyperglycemia that, over years, results in 
microvascular and coronary artery disease. In 2016, following years of clinical trials performed at Stanford and 
other centers, the FDA approved the Medtronic 670G "hybrid" closed-loop system which automatically controls 
insulin delivery based on continuous glucose monitor (CGM) data [137]. Unfortunately, current subcutaneous 
insulin pharmacokinetics are too slow to provide meal coverage without announcement and the kinetics make 
it necessary to choose between hypoglycemia and hyperglycemia prevention, inevitably generating alarms 
when the user hits the opposite extreme [138]. Additionally, there are many who stop using CGM or insulin 
pumps; there reasons for discontinuation include: alarms, trust in the technology and dislike of wearing devices 
[102]. An implanted "invisible" pump could deliver intraperitoneal insulin with more rapid pharmacokinetics 
providing full closed-loop glucose control and thereby reduce the burden and morbidity of diabetes. 
Prior investigation of intravenous and intraperitoneal automated insulin delivery technology were limited 
by the absence of practical, accurate CGM technology. Consequently, these approaches were erroneously 
discarded. CGM, catheter and insulin pump technology continue to evolve rapidly, but the optimal location of 
insulin delivery for full closed-loop control remains unknown. We posit that long-term intraperitoneal insulin 
delivery will be more physiologic with multiple benefits including improved body composition and BMI 
(important additional cardiovascular risk factors), bone health and user experience while at the same time 
providing the necessary kinetics and glucagon response for fully automated insulin delivery. Intraperitoneal 
insulin delivery will be simulated from available data with assessment of multiple control strategies. 
AIM 1: To identify unique benefits of long-term intraperitoneal insulin use. Utilizing data being collected 
from Dr. Eric Renard's (co-mentor) cohort of intraperitoneal users with type 1 diabetes, we will evaluate body 
composition, bone health and human factors compared to matched controls using subcutaneous insulin. 
Hypothesis 1: Long-term intraperitoneal use is associated with decreased BMI, body fat percentage and 
visceral adiposity with improved markers of bone health, and more positive opinions of diabetes technology. 
 
AIM 2: To describe the pharmacokinetics and compare glucagon response to hypoglycemia of novel 
insulin formulations delivered via upper peritoneal, lower peritoneal and subcutaneous routes. 
Hypothesis 2: Pharmacokinetics of intraperitoneal insulin will be faster and lead to greater counter-regulatory 
glucagon response than subcutaneous insulin. Upper peritoneal delivery will be faster than lower peritoneum. 
 
AIM 3: To use available intraperitoneal pharmacokinetic and counter-regulatory data to perform in 
silico modeling and test performance with various control strategies. The optimal algorithm will be the 
least computationally demanding that provides glycemic control in range (70-180mg/dL) over a variety of 
physiologic conditions. 
Hypothesis 3: With more rapid pharmacokinetics we can utilize more 
straightforward control strategies to achieve >90% time in range. 
This work will deliver a greatly needed control strategy for 
intraperitoneal insulin delivery that allows for full closed-loop glucose 
control. Our results will help guide the development of an implanted 
insulin pump being developed by PhysioLogic Devices (Figure 1). An 
efficient control algorithm will be needed to run on an embedded 
microcontroller with limited power. The goal of our combined efforts will 
be multi-center human clinical trials to achieve full closed-loop, reducing 
the burden of diabetes, and achieving optimum glycemic control. 
 
 
 
Figure 1. ThinPump vs Prior 
MiniMed 2007 (inches) 

e. 
e
AIM 2: To describe the pharmacokinetics and compare glucagon response to hypoglycemia of novel 
insulin formulations delivered via upper peritoneal, lower peritoneal and subcutaneous routes. 
Hypothesis 2: Pharmacokinetics of intraperitoneal insulin will be faster and lead to greater counter-regulatory 
glucagon response than subcutaneous insulin. Upper peritoneal delivery will be faster than lower peritoneum. 
Rationale/Preliminary Data: All prior intraperitoneal pharmacokinetic studies used only concentrated regular 
insulin [2, 149, 150], which may be too slow to provide full closed-loop insulin delivery without meal 
announcement [117, 119, 124]. Dr. Appel, an R01-funded Stanford collaborator, has developed excipients that 
stabilize insulin analogs [234] for implanted delivery. Novo Nordisk received FDA approval for fast-acting 
insulin aspart (Fiasp) in 2017. It is the fastest subcutaneous insulin and contains the excipients niacinamide 
and L-arginine hydrochloride thought to increase the formation of biologically active Aspart monomers, 
accelerate insulin absorption and add stability [235]. A description of intraperitoneal Fiasp kinetics, as well as 
counter-regulatory hormonal factors that may counter hypoglycemia is needed. Upper versus lower peritoneal 
delivery may also affect insulin kinetics [2]. Another important benefit of intraperitoneal insulin is restoration of 
glucagon response in longstanding diabetes, which has been studied in a small number of intraperitoneal 
users [21-25]. We conducted a preliminary proof-of-concept study on intravenous, intraperitoneal and 
subcutaneous Fiasp administration in one subject to compare kinetics in each compartment (Figure 2). 
Glucose data was collected by raising blood 
sugar to ~300mg/dL for 30 minutes with only basal 
insulin running (no recent boluses) then 
administering a fixed dose of Fiasp in each 
compartment. The experiment concluded when 
glucose stabilized for 15 minutes. In each 
compartment Fiasp had a shorter duration of action 
than prior studies with regular insulin (IV: 50mins vs 
90 mins [236], IP: 85mins vs 180mins [237] and 
SubQ: 4hrs vs 8.4hrs [238]). Intravenous and 
intraperitoneal insulin provide substantially more 
rapid glucose reduction than subcutaneous. 
Ultrasound-guided intraperitoneal insulin 
administration was painless. 
 
Research Design: This will be a descriptive 
pharmacokinetic study of upper and lower versus 
subcutaneous Fiasp, with assessment of glucagon 
response to insulin-induced hypoglycemia. 15 healthy 
adult participants with type 1 diabetes on insulin pump and 
continuous glucose monitor will be consented and asked 
to come in for three visits separated by at least one week. 
Before any other invasive procedure the abdominal area 
will be assessed by an experienced interventional 
radiologist with gray-scale and color Doppler ultrasound to 
determine the safest puncture site (Figure 3). Gray-scale 
sonography will be used to find the area that provides the 
most separation between the anterior abdominal wall and 
the bowel loops. If the experienced interventional 
radiologist feels no safe area exists, the subject will be 
excluded. 
Participants will fast overnight and suspend subcutaneous 
insulin delivery approximately 1 hour prior to each procedur 
For the first two visits, participants will be randomized to eith 
upper or lower peritoneal injection. An IV will be inserted 
for blood draws for YSI glucose, insulin, and glucagon levels. Another IV will be placed for dextrose 
administration. Color Doppler sonography of the puncture site will be performed to visualize the epigastric 
vessels and verify they are at least 1 cm away from the determined puncture site. Under sonographic 
guidance, a 22-gauge needle is inserted at the selected site with the needle angled 45° caudally. Real-time 
Figure 2. Glucose Response to IV, IP and 
Subcutaneous Fiasp 
350 
250 
150 
50 
0 
50 
100 
150 
200 
250 
Time (Minutes) 
IV Fiasp 
IP Fiasp (Normalized) 
SubQ Fiasp (Normalized) 
Figure 3. Anterior Abdominal Ultrasound with 
Needle Placement (Red Line) 
Blood Glucose (mg/dl) 

visualization of the needle insertion through the subcutaneous tissue, rectus abdominis muscle, and 
peritoneum will be performed. The peritoneum is seen as an echogenic line just deep in relation to the rectus 
abdominis muscle fibers. The needle will be taken to the edge of this echogenic line which may be 
associated with minimal momentary discomfort [239]. Approximately 0.25 units/kg Fiasp will be administered 
through the needle and the needle removed. Following injection, blood collection and measures will occur 
every 5 minutes for either 150 minutes or until glucose concentration has a stable trend. A 10% dextrose 
bolus of 2.5mL/kg will be provided following a blood sugar reading ≤50mg/dL. After 150 minutes have 
elapsed or glucose remains stable within 10mg/dL for 2 time points, the patient will resume their home insulin 
regimen. Data from the patient’s CGM will be downloaded. 
At least one week from the last peritoneal injection a similar subcutaneous procedure will take place. 
An IV will be inserted for blood draws for YSI glucose, insulin, and glucagon levels. Another IV will be placed 
for dextrose administration. Approximately 0.2 units/kg Fiasp will be administered by subcutaneous injection. 
Following injection, blood collection and measures will occur every 15 minutes for 6 hours or until glucose is 
stable. A 10% dextrose bolus of 2.5mL/kg will be provided following a blood sugar reading ≤50mg/dL. After 
6 hours have elapsed or glucose remains stable within 10mg/dL for 2 time points, the patient will resume their 
home insulin regimen. Data from the patient’s CGM will be downloaded. See Figure 4 for study diagram. 
Statistical Considerations 
and Power Analysis: 
Using analyses 
appropriate for paired 
measures, we will employ 
paired t-tests or the 
analogous non- 
parametric test (e.g., 
Wilcoxon signed-rank) to 
assess differences in 
pharmacokinetic features 
between delivery 
mechanisms. In the prior 
2000 study by Oskarsson 
and colleagues, 7 
subjects with longstanding type 1 diabetes receiving subcutaneous and intraperitoneal insulin underwent 
induced hypoglycemia with IV insulin and had glucagon measured at baseline and during hypoglycemia [1]. 
The maximal glucagon response subtracted from baseline was 7.5 ± 3.0 pg/mL on subcutaneous insulin and 
17.0 ± 3.1 pg/mL on intraperitoneal insulin. Assuming a type I error rate of 0.05, 15 individuals will provide 
>90% power to detect an effect size of 1.0 (maximal change in glucagon of 3.0). 
Expected Outcomes: We will test if there is a significant difference in glucagon response during hypoglycemia 
between intraperitoneal and subcutaneous administration. A mean pharmacokinetic curve will be generated 
from the above data for upper/lower intraperitoneal and subcutaneous insulin administration. We anticipate 
that intraperitoneal Fiasp will have faster pharmacokinetics than subcutaneous delivery, and that 
intraperitoneal delivery will result in a more significant counter-regulatory glucagon response. The upper 
peritoneal pharmacokinetic profile may be more rapid than lower peritoneal delivery. 
 
Potential Pitfalls & Alternative Strategies: There has been only 1 reported case of inadvertent bowel puncture 
with ultrasound guidance, occurring after the probe was removed and the needle unintentionally advanced. 
The patient received antibiotics and had no clinical sequelae [240]. We are deeply vested in the safety of our 
human subjects. All invasive procedures will be performed by an experienced interventional radiologist. To 
avoid this specific complication we will only take the needle tip to the edge of the visceral peritoneum, use a 
smaller needle and continue ultrasound recording until the needle is removed. The procedure to access the 
intraperitoneal space is derived from that used to place intraperitoneal catheters for peritoneal dialysis. An 
alternative procedure would be to perform the study in those with existing peritoneal catheters. Subjects with 
peritoneal dialysis catheters likely have impaired renal clearance or have recently received kidney transplant, 
which would alter pharmacokinetics. We have chosen not to use existing intraperitoneal pump users since 
prolonged suspension of insulin delivery may increase the risk of occlusions. We use Fiasp as it is the 
fastest subcutaneous insulin available. 1-hour suspension reduces plasma insulin with low risk of ketosis 
[241]. 
Figure 4. SA2 Study Diagram 

Contact PD/PI: Lal, Rayhan 
 
 
 
 
Section 2 - Study Population Characteristics (Study 1) 
 
2.1. Conditions or Focus of Study 
❍ Type 1 Diabetes Mellitus 
2.2. Eligibility Criteria 
Eligibility Criteria 
To be eligible for the study, a subject must meet the following criteria: 
1. 
18-60 years of age 
2. 
Clinical diagnosis of type 1 diabetes 
3. 
On insulin pump therapy and continuous glucose monitor (CGM) for at least 3 months 
4. 
Ability to safely receive intraperitoneal injection 
5. 
For females, not currently known to be pregnant 
6. 
Understanding and willingness to follow the protocol and sign informed consent 
7. 
Ability to speak, read and write in the language of the investigators 
 
Exclusion Criteria 
The presence of any of the following is an exclusion for the study: 
1. 
Diabetic ketoacidosis in the past 3 months 
2. 
Severe hypoglycemia resulting in seizure or loss of consciousness within 3 months prior to enrollment 
3. 
Pregnant or lactating 
4. 
Active infection 
5. 
A known medical condition that in the judgment of the investigator might interfere with the completion of the protocol 
6. 
Known cardiovascular events in the last 6 months 
7. 
Known seizure disorder 
8. 
Inpatient psychiatric treatment in the past 6 months 
9. 
Lack of stability on medication 1 month prior to enrollment including antihypertensive, thyroid, anti-depressant or lipid 
lowering medication. 
10. 
Suspected drug or alcohol abuse 
11. 
Chronic kidney disease (GFR < 60 mL/min/1.73mA2) 
2.3. Age Limits 
Min Age: 
18 Years 
Max Age:  60 Years 
 
INCLUSION OF WOMEN, MINORITIES, AND CHILDREN 
We will attempt to recruit an equal gender distribution and minority population representative of the 
surrounding demographic of people with type 1 diabetes. We are excluding children in these initial studies of 
intraperitoneal insulin injections. We hope to eventually be able perform studies on this more vulnerable 
population to improve modeling. 
 
RECRUITMENT AND RETENTION PLAN 
We will contact adult with type 1 diabetes using our existing database of patients who have consented to be 
contacted about future diabetes research studies. A short description of the present study will be given to 
them via e-mail, phone or in-person. We will also recruit subjects at the time of their scheduled appointments. 
A one-page brochure will be prepared and sent to providers who have referred patients to us in the past. 
Information on the study will also be posted on our website, and the information provided on the brochure will 
also be made available to diabetes support groups in our area and at local events hosted by JDRF and 
CarbDM. If a person expresses interest, then the study will be presented in detail. The study will be eligible to 
adults with type 1 diabetes, in good health, who are not currently enrolled in other intervention studies. 
Subjects participating in a registry study (no interventions) may participate. 
 
Participants will be informed that the study will require 3 visits, at least 1 week apart. We will obtain and verify 
contact information. The intraperitoneal experiments will be conducted first, as this is the more invasive 
intervention. To reduce unnecessary exposure, we will only perform the subcutaneous intervention once we 
are certain that we can safely perform intraperitoneal injections. Patients completing the intraperitoneal visits 
are likely to return for subcutaneous testing since this represents standard of care for insulin delivery. 

Contact PD/PI: Lal, Rayhan 
 
 
 
STUDY TIMELINE 
We intend to perform specific aim 2 during the second and third years (1/2022-6/2023) of funding. See Figure 
1 for study diagram. 
 
Figure 1. SA2 Study Diagram 
 
We plan to recruit 15 subjects, and each individual will need to be consented and come in for three visits 1 
week apart. Given the amount of testing and monitoring needed for each subject, we will perform testing on 1 
subject at a time. Allocating 3 weeks for each participant gives a total study duration of around 1 year. See 
Table 1 for study timeline. 
 
Table 1. Study Timeline 
Task 
Estimated Completion Date 
(Month / Year) 
Finalization of protocol, informed consent 
1/2022 
IRB Approval 
2/2022 
Major equipment, materials procured 
6/2022 
DSMB committee planning 
6/2022 
Study staff recruitment and training complete 
6/2022 
25% subjects complete study 
9/2022 
50% subjects complete study 
12/2022 
75% subjects complete study 
3/2023 
Final Report 
6/2023 

Contact PD/PI: Lal, Rayhan 
 
 
 
 
PROTECTION OF HUMAN SUBJECTS 
1. 
Risks to Human Subjects 
Human Subjects Involvement, Characteristics, and Design 
In Aim 2 we will require human subjects to collect real-world pharmacokinetic data and compare glucagon 
response to hypoglycemia for insulin Fiasp delivered via upper peritoneal, lower peritoneal and subcutaneous 
routes. 15 healthy adult participants (age 18-60 years) with type 1 diabetes on insulin pump and continuous 
glucose monitor will be recruited. Patients with other chronic health conditions must demonstrate stability on 
current treatment regimens for at least 3 months. Subjects will be excluded if they have had recent severe 
hypoglycemia or diabetic ketoacidosis. Pregnant or breastfeeding individuals and those with medical 
conditions that alter insulin resistance, insulin clearance, mentation, seizure threshold or increase the risk of 
major adverse cardiac events will also be excluded. 
 
The diabetes clinic at Stanford Hospital and Clinics serves a large, diverse population with over 400 adults with 
type 1 diabetes. This population represents a diverse mix of urban, suburban, and rural patients from a variety 
of racial and ethnic backgrounds. 
 
Sources of Materials 
Any individually identifiable private information about human subjects will be 
obtained at enrollment in a private room. Health information related to this study will include name, age, 
gender, race/ethnicity, diabetes duration, height/weight, pregnancy test results if female, date of study visits, 
insulin doses, hemoglobin A1c, continuous glucose monitoring results, measures of YSI glucose and 
insulin/glucagon ELISA. During the procedure, venous blood will be collected and appropriately disposed of 
when lab processing is complete. For security and confidentiality purposes, subjects will be assigned an 
identifier that will be used instead of their name. Study doctors and study coordinators are responsible for de- 
identifying the data. Dr. Lal and the research staff involved with this study will have access to the data and 
specimens. Staff will be current in HIPAA and CITI training, and will be reminded during training for this specific 
study to maintain privacy of participants and confidentiality of the data and specimens. 
Potential Risks 
Participation includes travel to Stanford and possible missed work that may pose a financial hardship. Injection 
and catheter placement carry common risks of discomfort, bleeding, bruising and infection. For more invasive 
intraperitoneal catheter insertion procedures (rather than injection utilizing our technique), there has been one 
reported case of bowel puncture, treated with antibiotics, without clinical sequelae. All procedures will be 
carried out by experienced providers, further decreasing the risk of complications. Time-limited hyperglycemia 
may occur prior to insulin injection, when the insulin pump is suspended, this relatively short period is not 
associated with diabetic ketoacidosis or long-term sequelae. During the trial subjects will undergo insulin- 
induced hypoglycemia which may be associated with temporary sweating, jitteriness, and not feeling well. The 
blood volume needed for each visit will be approximately 100 mL. The alternative is not to participate. 
 
 
2. 
Adequacy of Protection against Risks 
Recruitment and Informed Consent 
We will contact adult with type 1 diabetes using our existing database of patients who have consented to be 
contacted about future diabetes research studies. A short description of the present study will be given to 
them via e-mail, phone or in-person. We will also recruit subjects at the time of their scheduled appointments. 
A one-page brochure will be prepared and sent to providers who have referred patients to us in the past. 
Information on the study will also be posted on our website, and the information provided on the brochure will 
also be made available to diabetes support groups in our area and at local events hosted by JDRF and 
CarbDM. 

Contact PD/PI: Lal, Rayhan 
 
 
 
If a person expresses interest, then the study will be presented in detail. Informed consent will be obtained 
from adult participants by Dr. Lal or trained research staff under the supervision of Dr. Lal. Consent 
documents will discuss the potential risks of the study (time to complete study procedures, potential breach of 
confidentiality of data, intravenous catheter placement, intraperitoneal/subcutaneous injection, hyperglycemia, 
hypoglycemia and blood draws). Benefits of participating in the research (improved therapy for others with type 
1 diabetes), and the alternative of not participating in the study will be discussed. The potential participant will 
be given time to review the consent and ask any questions in a private room. Dr. Lal will be available to 
discuss the consent process with participants. 
 
Protections against Risk 
Subjects will be instructed on the signs and symptoms of hypoglycemia and hyperglycemia, and the 
interventions we will take to correct these states during the study procedure. They will be wearing a continuous 
glucose sensor which will aid in the early detection of hypoglycemia between YSI measurements. Patients will 
be offered topical anesthetic prior to any of these procedures to reduce discomfort. Following injection and 
removal of intravenous catheter pressure will be applied to reduce and stop bleeding. All areas will be 
cleansed prior to invasive procedures and intraperitoneal injections will be carried out under sterile conditions 
to reduce risk of infection. For safety, intraperitoneal injections will be performed under continuous ultrasound 
guidance until the needle is removed and needles will be advanced only to the visceral peritoneal membrane to 
eliminate concern of bowel puncture. Where needed, intravenous catheter placement can be performed under 
ultrasound guidance as well. In addition, all subjects will be provided with the study doctor's contact 
information should they request any medical guidance following procedures. 
 
A Data and Safety Monitoring Board (DSMB) will be formed consisting of 2 adult endocrinologists and an 
interventional radiologist working at institutions other than Stanford. The DSMB will review the protocol and 
procedures before the study is started, and will review the results after 5 patients have completed the three 
CTRU admissions. The PI will be responsible for reporting unexpected problematic events involving any 
aspect of the study to the DSMB, NIH and local IRB per institutional guidelines. Unanticipated problems to be 
assessed include adverse events, deviations from the study protocol, problems with informed consent, and 
confidentiality violations. The PI will report unanticipated problems to the DSMB, NIH and IRB within 3 
business days of their occurrence. A significant study related adverse event (such as seizure, diabetic 
ketoacidosis, bowel puncture, severe bleeding or infection) would result in the study being put on hold until the 
DSMB has reviewed the event. The DSMB will review such cases and determine what actions must be taken 
to address or resolve the situation and if it is safe to continue the study. 
 
 
3. 
Potential Benefits of the Proposed Research to Human Subjects and Others 
Use of Continuous Glucose Monitor data will provide each subject individualized information about their 
glucose response to intraperitoneal and subcutaneous insulin. The data on subcutaneous insulin may allow 
optimization of active insulin time for pump therapy. Additionally, participants with long-standing diabetes will 
acquire data about his or her glucagon secretory capacity when insulin is delivered in a more physiologic 
manner. The precautions taken greatly reduce any risk to the subjects and optimize the benefits. 
 
 
4. 
Importance of the Knowledge to be gained 
Insulin replacement treatment is a significant burden with a narrow therapeutic margin, too much insulin results 
in acutely debilitating hypoglycemia and too little causes hyperglycemia that, over years, results in 
microvascular and coronary artery disease. Unfortunately, current subcutaneous insulin pharmacokinetics are 
too slow to provide automated meal coverage and the kinetics make it necessary to choose between 
hypoglycemia and hyperglycemia prevention, inevitably generating alarms when the user hits the opposite 
extreme. Additionally, there are many who stop using CGM or insulin pumps; there reasons for discontinuation 
include: alarms, trust in the technology and dislike of wearing devices. An implanted "invisible" pump could 
deliver intraperitoneal insulin with more rapid pharmacokinetics providing full closed-loop glucose control and 
thereby reduce the burden and morbidity of diabetes. 

Contact PD/PI: Lal, Rayhan 
 
 
 
In order to test control algorithms for full closed-loop control we will need a description of insulin kinetics in the 
intraperitoneal space, as well as counter-regulatory hormonal factors that could counter hypoglycemia. All 
prior studies have used only concentrated regular insulin, which may be too slow to provide full closed-loop 
insulin delivery without meal announcement. Further, Dr. Eric Appel at Stanford University has recently 
developed excipients that stabilize newer concentrated insulin analogs. The pharmacokinetics of fast-acting 
insulin aspart (Fiasp) is untested in the intraperitoneal space. Another important benefit of intraperitoneal 
insulin is restoration of glucagon response, which has been reported in a small number of intraperitoneal 
insulin users. 
 
The risks of the current study are minimal, with multiple safeguards in place. Data from the current study will 
directly inform a model that can be abstracted to a wide array of simulated patients. Findings from the current 
study will be important for the future study and development of intraperitoneal closed-loop technology. Such 
technology may be useful for a large number of patients utilizing insulin. 
 
DATA AND SAFETY MONITORING PLAN 
This is a single-site descriptive pharmacokinetic study comparing glucagon response to hypoglycemia for 
insulin Fiasp delivered via upper peritoneal, lower peritoneal and subcutaneous routes on three separate visits 
separated by at least one week. Demographic data and venous blood samples will be collected including 
glucose determined by YSI, and insulin/glucagon measured by ELISA. Following hypoglycemia :550mg/dL, 
patients will receive intravenous dextrose. See Figure 1 for study diagram. The primary outcome will be 
glucagon response to induced hypoglycemia and a secondary outcome will be descriptive pharmacokinetics. 
15 healthy adults with type 1 diabetes on insulin pump and continuous glucose monitor will be consented and 
patient demographic data collected. Dr. Lal or a research assistant will consent subjects in a private room with 
sufficient time allocated to answer any questions. 
Figure 1. SA2 Study Diagram 
 
Before any other invasive procedure the abdominal area will be assessed by an experienced interventional 
radiologist with gray-scale and color Doppler ultrasound to determine the safest puncture site. If the 
experienced interventional radiologist feels no safe area exists, the subject will be excluded prior to any 
invasive procedures. Subjects will perform the more difficult intraperitoneal interventions first, in random order, 
to avoid unnecessary procedures. If intraperitoneal access is unsuccessful, the subject will be excluded. To 
avoid the possibility of even minor bowel puncture, we will only take the needle tip to the edge of the visceral 
peritoneum, use a smaller needle and continue ultrasound recording until the needle is removed. The 
procedure to access the intraperitoneal space is derived from that used to place intraperitoneal catheters for 
peritoneal dialysis. These widespread techniques are performed safely at many health centers. 
 
A Data and Safety Monitoring Board (DSMB) will be formed consisting of 2 adult endocrinologists and an 
interventional radiologist working at institutions other than Stanford. The DSMB will review the protocol and 
procedures before the study is started, and will review the results after 5 patients have completed the three 
CTRU admissions. Dr. Lal, affiliated research staff and DSMB, will periodically perform data and safety 

Contact PD/PI: Lal, Rayhan 
 
 
monitoring on an ongoing basis. During the course of the trial, data will be reviewed weekly for completeness 
and accuracy. Frequent reviews will be performed to examine the occurrence of adverse events and whether 
participants are satisfied with their participation. The DSMB will be responsible for evaluating each 
unanticipated problem and determining whether it affects the risk/benefit ratio of the study and whether 
modifications to the protocol and consent forms are required. The PI will be responsible for reporting 
unexpected problematic events involving any aspect of the study to the NIH, DSMB and local IRB per 
institutional guidelines. Unanticipated problems to be assessed include adverse events, deviations from the 
study protocol, problems with informed consent, and confidentiality violations. Secure communication between 
the study team and participants will occur by telephone. All study samples will be de-identified, data will be 
password protected and encrypted. The PI will report unanticipated problems to the NIH, DSMB and IRB 
within 3 business days of their occurrence. A significant study related adverse event (such as seizure, diabetic 
ketoacidosis, bowel puncture, severe bleeding or infection) would result in the study being put on hold until the 
DSMB has reviewed the event. The DSMB will review such cases and determine what actions must be taken 
to address or resolve the situation and if it is safe to continue the study. 
 
OVERALL STRUCTURE OF STUDY TEAM 
The principal investigator for the study will be Dr. Rayhan Lal. Dr. Avnesh Thakor, an experienced 
interventional radiologist and Dr. Victoria Young (diagnostic radiologist) 
will be performing intraperitoneal injection under ultrasound guidance. The study will 
take place in Stanford's Clinical and Translational Research Unit, staffed by specialized research nurses 
familiar with diabetes study protocols, who will place IVs and perform blood draws. A research assistant will be 
in charge of enrolling, contacting and scheduling subjects. YSI glucose measures and insulin/glucagon 
ELISAs will be performed either by Dr. Lal or qualified study personnel. 
 
Section 4 - Protocol Synopsis (Study 1) 
 
4.1. Brief Summary 
This will be a descriptive pharmacokinetic study of intraperitoneal versus subcutaneous Fiasp, with assessment of glucagon 
response to insulin-induced hypoglycemia. 
4.2. Study Design 
4.2.a. Narrative Study Description 
15 healthy adult participants with type 1 diabetes on insulin pump and continuous glucose monitor will be consented and 
asked to come in for three visits separated by at least one week. Before any other invasive procedure, the abdominal 
area will be assessed by an experienced radiologist with gray-scale and color Doppler ultrasound 
to determine the safest puncture site. Gray-scale sonography will be used to find the area that provides the most 
separation between the anterior abdominal wall and the bowel loops. If the radiologist feels 
no safe area exists, the subject will be excluded. 
 
Participants will fast overnight and suspend subcutaneous insulin delivery 3 hours prior to each procedure. For the 
first two visits, participants will be randomized to either upper or lower peritoneal injection. An IV will be inserted for 
blood draws for YSI glucose, insulin, and glucagon levels. Another IV will be placed for dextrose administration. 
Color Doppler sonography of the puncture site will be performed to visualize epigastric vessels and verify that they are 
at least 1cm away from the determined puncture site. Under sonographic guidance, a 22-gauge needle is inserted 
at the selected site with the needle angled 45° caudally. Real-time visualization of the needle insertion through the 
subcutaneous tissue, rectus abdominis muscle, and peritoneum will be performed. The peritoneum is seen as an 
echogenic line just deep in relation to the rectus abdominis muscle fibers. The needle will be taken to the edge of this 
echogenic line which may be associated with minimal momentary discomfort. Approximately 0.25u/kg Fiasp 
will be administered through the needle and the needle removed. Following injection, blood collection and measures will 
occur every 5 minutes for 150 minutes or until glucose 
stabilizes. A 10% dextrose bolus of 2.5ml/kg will be provided following a blood sugar reading ೦50mg/dl. After 150 
minutes have elapsed or glucose remains stable within 10mg/dl for 2 time points, the patient will resume 
their home insulin regimen. Data from the patient's CGM will be downloaded. 
 
At least one week from the last peritoneal injection a similar subcutaneous procedure will take place. An IV will 
be inserted for blood draws for YSI glucose, insulin, and glucagon levels. Another IV will be placed for dextrose 
administration. Approximately 0.25 units/kg 
Fiasp will be administered by subcutaneous injection. Following injection, blood collection 
and measures will occur every 15 minutes for 6 hours or until glucose stabalizes. A 10% 
dextrose bolus of 2.5ml/kg will be provided following a blood sugar reading ≤ 50mg/dl. After  

Contact PD/PI: Lal, Rayhan 
 
 
 
 4 hours have elapsed and glucose remains stable within 10mg/dl for 2 time points, the patient 
will resume their home insulin regiment. Data from the patient's CGM will be downloaded. 
 
 
4.3. Outcome Measures 
 
Type 
Name 
Time Frame 
Brief Description 
Primary 
Glucagon Response to 
Induced Hypoglycemia 
Determined during upper 
peritoneal, lower peritoneal 
and subcutaneous infusion of 
insulin 
Patient's will be given insulin via upper peritoneal, 
lower peritoneal and subcutaneous routes 
sufficient to induce hypoglycemia. We will 
measure change in glucagon response for venous 
glucose ೦50mg/dl 
Secondary 
Descriptive pharmacokinetics 
Determined during upper 
peritoneal, lower peritoneal 
and subcutaneous infusion of 
insulin 
Insulin levels will be measured following upper 
peritoneal, lower peritoneal and subcutaneous 
insulin administration to better characterize the 
kinetics of intraperitoneal insulin administration. 
 
 
STATISTICAL DESIGN AND POWER 
Using analyses appropriate for paired measures, we will employ paired t-tests or the analogous non-parametric 
test (e.g., Wilcoxon signed-rank) to assess differences in pharmacokinetic features between delivery 
mechanisms. In the prior 2000 study by Oskarsson and colleagues, 7 subjects with longstanding type 1 
diabetes receiving subcutaneous and intraperitoneal insulin underwent induced hypoglycemia with IV insulin 
and had glucagon measured at baseline and during hypoglycemia. The maximal glucagon response 
subtracted from baseline was 7.5 ± 3.0 pg/ml on subcutaneous insulin and 17.0 ± 3.1 pg/ml on intraperitoneal 
insulin. Assuming a type I error rate of 0.05, 15 individuals will provide >90% power to detect an effect size of 
1.0 (maximal change in glucagon of 3.0).