Role of Glucagon-Like Peptide-1 (GLP-1) in Congenital Hyperinsulinism: Effect of Exendin (9-39) on Glucose Requirements to Maintain Euglycemia
Phase: PHASE1
Conditions: Congenital Hyperinsulinism
Sponsor: Diva De Leon

PI: Diva D. De León, MD 
 
 
 
Title: 
 
ROLE OF GLP-1 IN CONGENITAL HYPERINSULINISM: 
EFFECT OF EXENDIN-(9-39) ON GLUCOSE 
REQUIREMENTS TO MAINTAIN EUGLYCEMIA  
Study Key Name 
De LeónD_08-10-6256 
Protocol No: 
De LeónD_08-10-6256 
Study Product: 
Exendin-(9-39) 
FDA IND 
76,612 
Protocol Date: 
September 2008  (revised December, 2008, May2011, 
February, 2015) April 2017 
Amendment 1 Date: 4/16/09 
Amendment 2 Date: 6/23/09 
Amendment 3 Date: 2/03/10 
Amendment 4 Date: 7/20/10 
Amendment 5 Date: 1/6/11 
Amendment 6 Date: 5/ 5/11 
Amendment 7 Date: 12/18/14 
 
Amendment 8 Date : 2/18/15 
Amendment 9 Date:  10/26/15 
Amendment 10 Date: 5/22/16 
Amendment 11 Date 11/21/16 
Amendment 12 Date 4/25/17 
 
 
 
 
Sponsor  
Diva D. De León, MD 
Division of Endocrinology 
The Children’s Hospital of Philadelphia 
3615 Civic Center Blvd 
ARC, Room 802A 
Philadelphia, PA 1912 
Phone: 267-426-5529 
 
Site Principal Investigator 
Diva D. De León, MD 
Division of Endocrinology 
The Children’s Hospital of Philadelphia 
3615 Civic Center Blvd 
ARC, Room 802A 
Philadelphia, PA 1912 

PI: Diva D. De León, MD 
 
 
 
 
 
Phone: 267-426-5529 
 
 
 
 
CONFIDENTIAL 
This document is confidential and the property of the Children’s Hospital of Philadelphia.  
No part of it may be transmitted, reproduced, published, or used by other persons without 
prior written authorization from the study sponsor. 
 
Table of Contents 
 
 
 
Table of Contents.................................................................................................. ii 
List of Abbreviations .............................................................................................. v 
Study Summary ................................................................................................... vi 
Schedule of Events ............................................................................................. vii 
Schedule of Blood Drawing ................................................................................. viii 
1. 
Introduction .................................................................................................... 1 
1.1. Background Information and Rationale .................................................... 1 
1.1.1. Congenital Hyperinsulinism ............................................................... 1 
1.1.2. Clinical Phenotype of KATP Hyperinsulinism .................................... 2 
1.1.3. Metabolism and Insulin Secretion in Islets Lacking KATP Channels . 3 
1.1.4. Glucagon-like Peptide-1 Receptor Agonists and Antagonists ........... 3 
1.1.5. Significance ....................................................................................... 5 
1.2. Name and Description of Investigational Product .................................... 6 
1.2.1. Exendin-(9-39) .................................................................................. 6 
1.2.2. Chemistry, manufacturing, control ..................................................... 6 
1.2.3. Toxicity .............................................................................................. 7 
1.3. Findings from Pre-Clinical and Clinical Studies (see attachments) .......... 8 
1.3.1. Findings from Pre-Clinical Research ................................................. 8 
1.3.2. Findings from Clinical Research ........................................................ 9 
1.4. Dose Rationale and Risk/Benefits ........................................................... 9 
1.5. Compliance Statement........................................................................... 13 
2. 
Study Objectives .......................................................................................... 13 

PI: Diva D. De León, MD 
 
 
 
 
 
2.1. Specific Aim ........................................................................................... 13 
3. 
Study Design ............................................................................................... 14 
3.1. General Design ...................................................................................... 14 
3.2. Experimental Design .............................................................................. 14 
3.3. Study Population .................................................................................... 15 
3.3.1. Inclusion and Exclusion Criteria ...................................................... 15 
3.4. Study Procedures .................................................................................. 16 
3.5. Sample Size and Data Analysis. ............................................................ 19 
3.5.1. Data Analysis .................................................................................. 19 
3.5.2. Variables and time points ................................................................ 19 
3.5.3. Approach to analysis ....................................................................... 19 
3.5.4. Statistical Methods .......................................................................... 20 
4. 
Subject Selection and Withdrawal ............................................................... 22 
4.1. Inclusion and Exclusion Criteria ............................................................. 22 
4.2. Rationale for Using Neonates and Children ........................................... 22 
4.3. Subject Recruitment............................................................................... 23 
4.4. Early Withdrawal of Subjects ................................................................. 23 
4.4.1. When and How to Withdraw Subjects ............................................. 23 
4.4.2. Data Collection and Follow-up for Withdrawn Subjects ................... 23 
5. 
Safety and Adverse Events.......................................................................... 23 
5.1. Definitions .............................................................................................. 23 
5.2. Recording of Adverse Events ................................................................ 25 
5.3. Reporting of Serious Adverse Events .................................................... 26 
5.3.1. Study Sponsor Notification by Investigator ...................................... 26 
5.4. Dose Escalation Decisions .................................................................... 27 
5.5. Stopping Rules ...................................................................................... 27 
5.6. Medical Monitoring ................................................................................. 28 
5.6.1. Data and Safety Monitoring Board .................................................. 28 
6. 
Data Handling and Record Keeping ............................................................ 28 
6.1. Confidentiality ........................................................................................ 28 
6.2. Source Documents ................................................................................ 29 
6.3. Case Report Forms................................................................................ 29 
6.4. Records Retention ................................................................................. 29 
7. 
Study Monitoring, Auditing, and Inspecting .................................................. 29 

PI: Diva D. De León, MD 
 
 
 
 
 
7.1. Study Monitoring Plan ............................................................................ 29 
7.2. Auditing and Inspecting.......................................................................... 29 
8. 
Ethical Considerations ................................................................................. 30 
9. 
Study Finances ............................................................................................ 30 
9.1. Funding Source ..................................................................................... 30 
9.2. Conflict of Interest .................................................................................. 30 
9.3. Subject Stipends or Payments ............................................................... 30 
10. 
Publication Plan ........................................................................................ 30 
11. 
References ................................................................................................ 31 
 
12.     Attachments 
• Published Manuscript 
• Data Safety Monitoring Plan 
 
 
 
 
 

PI: Diva D. De León, MD 
 
 
 
 
 
 
List of Abbreviations 
 
CHI:   
congenital hyperinsulinism 
 
Ex-9:   
Exendin-(9-39) 
 
GLP-1:  
glucagon-like peptide-1 
 
GLP-1r:  
glucagon-like peptide-1 receptor 
 
KATP:   
ATP- sensitive potassium channel 
 
KATPHI:  
congenital hyperinsulinism due to mutation in the KATP channel 
 
GIR:   
glucose infusion rate 
 
 
 

PI: Diva D. De León, MD 
 
 
 
 
 
 
Study Summary 
Title 
Role of GLP-1 in Congenital Hyperinsulinism: Effect of 
exendin-(9-39) on glucose requirements to maintain 
euglycemia 
Short Title 
Effect of Ex-9 on glucose requirements 
Phase 
Phase 1/2 
Methodology 
Open label study 
Study Duration 
2 years 
Study Center(s) 
Single-center  
Objectives 
To examine the effect of exendin-(9-39) on glucose 
requirements to maintain euglycemia in subjects with 
congenital hyperinsulinism unresponsive to medical 
therapy 
Number of 
Subjects 
Approximately 30 subjects 
Diagnosis and 
Main Inclusion 
Criteria 
Congenital hyperinsulinism  
Main inclusion criteria: unresponsive to medical therapy 
with diazoxide 
Study Product, 
Dose, Route, 
Regimen, 
Duration of 
administration 
Exendin (9-39) 1000-30000 pmol/kg/min (0.2-6 mg/kg/hr) 
intravenous infusion over 9 hours. 
Reference 
therapy 
Effect will be evaluated compared to vehicle (normal 
saline) baseline 
Statistical 
Methodology 
Average glucose infusion rate during the last 2 hours of 
exendin-(9-39) infusion will be compared to glucose 
infusion rate during the last 2 hours of vehicle infusion. 
Standard t-test, p<0.05 
 

PI: Diva D. De León, MD 
 
 
 
 
 
Schedule of Events 
 
STUDY DAYS 1 & 2*  
Procedures 
Day 0 
(regardless 
of group 
assignment) 
Vehicle 
infusion 
day 
Exendin –
(9-39) 
infusion 
day 
Hypersensitivity test1 chemistry 
profile,electrocardiogram,CBC,urinalysis2  
x 
 
 
Heart rate, blood pressure, respiratory 
rate, temperature 
 
x 
x 
Maintain blood glucose >70mg/dL -
dextrose infusion rate will be adjusted to 
maintain glucose in the range of 70-
90mg/dL3   
 
x 
x 
Infuse Saline (vehicle) for 9 hours 
 
x 
 
Infuse exendin-(9-39) for 9 hours 
 
 
x 
Blood glucose will be checked every 
30min by heel stick during study period  
 
x 
x 
Betahydroxybutyrate will be checked 
every hour by heel stick during the study 
period 
 
x 
x 
Plasma levels of exendin-(9-39) 1hr, 5hr, 
9hr during study period and, 1hr, 3hr and 
after infusion is discontinued 
 
 
x 
Plasma glucose and plasma insulin will 
be measured at 0,1, 5, and 9 hours  
 
x 
x 
 
1 Test of immediate hypersensitivity may be done the day prior or the morning of 
the study prior to the start of the infusion. 
2 Chemistry profile, CBC, and urinalysis will be repeated at end of study. 
3 Blood glucose will be checked every 30 minutes by heel stick during study 
period 
 
*Day 1 and 2 crossover randomized design 

PI: Diva D. De León, MD 
 
 
 
 
 
Schedule of Blood Drawing 
 
Study Day 1 & 2: 
(crossover randomized design) 
 
 
 
Total blood volume for Day 1 is 9.4 mL about 2 teaspoons 
Total blood volume for Day 2 is 18.2 mL about 3 2/3 teaspoons 
Total blood volume for safety laboratories before and after the study is 10 mL  
Blood test 
Time 
points 
 
 
 
Post 
infusion 
 
 
0hr 
 
1hr 
5hr 
 
9hr 
 
10hr 
12hr 
Blood Glucose1 
x 
x 
x 
x 
x 
x 
Betahydroxybutyrate2 
x 
x 
x 
x 
x 
x 
Plasma glucose and 
plasma insulin 
x 
x 
x 
x 
 
x3 
Plasma levels of 
exendin- (9-39) (study 
drug day only) 
 
x 
x 
x 
x 
x 
1 Blood glucose will be checked every 30 minutes by heelstick. Subjects who have discontinued the 
dextrose infusion at hour 9 during the exendin-(9-39) infusion will continue to have glucose levels checked 
every 30 minutes up to hour 12 or until blood glucose < 70 mg/dL, whichever comes first 
2 Betahydroxybutyrate will be checked hourly by heel stick. Subjects who have discontinued the dextrose 
infusion at hour 9 during the exendin-(9-39) infusion will continue to have betahydroxybutyrate checked 
every hour up to hour 12 or until blood glucose < 70 mg/dL, whichever comes first 
3 Subjects who have discontinued the dextrose infusion at hour 9 during the exendin-(9-39) infusion will 
have plasma glucose and plasma insulin levels checked either at hour 12 or when blood glucose < 70 
mg/dL, whichever comes first 
 

 
 
Role of GLP-1 in Congenital Hyperinsulinism 
1. Introduction 
This document is a protocol for a human research study. This study is to be 
conducted according to US and international standards of Good Clinical Practice 
(FDA Title 21 part 312 and International Conference on Harmonization 
guidelines), applicable government regulations and Institutional research policies 
and procedures.  
 
1.1. Background Information and Rationale 
1.1.1. Congenital Hyperinsulinism 
In infants and children, as in adults, the most common cause of hypoglycemia is 
hyperinsulinism (HI). However, unlike adults, HI in children most often represents 
a genetic disorder of insulin regulation rather than an acquired islet tumor (1). 
Congenital HI (CHI) is a genetic disorder of pancreatic β-cell function 
characterized by failure to suppress insulin secretion in the presence of 
hypoglycemia, resulting in brain damage or death if inadequately treated. The 
estimated incidence of CHI in this country is 1:20,000 to 1:50,000. Mutations in 
nine genes have been associated with CHI: ABCC8, the gene encoding the 
sulfonylurea receptor-1 (SUR-1) (2); KCNJ11, the gene encoding the inward 
rectifying potassium channel (Kir6.2) (3; 4); glucokinase (GCK) (5); glutamate 
dehydrogenase (GLUD-1) (6); HADHSC encoding the mitochondrial enzyme 
short-chain 3-hydroxyacyl-CoA dehydrogenase (SCHAD) (7); and SCL16A1, 
which encodes the monocarboxylate transporter 1 (MCT1) (8); HNF1A, the gene 
encoding hepatocyte nuclear factor 1 alpha (9); and UCP2, encoding uncoupling 
protein 2 (10). Hyperinsulinism can also be associated with Beckwith Wiedemann 
syndrome, which results from various genetic or epigenetic anomalies in the 
highly imprinted region of chromosome 11p15.5 (11).   Loss-of-function 
mutations in the KATP channel (composed of two subunits: Kir6.2 and SUR-1) are 
responsible for the most common and severe form of HI (KATPHI), with most 
patients requiring near-total pancreatectomy to control hypoglycemia, leading to 
prolonged hospitalization and life threatening complications (1). Overall, 
inactivating KATP channel mutations are found in 90% of cases that require 
surgery. In 9% of these cases a mutation is not identified (12). 
The KATP-sensitive channels couple the metabolic state of the β-cell to membrane 
potential by responding to changes in intracellular ATP concentration. In 
pancreatic β-cells, closure of the channel by the elevation of ATP/ADP ratio 
following stimulation with glucose leads to depolarization of the membrane and 
activation of a voltage-dependent calcium channel that ultimately results in 
exocytosis of insulin-containing granules (13). Diazoxide, the mainstay of medical 
therapy for hyperinsulinism, suppresses insulin by promoting the opening of the 
β-cell KATP channels; therefore it is ineffective in patients with KATPHI. The second 
line of medical therapy for hyperinsulinism is octreotide, a somatostatin analog. 

 
 
2
The initial response to octreotide is good in most infants with hyperinsulinism but 
tachyphylaxis develops after a few doses, rendering therapy inadequate for long-
term use in most cases (14). Calcium channel blockers have also been tried 
unsuccessfully (15). Thus, most of these patients require surgical palliation by 
near-total pancreatectomy, which is not curative but carries a high risk of either 
persistent hypoglycemia or insulin-requiring diabetes (1).  
We have now proof-of-concept data in both animal models (16) and in affected 
patients (17) indicating that exendin-(9-39) is a promising potential therapy for 
infants with CHI that cannot be treated with currently-available medications (see 
preliminary results). In an animal model of KATPHyperinsulinism (SUR-1-/- mouse), 
a continuous infusion of exendin-(9-39) corrected the fasting hypoglycemia by 
inhibiting insulin secretion. Furthermore, in islets isolated from these mice, 
exendin-(9-39) did not only inhibit baseline insulin secretion but also blocked 
amino acid-stimulated insulin secretion (16), suggesting that this peptide may 
correct both fasting hypoglycemia and protein-induced hypoglycemia in affected 
human subjects. 
1.1.2. Clinical Phenotype of KATP Hyperinsulinism 
KATPHI is characterized by large for gestational age birth weight (due to 
stimulation of fetal growth by excessive insulin in utero), neonatal onset of 
hypoglycemia, and unresponsiveness to diazoxide therapy. In addition to fasting 
hypoglycemia, children with KATPHI have protein-induced hypoglycemia (18). 
Most reported KATP channel mutations are recessive, however a few dominantly 
expressed mutations have been reported (19-21). The dominant defects retain 
responsiveness to diazoxide and tend to be milder.   
There are at least two distinct histological forms of KATPHI, diffuse 
hyperinsulinism and focal hyperinsulinism. In focal hyperinsulinism 
(approximately 40-60% of all cases) a somatic reduction to homozygosity (or 
hemizygosity) of a paternally inherited mutation of ABCC8 or KCNJ11 and a 
specific loss of maternal alleles of the imprinted chromosome 11p15 region result 
in a focal lesion. Pre-operative identification and localization of these focal 
lesions by 18F-fluoro-L-DOPA facilitates local resection of the lesion and cure of 
this form of hyperinsulinism (22-24). Infants with diffuse hyperinsulinism require a 
near-total pancreatectomy (98%) to control the hypoglycemia and often require 
additional therapy with octreotide, and/or frequent feedings to maintain 
euglycemia. At The Children’s Hospital of Philadelphia’s Congenital 
Hyperinsulinism Center, the largest center in this country caring for children with 
disorders of insulin regulation, we evaluate and treat approximately 20-30 infants 
with medically-unresponsive hyperinsulinism requiring pancreatectomy every 
year. Among cases with diffuse hyperinsulinism, approximately 54% had 
persistent hypoglycemia after a near-total pancreatectomy, up to 24% required a 
second pancreatectomy for persistent hypoglycemia, 18% had persistent 
hypoglycemia but were medically controlled, and 20% had insulin-requiring 
diabetes. Thirty-one percent of the cases had surgical complications, including 
bowel obstruction, pancreatic exocrine insufficiency, necrotizing enterocolitis and 
death (1 from necrotizing enterocolitis and 1 from bowel obstruction).  

 
 
3
1.1.3. Metabolism and Insulin Secretion in Islets Lacking KATP Channels 
Animal models have been generated to replicate the defect in human KATPHI. 
Mice lacking Kir6.2-containing KATP channels (Kir6.2-/- mice) show transient 
hypoglycemia as neonates. With age the Kir6.2-/- mice develop fasting 
hyperglycemia and glucose intolerance (25).  SUR-1 knockout (SUR1-/-) mice 
have also been generated (26). SUR1-/- mice are both significantly more 
hyperglycemic when glucose-loaded and significantly more hypoglycemic when 
fasted than the control animals (27). Despite their impaired response to glucose, 
SUR1-/- mice secrete normal amounts of insulin after a meal, through intact 
second phase insulin secretion (28). 
Isolated islets from SUR1-/- mice, exhibit all the features expected to result from 
nonfunctional KATP channels, including β-cell depolarization and elevation of 
intracellular calcium (28; 29). SUR-1-/- rodent islets exhibit an abnormal pattern of 
basal and fuel-stimulated insulin secretion. Basal insulin secretion is two-three 
fold higher in SUR-1-/- islets compared to wild type controls (30; 31). Although the 
pattern of glucose-stimulated insulin secretion in these islets has been an issue 
of controversy, in all but one study (32) the response to high glucose was 
virtually absent or small compared to control islets (28-30; 33; 34). Stimulation by 
acetylcholine and GLP-1 have been shown to increase glucose responsiveness 
in these islets (34). In contrast to the poor response to glucose, isolated SUR-1-/- 
islets are hypersensitive to amino acids. After stimulation with an amino acid 
mixture, insulin release increases by 3-fold in SUR-1-/- islets, while normal islets 
are not affected by this stimulus, unless depolarized with glucose or 
sulfonylureas (30). These findings are congruent with the clinical observation of 
protein sensitivity in KATPHI (35). Evidence from SUR-1-/- islest (36) and Kir6.2-/- 
(37) and SUR-1-/- (38) mice demonstrating impaired glucagon secretion 
implicates KATP channels as regulators of glucagon secretion. The role of KATP 
channels in glucagon secretion seems to be independent of insulin and directly 
regulated by alpha cells KATP channels (39). 
Isolated islets from human subjects with KATP hyperinsulinism have also been 
studied but in a more limited way. Electrophysiological studies of islets from 
infants with HI show an absence of KATP channel activity and constitutively 
elevated intracellular calcium. Basal insulin secretion from these islets was 10-
fold higher than controls. In static incubations, glucose caused release of insulin 
in a dose-dependent manner and acetylcholine, ATP and UTP also increased 
insulin secretion (40). 
1.1.4. Glucagon-like Peptide-1 Receptor Agonists and Antagonists 
Glucagon-like peptide-1 (GLP-1) is an incretin hormone secreted by 
enteroendocrine L-cells in response to ingested nutrients. GLP-1 was first 
reported in 1987 to be a potent stimulator of glucose-dependent insulin release 
(41). Since then, numerous studies using GLP-1 agonists, antagonists, as well as 
genetic loss-of and gain-of-function rodent models have demonstrated that GLP-
1 not only enhances postprandial insulin secretion (42-44) but has other actions 
that are complementary to the incretin effect, including inhibition of glucagon 

 
 
4
secretion (45; 46), hepatic glucose production (47; 48), gastric emptying (49; 50), 
and appetite (51; 52).  
The major physiological stimulus to L-cells is nutrient ingestion, with circulating 
levels of GLP-1 rising by two- to threefold in response to a mixed meal in humans 
(53). The regulation of GLP-1 secretion by ingested nutrients is complex and 
thought to involve indirect vagal pathways as well as direct luminal stimulation of 
the intestinal L-cells (54). Studies in a GLP-1-secreting cell line (GLUTag) have 
demonstrated that glucose and other metabolized sugars enter the L-cells (likely 
via a glucose transporter, GLUT-1 or GLUT-5) and induce depolarization by 
closure of KATP channels (Kir6.2/SUR-1) (55; 56). A rise in cytoplasmic Ca2+ 
concentration due to opening of voltage gated calcium channels is part of the 
secretion mechanism (57). A different mechanism involving electrogenic 
substrate entry to the cell through sodium-glucose transporters results in KATP 
channel independent glucose-stimulation of GLP-1 release (58). Given the 
common embryological origin of the pancreas and intestine it is not surprising 
that the enteroendocrine cells and β-cells share similar mechanisms of glucose 
sensing and response; furthermore, glucokinase, the “glucose-sensor” in β-cells, 
is also expressed in these cells (59). GLP-1 secretion has not been studied in 
KATPHI, but the observed similarities between pancreatic β-cells and 
enteroendocrine L-cells suggest that glucose-stimulated GLP-1 secretion may be 
affected in subjects with KATPHI. Furthermore, our islet studies suggest that the 
GLP-1r is constitutively active in SUR-1-/- islets (16). 
A single GLP-1 receptor (GLP-1r) has been identified and is expressed in the 
pancreatic islet, the gastrointestinal mucosa, heart, lung, kidney, and the brain 
(60).  A mouse with a targeted gene deletion of the GLP-1r has been shown to 
have fasting hyperglycemia and glucose intolerance, but no apparent major 
abnormalities in the function of the lungs, GI tract or CNS (61-63). Studies in cell 
lines or transfected cells have demonstrated that GLP-1 binds to the GLP-1r and 
activates intracellular signaling in great part through activation of adenylyl cyclase 
and the generation of cAMP (64; 65).   
The exendin peptides, exendin-3 and exendin-4, were originally isolated from the 
saliva of the Gila Monster, Heloderma horridum, using an assay for N-terminus 
Histidine residues (66-69). Exendin-3 interacts with the VIP receptor, but exendin-4 
is a high affinity agonist of the GLP-1r.  Exendin-4 is bound more avidly than GLP-
1 (70), and is relatively more potent than GLP-1 in stimulating insulin secretion (71; 
72).  In addition, because it is not susceptible to metabolism by dipeptidyl-
peptidase IV, exendin-4 has a longer circulating half-life than GLP-1 (73; 74).  
Exendin-4 (Exenatide, Byetta), is approved for the treatment of type 2 diabetes 
mellitus, and other GLP-1 analogues are currently in late phase of clinical 
development (60) . A truncated form of exendin-4, exendin-(9-39), has been shown 
to be a specific antagonist of the GLP-1r in vitro (71; 75) and in vivo in a variety of 
animal models (76-78) and in humans (79). We have shown that antagonism of the 
GLP-1r by exendin-(9-39) results in a persistent elevation of fasting blood glucose 
levels in normal mice (80).  

 
 
5
In human subjects, Schirra and colleagues used exendin-(9-39) during glucose 
clamps, with and without concurrent infusions of GLP-1 (79).  At a dose of 300 
pmol/kg/min (0.06 mg/kg/hr), exendin-(9-39) blocked GLP-1 induced insulin 
secretion by 85-95%.  In addition, administration of exendin-(9-39) increased 
plasma glucagon concentrations, indicating the importance of GLP-1 in the 
regulation of the islet α-cell.  Edwards et al. also infused exendin-(9-39) into 
healthy volunteers (81).  In this study subjects were given doses of 5-500 
pmol/kg/min (0.001-0.1 mg/kg/hr) during infusion of 0.5 pmol/kg/min of GLP-1.  
Significant antagonism of GLP-1-induced insulin secretion, a 21% decrease, was 
noted with 50 pmol/kg/min (0.01 mg/kg/hr) of exendin-(9-39), and 500 pmol/kg/min 
(0.1 mg/kg/hr) completely abolished the effect of exogenous GLP-1. Furthermore, 
administration of exendin-(9-39) to fasted subjects resulted in increased plasma 
fasting glucose levels. These investigators also studied the effect of exendin-(9-39) 
on endogenous GLP-1-stimulation of insulin secretion by infusing 500 pmol/kg/min 
(0.1 mg/kg/hr) during oral glucose tolerance tests.  In this experiment exendin-(9-
39) caused glucose intolerance relative to a control infusion of saline. The 
circulating half-life of exendin-(9-39) was determined to be ~ 30 minutes using a 
specific radioimmunoassay. Interestingly, in both studies the relative 
concentrations of exendin-(9-39) necessary to completely block GLP-1 were ~ 
1:1000, higher than would have been predicted by the relative binding of these two 
peptides determined in vitro (68; 70; 71).  These studies demonstrate that exendin-
(9-39) acts as a GLP-1r antagonist in humans, and that GLP-1 has a physiologic 
role in glucose metabolism in healthy subjects.  
 
1.1.5. Significance 
Congenital hyperinsulinism is a devastating disease affecting approximately 100 
to 200 neonates each year in the USA. The lack of effective medical therapies 
results in the need for a near total pancreatectomy to ameliorate the 
hypoglycemia. This surgical approach carries a high risk of complications such 
as diabetes, bowel obstruction, malabsorption, necrotizing enterocolitis and 
death. Furthermore, a significant number of the infants continue to have 
hypoglycemia after the surgery requiring continuous administration of glucose by 
a gastrostomy tube to maintain euglycemia. Despite the impressive recent 
advances in the understanding of the molecular biology of congenital 
hyperinsulinism, there have not been any advances in terms of medical therapies 
for over 20 years. As shown in the Preliminary Studies section, we have data 
showing very promising effects of antagonism of the GLP-1 receptor by exendin-
(9-39) not only in a mouse model but also in human subjects with hyperinsulinism 
due to KATP channel mutations. The development of this peptide as a therapeutic 
agent for this disorder would represent a major advance in the field.  
 

 
 
6
1.2. Name and Description of Investigational Product 
The principal investigator holds an investigational new drug application for 
the use of exendin-(9-39) in this population (IND#76,612). This protocol is 
being added to the original application. 
1.2.1. Exendin-(9-39) 
Exendin-(9-39), a truncated form of exendin-4 (exenatide, Byetta , FDA 
approved for the treatment of type 2 diabetes mellitus), is a specific antagonist of 
the GLP-1r with opposite effects on glucose levels than the agonist, exendin-4. In 
human studies, exendin-(9-39) has been shown to increase fasting plasma 
glucose levels (81). No side effects, including no effects on blood pressure and 
heart rate, have been reported with the use of this peptide in normal human 
subjects (79; 81). Similarly, the peptide has appeared to be well-tolerated in our 
pilot studies as well (see below). There is limited data on the pharmacokinetics of 
exendin-(9-39) in human subjects. The circulating half-life of exendin-(9-39) was 
determined to be ~ 30 minutes using a specific radioimmunoassay (81), but no 
data on the metabolism of the peptide is available. It is expected that the 
metabolism of exendin-(9-39) will be similar to the metabolism of the parent 
peptide, exendin-4 (Exenatide-Byetta, Amylin Pharmaceuticals, Inc.) from 
which it differs by only eight amino acids. The intravenous half-life of both 
peptides is very similar. Non-clinical studies have shown that exenatide is 
predominantly eliminated by glomerular filtration with subsequent proteolytic 
degradation. The mean apparent clearance of exenatide in humans is 9.1 L/h 
and the mean terminal half-life is 2.4 h. These pharmacokinetic characteristics of 
exenatide are independent of the dose. In patients with mild to moderate renal 
impairment (creatinine clearance 30 to 80 mL/min), exenatide clearance was only 
mildly reduced (Product insert, Amylin Pharmaceuticals, Inc.).  
 
1.2.2. Chemistry, manufacturing, control 
For our studies, exendin-(9-39) was synthetized by American Peptide Company 
(Coorporate Offices, 777 East Evelyn Street, Sunnyvale, CA 94086) under cGMP 
guidelines. The peptide was purified to ≥ 99% by HPLC, and the sequence and 
mass verified (by Mscan and mass spectral analysis). The investigational drug was 
formulated by the University of Iowa Pharmaceuticals (115 South Grand Avenue, 
G-20, Iowa City, Iowa, 52242, a GMP facility) in a 10mM Citrate Buffer, pH 6.0 
(Citric Acid Monohydrate USP, Sodium Citrate Dihydrate USP, and d-Mannitol, 
USP) and stored in sterile 5 mL vials with stopper and seal (West Pharmaceutical) 
in lyophilized form at -20° C. Each vial contains 25 mg of exendin-(9-39). For 
administration, the Investigational Pharmacy at the Children’s Hospital of 
Philadelphia will dilute the peptide in 0.9% NaCl and 0.25% human serum albumin 
to a final concentration of 0.1mg/mL. The 25% human serum albumin will be 
obtained from Grifols or Octapharma (based on availability). 
 

 
 
7
1.2.3. Toxicity 
Exendin-4, the naturally occurring Heloderma product, has been used extensively 
in human studies (83-85).  Side effects reported with exendin-4 have been limited, 
although in higher doses nausea has been reported.  Exendin-(9-39) is a synthetic 
molecule that has also been used in multiple human studies (79; 81; 86-91).  Dose 
ranging studies have been reported by both Schirra and Edwards (79; 81). In 
neither of the previous studies were adverse effects of exendin-(9-39) reported. In 
addition, no effects of exendin-(9-39) on blood pressure and heart rate were found 
on these studies.  In both animals and humans studies exendin-(9-39) seems to be 
relatively short-lived in the circulation.  While GLP-1 seems to play an important 
role in glucose tolerance it is not the only regulatory factor involved, and the 
glucose tolerance induced by exendin-(9-39) is relatively modest. In our studies, 
infusion of exendin-(9-39) to mice with a null mutation of the KATP channel did not 
significantly worsen the glucose tolerance of these mice, nor affected weight gain 
(16). We have not observed any serious adverse events on the subjects we have 
studied under this IND: to date, all doses appear to have been generally safe and 
well tolerated in all three populations studied.   There have been no SAEs, deaths, 
or withdrawals due to study drug.    
Toxicology studies were completed in Sprague Dawley rats (7±1 days of age) 
and beagle dogs (13 days of age). In 14-day non-GLP studies, three daily 
subcutaneous (SC) doses of 15, 50, and 150 mg/kg/dose were administered to 
rats and 5, 15, and 40 mg/kg/dose were administered to dogs. Based on the lack 
of toxicologically significant findings, doses for GLP 28-day studies were 
increased to 20, 80, and 300 mg/kg/dose three times daily for rats and 10, 30, 
and 100 mg/kg/dose three times daily for dogs. Toxicological endpoints 
evaluated included: clinical observations, body weight, food consumption, clinical 
pathology, CNS assessment (rats), electrocardiography (dogs), toxicokinetics, 
and histopathology. The only exendin (9-39)-related observations noted were 
increased serum glucose in female rats and decreased serum triglycerides in 
male rats. In the cardiovascular safety pharmacology study, beagle dogs (7 to 8 
months old) were administered a single SC dose of vehicle or 5, 20, or 80 mg/kg 
exendin (9-39) in a 4 x 4 Latin-square design. No toxicologically significant 
findings were observed. A dose proportional increase in exendin-(9-39) plasma 
exposure was observed; combined average AUClast on Day 28 in male and 
female rats at the 300 mg/kg/dose was 249,000 ng•h/mL and at the 100 
mg/kg/dose in dogs was 340,500 ng•h/mL. In conclusion, based on the available 
data, no observed adverse effect levels (NOAELs) were 900 mg/kg/day in rats 
and at 300 mg/kg/day in dogs. The human equivalent intravenous dose based on 
body surface area and a bioavailability of 70% are 116 mg/kg/day and 102 
mg/kg/day.  
 

 
 
8
1.3. Findings from Pre-Clinical and Clinical Studies (see 
attachments) 
1.3.1. Findings from Pre-Clinical Research 
We have conducted experiments that showed a significant effect of exendin-(9-
39) on fasting blood glucose levels in SUR1-/- mice. Mice carrying a null mutation 
in the SUR-1 gene exhibit significant fasting hypoglycemia (59.4±1.5 mg/dL vs. 
75±1.8 mg/dL, p=0.00000003) and glucose intolerance when compared to wild-
type littermates.  
To evaluate the effect of GLP-1r antagonism in mice lacking KATP channels, we 
treated SUR1-/- mice with exendin-(9-39). Twelve-18 wk old male SUR1-/- (n=22) 
and wild type littermates (n=23) were randomized to treatment or vehicle. The 
treatment group received a continuous infusion of exendin-(9-39) at a dose of 
150 pmol/kg/min (0.03 mg/kg/hr) via a subcutaneous mini-osmotic pump (Alzet 
model 2002) for 2 wks. The control group received an infusion of vehicle 
(0.9%NaCl/1%BSA). On day 7, fasting blood glucose was significantly lower in 
vehicle-treated SUR-1-/- mice compared to vehicle-treated wild-type littermates 
(p=0.000002). Treatment with exendin-(9-39) significantly raised fasting blood 
glucose in SUR-1-/- mice compared to vehicle-treated SUR-1-/- mice (82.2±6.3 
mg/dL vs. 63.2±4.9 mg/dL, p=0.03, on day 3; 82±4.7 mg/dL vs. 56.4±4.3 mg/dL, 
p=0.0006, on day 7). Fasting insulin/glucose ratio was increased in SUR-1-/- mice 
compared to wild-type littermate control mice (p=0.04) and was normalized by 
exendin-(9-39) treatment (WT vs. SUR-1-/-Ex-(9-39): p= 0.32), suggestive of a 
direct islet effect of exendin-(9-39) on insulin secretion. Insulin sensitivity 
determined by the measurement of blood glucose in response to an 
intraperitoneal injection of insulin (0.5 U/kg) was unaffected by treatment. 
Similarly, glucose tolerance, which is impaired in SUR-1-/- mice, was not 
significantly affected by treatment with exendin-(9-39) (fig. 5). Weight gain was 
not different in the experimental groups.  
The in vivo studies were confirmed by perifusion studies. Islets were isolated 
from SUR1-/- mice by collagenase digestion and cultured for 3 days in RPMI 1640 
medium containing 10 mM glucose. Batches of 100 cultured islets were loaded 
onto a nylon filter in a chamber and perifused with Krebs-Ringer bicarbonate 
buffer with 0.25% bovine serum albumin at a flow rate of 2mL/min. Islets were 
perifused with a ramp of a physiologic mixture of amino acids (0-12 mM) in the 
presence or absence of exendin-(9-39) at a concentration of 100 nM. As 
previously reported (30) the SUR1-/- islets abnormally released insulin in 
response to a mixture of amino acids. This response to amino acids was blocked 
by exendin-(9-39). The insulin response to KCl was similar in the presence and 
absence of exendin-(9-39). The effect of exendin-(9-39) on cAMP was 
determined in static incubations of isolated islets. In the absence of exogenous 
GLP-1, exendin-(9-39) significantly decreased basal intracellular cAMP in SUR-1-
/- islets. Amino acids significantly increased cAMP levels in SUR-1-/- islets 
compared to baseline and this effect was significantly reduced by exendin-(9-39). 
In static incubations, the effect of exendin-(9-39) on cAMP levels mirrored its 
effect on insulin secretion, suggesting that exendin-(9-39) effects on insulin 

 
 
9
secretion in SUR-1-/- islets are mediated by changes in cAMP. Baseline insulin 
secretion was significantly reduced by exendin-(9-39). As seen in the perifusion 
studies, amino acids significantly increased insulin secretion in SUR-1-/- islets 
and exendin-(9-39) significantly reduced amino acid-stimulated insulin secretion. 
Finally, we studied the effect of exendin-(9-39) on the characteristically elevated 
intracellular calcium concentration of SUR-1-/- islets (30).  Exendin-(9-39) did not 
affect basal or the amino acid-stimulated rise in calcium. 
1.3.2. Findings from Clinical Research 
Preliminary Studies: Exendin-(9-39) inhibits insulin secretion and elevates 
fasting blood glucose levels in subjects with KATP hyperinsulinism (17).  
Subjects (n=9,6F) age 15-47 yrs with congenital hyperinsulinism were admitted 
to the inpatient unit of the CHOP CTRC. After an overnight fast, subjects 
received an intravenous infusion of vehicle (0.9%NaCl) for 1 hour followed by an 
intravenous infusion of exendin-(9-39) at three different doses [100, 300 and 500 
pmol/Kg/min (0.02, 0.06 and 0.1 mg/kg/hr)] for 2 hours each or vehicle for 6 
hours. All subjects underwent the vehicle and exendin-(9-39) infusions in 
randomized order and on different days. Blood samples for blood glucose, 
insulin, C-peptide, glucagon, and intact GLP-1 were obtained at multiple time 
points during the infusions. Exendin-(9-39) increased fasting blood glucose levels 
in all subjects compared to vehicle [average fasting blood glucose during study 
on vehicle vs. exendin-(9-39): 84±12.2mg/dL vs. 105±23.2mg/dL p<0.01]. Six of 
the subject had hypoglycemia (blood glucose < 70 mg/dL)during vehicle infusion 
while none of them had hypoglycemia during exendin-(9-39) infusion. Fasting 
insulin to glucose ratio was significantly lower during exendin-(9-39) infusion 
compared to vehicle (0.08±0.03 vs. 0.12±0.04, p=0.01) (fig.5). Fasting glucagon 
and GLP-1 levels were not different during exendin-(9-39) infusion compared to 
vehicle. Exendin-(9-39) was well tolerated with no side effects. 
 
The preliminary pre-clinical and clinical studies demonstrate that antagonism of 
the GLP-1r by exendin-(9-39): 1) suppresses insulin secretion and elevates 
fasting blood glucose levels in SUR-1-/- mice; 2) suppresses baseline and amino 
acid-stimulated insulin secretion in SUR-1-/- islets; and 3) suppresses insulin and 
elevates fasting blood glucose levels in human subjects with KATPHI. The insulin 
inhibitory effect seems to be mediated by the effect of exendin-(9-39) on 
intracellular cAMP levels in pancreatic β-cells. The effects of exendin-(9-39) on 
SUR-1-/- islets in the absence of agonist stimulation suggest that the GLP-1 
receptor is constitutively active in these islets. Overall, our findings suggest a 
potential role for GLP-1 in the pathogenesis of KATP hyperinsulinism. Clearly, the 
promising effects of exendin-(9-39) in the mouse model of KATPHI and in subjects 
with KATP hyperinsulinism suggest a therapeutic potential for GLP-1 receptor 
antagonism in this disorder.  
1.4. Dose Rationale and Risk/Benefits 
The doses used in previous human studies ranged from 30 to 900 pmol/kg/min 
(0.006 to 0.18 mg/kg/hr) (79; 81; 86-91). Schirra et al.(79) demonstrated that 

 
 
10
under physiological post-prandial plasma levels of GLP-1 (achieved by an 
intravenous infusion) administration of exendin-(9-39) at 30 and 60 pmol/kg/min 
(0.006 and 0.012 mg/kg/hr) significantly reduced the glucose infusion rate 
required to maintain blood glucose at 140 mg/dL in normal subjects, while a dose 
of 300 pmol/kg/min (0.06 mg/kg/hr) totally abolished the elevated demand for 
exogenous glucose under the experimental conditions. Furthermore, at 
euglycemia, infusion of exendin-(9-39) at 300 pmol/kg/min (0.06 mg/kg/hr) 
significantly raised basal glucose and glucagon. Edwards et al.(81) studied the 
effect of exendin-(9-39) on fasting plasma glucose in normal adult volunteers. 
They found that exendin-(9-39) infused at a dose of 500 pmol/kg/min (0.1 
mg/kg/hr) increased fasting plasma glucose significantly compared with controls 
infused with saline. After cessation of exendin-(9-39) infusion, the plasma 
glucose level in response to exendin-(9-39) dropped to that of the control. In 
summary, these studies demonstrated that at a dose of 300 pmol/kg/min (0.06 
mg/kg/hr), exendin-(9-39), abolishes the effects of physiologic post-prandial 
plasma levels of GLP-1, and that a higher dose of 500 pmol/kg/min (0.1 
mg/kg/hr) increases fasting plasma glucose levels in normal subjects. In these 
studies, exendin-(9-39) was well tolerated by all subjects and there was not effect 
on pulse or blood pressure. No adverse effects related to exendin-(9-39) were 
reported in the previously discussed studies.  
In our studies in mice with a null mutation of SUR-1, a pilot study demonstrated 
that a dose of 150 pmol/kg/min (0.03 mg/kg/hr) was effective in increasing fasting 
blood glucose levels, while a lower dose of 50 pmol/kg/min (0.01 mg/kg/hr) did 
not have an effect.  In our pilot human studies, we have used a dose ranging 
from 100-500 pmol/kg/min (0.02-0.1 mg/kg/hr). From these studies the higher 
dose (500 pmol/kg/min) was given at the end of the infusion elevating blood 
glucose levels after a long fast (18 hrs). These doses were well tolerated. We 
have studied 2 neonates at this dose level administered over 6 hrs and did not 
find an effect on glucose infusion rates.  
 
We developed a specific and sensitive LC-MS/MS method to quantify the 
concentration of exendin-(9-39) in human plasma (82) and measured exendin(9-
39) concentration serially in individuals who participated in our research studies 
and received exendin-(9-39) intravenously. A total of 202 PK observations from 
twenty-six adult and pediatric subjects were included in the analysis. The final 
parameter estimates were obtained using FOCE with interaction method in 
NONMEM (version 7.3).  A linear two-compartment model best described the 
observed data, and the PK parameters were estimated with good precision 
(%CV<50).  The PK parameters were related to body weight and age. Gender 
and creatinine clearance did not affect the clearance of exendin-(9-39) in the 
studied population.  Typical clearance and elimination half-life for pediatric 
population with median weight 5 Kg are 1.64 L/hr and 0.94 hr, respectively. 
The final model parameters are presented in the table below: 
 

 
 
11
PARAMETERS 
Population Mean (SE) 
Population Variance 
(%CV) 
CL (L/hr) 
VC  (L) 
Q (L/hr) 
Vp (L) 
11.9 (0.781) 
8.57 (0.925) 
3.85 (1.36) 
7.00 (1.24) 
0.0722 (0.0309) 
-  
- 
- 
σ_Proportional error 
0.310 (0.0381) 
- 
 
Based on our clinical data to date including the observed and modeled PK data, 
we are proposing additional dose-escalation cohorts starting with a dose that is 
2-fold higher than the highest dose used in the pilot study [1000 pmol/kg/min (0.2 
mg/kg/hr)] up to a maximum dose that is lower than the human equivalent 
(assuming 70% bioavailability) NOAELs from the toxicology studies in rats and 
dogs. The estimated range of AUC (A) and CMax (B) with these doses were 
simulated using the developed population PK model and are shown as follows:  
 
 
 
The dotted line is the exposure of the NOELdose in dog.  The dashed line is the exposure of the NOEL dose in rat.  
AUC0-inf = Area under the concentration-time curve from time=0 to infinity; Number of simulated subject = 1000;  Open 
circle = Median; Error Bar = 95 % percentile  
 
Clinical and nonclinical pharmacokinetic parameters and safety factors are 
summarized in the following table. 
Study Type 
Dose 
(mg/kg/hr) 
Cmax 
(ng/mL) 
AUC 
(ng*hr/mL) 
Proposed in Neonates 
0.2 
69.45a 
625.5 a 
Proposed in Neonates 
0.6 
208.3 a 
1876 a 
Proposed in Neonates 
2 
694.5 a 
6255 a 
Proposed in Neonates 
6 
2083 a 
18764 a 

 
 
12
Rat (Study #13835B) 
 
900 mg/kg/day 
(300 mg/kg TID) 
 
63200b 
249,000  
Dog (Study #13835D) 
300 mg/kg/day 
(100 mg/kg TID) 
49500c 
340,500  
 
a – median value of 1000 simulated subjects; b – represented Cmax value of male rats following a single 
dose administration; c – represented Cmax values of female dogs on Day 28 
 
Safety Margins based on dose and exposure (AUC) 
 
Proposed 
dose rate 
(mg/kg/hr) 
Total 
dose 
over 9 
hoursa 
(mg/kg) 
Safety 
margin 
based on 
HED from 
rat (300 
mg/kg/day)
b 
Safety 
margin 
based on 
HED from 
dog (900 
mg/kg/day)
b 
Safety 
margin 
based on 
Cmax 
from rat 
(63200 
ng/mL)c 
Safety 
margin 
based 
on 
Cmax 
from 
dog 
(49500 
ng/mL)d 
Safety 
margin 
based on 
AUC 
from rat 
(249000 
ng*hr/mL
)  
Safety 
margin 
based on 
AUC from 
dog 
(340500 
ng*hr/mL) 
0.2 
1.8 
57 
65 
910 
713 
398 
544 
0.6 
5.4 
18 
22 
303 
238 
133 
181 
2.0 
18 
5.6 
6.5 
91 
71 
40 
54 
6.0 
54 
1.9 
2.2 
30 
24 
13 
18 
a – Assuming infusion over nine hours is the daily dose 
b – For rat HED is 102 mg/kg/day; for dog HED is 117 mg/kg/day; calculations includes bioavailability of 70% 
c – represented Cmax value of male rats following a single dose administration; d– represented Cmax values 
of female dogs on Day 28 
 
Exendin -(9-39) will be administered intravenously as in the previous human 
studies. In short-term infusions studies Schirra (79) and Edwards (81) did not find 
a cumulative or persistent effect once the infusion was discontinued. No adverse 
effects of exendin-(9-39) were reported in the previously discussed studies. 
Exendin-(9-39) was well tolerated by all subjects and there was not effect on 
pulse or blood pressure.  
In the children, adolescents and adults with congenital hyperinsulinism that we 
have studied to date, all doses appear to have been generally safe and well 
tolerated in all three populations studied.   There have been no SAEs, deaths, or 
withdrawals due to study drug.   Adverse events, regardless of causality, were 
reported in 19 of the 31 subjects (61.3%) treated to date.  Treatment-related AEs 
were reported in only 3 subjects (9.7%).   The most common adverse event 
observed as expected in this population was hypoglycemia (16 of 31 subjects, 
51.6%); the majority of these events were Grade 1 or 2 and all were assessed as 
unrelated to investigational drug. Adverse events possibly related to the 
investigational drug included emesis (Grade 1) in one subject and transient 
hyperglycemia in two subjects (Grade 3). The occurrence of adverse events was 
balanced between the investigational drug and vehicle conditions. 
Other than the effects on glucose homeostasis, which appears to be transient in 
human subjects, we do not anticipate other effects. Therefore, the anticipated 
benefits derived from these experiments which includes our understanding of the 

 
 
13
physiopathologic role of GLP-1 in congenital hyperinsulinism, and moreover, the 
potential effect of exendin-(9-39) in controlling the severe hypoglycemia affecting 
these patients in face of the lack of effective medical therapy justify the proposed 
studies.  
1.5. Compliance Statement 
This study will be conducted in full accordance with all applicable Children’s 
Hospital of Philadelphia Research Policies and Procedures and all applicable 
Federal and state laws and regulations including 45 CFR 46, 21 CFR Parts 50, 
54, 56, 312, 314 and 812 and the Good Clinical Practice: Consolidated Guideline 
approved by the International Conference on Harmonization (ICH). Any episode 
of noncompliance will be documented. 
The investigators will perform the study in accordance with this protocol, will 
obtain consent and assent, and will report adverse events in accordance with 
The Children’s Hospital of Philadelphia IRB Policies and Procedures and all 
federal requirements. Collection, recording, and reporting of data will be accurate 
and will ensure the privacy, health, and welfare of research subjects during and 
after the study.  
2. Study Objectives 
Congenital hyperinsulinism due to mutations in the KATP channel (KATPHI) is 
characterized by severe hypoglycemia unresponsive to available medical therapy. 
Currently, most patients require a pancreatectomy to control the hypoglycemia, 
leading to prolonged hospitalization and life-threatening complications. Our pre-
clinical studies demonstrate that antagonism of the glucagon-like peptide-1 receptor 
(GLP-1r) by exendin-(9-39) suppresses insulin secretion and corrects fasting 
hypoglycemia in mice lacking KATP channels (SUR-1-/- mice). Preliminary results from 
a clinical pilot study indicate that an intravenous infusion of exendin-(9-39) in older 
adolescents and adult human subjects with KATPHI raises fasting blood glucose 
levels. In this study we will evaluate the effects of exendin-(9-39) on glucose 
requirements to maintain euglycemia in subjects who have failed medical therapy.  
2.1. Specific Aim  
To examine the effect of exendin-(9-39) on glucose requirements to 
maintain euglycemia in infants with congenital hyperinsulinism 
unresponsive to medical therapy. 
Secondary Aim. To determine therapeutic plasma levels, plasma half-life 
and pharmacokinetics of exendin-(9-39) during an intravenous infusion.  
 
Hypothesis: In infants with hyperinsulinism unresponsive to medical therapy, 
antagonism of the GLP-1 receptor by exendin-(9-39) will result in decreased 
glucose requirements to maintain euglycemia, as a result of suppressed insulin 
and increased glucagon secretion. 

 
 
14
Rationale: Infants with congenital hyperinsulinism present with severe 
hypoglycemia shortly after birth. Approximately 50% of these infants are 
unresponsive to available medical therapy (diazoxide and octreotide) and require 
a pancreatectomy to ameliorate the hypoglycemia. Before surgery, the 
maintenance of euglycemia is dependent on high glucose infusion rates (up to 
20-25 mg/Kg/min) by intravenous or central lines. This practice is frequently 
associated with severe complications including sepsis and fluid overload which in 
the presence of the characteristic myocardial hypertrophy seen in these patients 
puts them at high risk for heart failure. Based on published studies demonstrating 
that exendin-(9-39) reduces the glucose infusion rates required to maintain blood 
glucose levels at a target level in normal human subjects (79) and our preliminary 
data demonstrating the insulin suppressant effects of exendin-(9-39) in subjects 
with hyperinsulinism, we propose that by continuously infusing exendin-(9-39) we 
will be able to reduce the glucose infusion rates needed to maintain euglycemia 
in infants with congenital hyperinsulinism. 
Primary outcome variable: glucose infusion rate during the last 2 hrs of infusion 
of exendin-(9-39).  
Secondary outcome variables: plasma glucose 1 hr after initiation of infusion, 
insulin, and betahydroxybutyrate levels measured at different intervals during the 
study. Exendin-(9-39) plasma levels. 
Safety variables: Primary safety endpoints will include all types of adverse 
experiences, in addition to laboratory safety tests (hematology, chemistry, and 
urinalysis). 12-lead electrocardiograms (ECGs), vital signs and physical 
examinations will also be recorded. 
3. Study Design 
3.1. General Design 
This is an open label randomized, crossover study aim to examine the effects of 
the investigative peptide, exendin-(9-39) on a key feature of the phenotype of 
congenital hyperinsulinism: 1) increased glucose requirements to maintain 
euglycemia. 
The proposed human studies will be facilitated by the support of the Clinical and 
Translational Research Center (CTRC) at The Children's Hospital of Philadelphia 
and by having access to the largest pool of patients with congenital 
hyperinsulinism in this country through the Hyperinsulinism Center at The 
Children's Hospital of Philadelphia.  
3.2. Experimental Design  
We will compare the glucose infusion rate (measured in mg/Kg/min) required to 
maintain euglycemia (defined as a blood glucose > 70 mg/dL) with a concomitant 
intravenous infusion of exendin-(9-39) and vehicle in infants with congenital 
hyperinsulinism unresponsive to medical therapy. Each subject, in random order, 
will be evaluated on two separate days for a total of 12-15 hours each day. 

 
 
15
During the first 3 hours, glucose infusion rates will be titrated to keep blood 
glucose in the range of 70-90 mg/dL, then, the study treatment period will start. 
On one day with an infusion of vehicle (normal saline) rates of glucose infusion to 
maintain blood glucose in the 70-90 mg/dL range will be calculated. To help 
inform the pharmacokinetic-pharmacodynamic relationship, subjects who have 
been able to discontinue the dextrose infusion and who are not on supplemental 
dextrose infusion at the end of the study will continue to be monitored without 
additional dextrose infusion for up to 3 hours after the end of the study drug 
infusion, or until blood glucose is < 70 mg/dL (whichever comes first). On the 
other day, subjects will receive a continuous intravenous infusion of exendin-(9-
39) and the glucose infusion rates to maintain blood glucose in the 70-90 mg/dL 
range will be calculated. Studies will be carried out in the neonatal intensive care 
unit or the inpatient CTRC unit at The Children’s Hospital of Philadelphia. 
3.3. Study Population 
Subjects will be recruited from patients referred to the Hyperinsulinism Center at 
The Children’s Hospital of Philadelphia, the largest center in the USA, with 
approximately 30 referrals/year of children with medically-unresponsive 
hyperinsulinism and an equal number of children with medically-responsive 
hyperinsulinism. Three hundred and sixty one pancreatectomies have been 
performed in children with congenital hyperinsulinism within the last 16 years at 
this center. We plan to enroll approximately 20 additional subjects, beyond the 9 
subjects already enrolled up through Amendment 6, making a total number of  
approximately 30 subjects for about 27 evaluable subjects and to include at least 
some subjects with diffuse disease.  
3.3.1. Inclusion and Exclusion Criteria 
Inclusion Criteria: 
 Confirmed diagnosis of congenital hyperinsulinism (based on clinical 
criteria: insulin, beta hydroxybutyrate, and/or free fatty acid plasma levels 
at the time of hypoglycemia, and/or glycemic response to glucagon at the 
time of hypoglycemia) 
 Age: from birth to 12 months 
 Failure to respond to diazoxide (defined as the failure to maintain blood 
glucose > 70 mg/dL without supraphysiologic rates of glucose infusion:> 
4-5 mg/Kg/min) 
Exclusion Criteria: 
 Evidence of a medical condition that might alter results, including active 
infection, kidney failure, severe liver dysfunction, severe respiratory or 
cardiac failure 
 Current therapy at the time of initiation of study procedures with 
medications that affect glucose metabolism, such as high dose 
glucocorticoids, ß-agonists, glucagon, diazoxide and octreotide. Subjects 
will be eligible to participate 4 hrs after glucagon discontinuation, 24 hrs 
after the last dose of octreotide and 72 hours after last dose of diazoxide 

 
 
16
 Subjects with suspected Beckwith-Wiedemann syndrome or other 
syndromic forms of congenital hyperinsulinism 
 
3.4. Study Procedures 
1. Test of immediate hypersensitivity. All subjects will have 5 ng of exendin-
(9-39) (0.05µg/mL) administered intradermally as a test of immediate 
hypersensitivity prior to the study. The test of immediate hypersensitivity 
may be done the day prior or the morning of the study prior to the start of 
the infusion. A wheal and flare reaction in the 30 minutes following peptide 
injection will be considered a positive test and the study will be canceled. 
2. Baseline liver and kidney function: Baseline laboratories for evaluation of 
liver and kidney function (ALT, AST, GGT, BUN, creatinine) will be 
obtained if the subject has not had these tests done within 72 hrs of the 
study. 
3. Safety evaluations: heart rate, blood pressure, respiratory rate and 
temperature will be measured each day at baseline. Heart rate, blood 
pressure and respiratory rate will be monitored then hourly during the 
treatment periods. Temperature will be measured at baseline, hourly 
during the study, and at the conclusion of the infusion periods. The 12-
lead ECG, as well as laboratory safety evaluations including CBC, 
urinalysis, liver and kidney function will be repeated at the end of the 
study. Any clinically significant abnormality would be repeated until values 
have returned to normal range/baseline. 
4. Study run-in period: During the 3 hours of run-in period, blood glucose will 
be monitored every 30 min by heel stick using a bedside glucose meter 
(Nova StatStrip point-of-care glucose monitor, Nova Biomedical 
Corporation, Waltham, MA, USA). The dextrose infusion rate will be 
adjusted to maintain glucose in the range of 70-90 mg/dL. The study run-
in period will be timed to start with a feeding in the morning and we will 
kept consistent between study days.  
5. Blood glucose monitoring during the study and maintenance of 
euglycemia. Blood glucose will be monitored every 30 minutes during the 
study period by heel stick using a bedside glucose meter (Nova StatStrip 
point-of-care glucose monitor, Nova Biomedical Corporation, Waltham, 
MA, USA). Rate of intravenous dextrose infusion will be adjusted as 
needed to maintain target blood glucose range of 70-90 mg/dL as per 
standard of clinical practice. If blood glucose concentration is < 70 mg/dL 
a second sample will be obtained immediately for confirmation. Correction 
of values below the target range will be confirmed by measuring a blood 
glucose 15 minutes after adjustments to the glucose infusion rate.  
6. Feedings: Infants will be allowed to continue feedings by mouth or by 
nasogastric/gastrostomy tube. Feedings will be continued every 3 hours 
and the volumes offered will be maintained equal during the two 9 hr study 

 
 
17
periods. The volume taken with each feeding will be recorded. Only 
intravenous glucose will be adjusted to maintain euglycemia.  
7. Randomization: The investigational drug services will assign the order of 
the studies by randomization.  They will inform the PI, study coordinator, 
and CTRC. 
8. Intravenous infusion of exendin-(9-39) and vehicle. All subjects will receive 
an infusion of exendin-(9-39) and vehicle for 9 hours on two separate days 
and in random order. Exendin-(9-39) /vehicle will be infused intravenously 
over a period of 9  hours starting at approximately the same time ± 90 
minutes on each day. The starting dose of exendin-(9-39) will be 1000 
pmol/kg/min (0.2 mg/kg/hr). The dose will be escalated as outlined below. 
The volume of saline to be infused will be calculated to match the volume 
rate of exendin-(9-39). 
9. Post-infusion follow-up for subjects who have been able to discontinue 
dextrose infusion. Subjects who have been able to discontinue the 
dextrose infusion and who are not on supplemental dextrose infusion at 
the end of the study will continue to be monitored without additional 
dextrose infusion for up to 3 hours after the end of the study drug infusion, 
or until blood glucose is < 70 mg/dL (whichever comes first). In addition to 
blood glucose monitoring every 30 minutes and betahydroxybutyrate 
every 1 hr from a capillary sample, a venous sample will be drawn at the 
end of 3 hours (or when blood glucose < 70 mg/dL, whichever comes first) 
for plasma insulin and glucose.  
10. Dose schemes.  
Scheme #1 (completed as of date of Protocol Amendment 7): exendin-(9-
39) infused for 12 hrs at a dose of 100 pmol/kg/min (0.02 mg/kg/hr). 
Scheme #2 (completed as of date of Protocol Amendment 7): exendin-(9-
39) infused for 12 hrs at a dose of 200 pmol/kg/min (0.04 mg/kg/hr). 
Scheme #3 (completed as of date of Protocol Amendment 7): exendin-(9-
39) infused for 6 hrs at a dose of 500 pmol/kg/min (0.1 mg/kg/hr). 
Scheme #4 (new as of date of Protocol Amendment 7): Dose escalation 
will be done as described below: 
a. Cohorts 1-2: at least 3 and up to 6 subjects per cohort, will be 
included in each of the first two cohorts. In any of the first 2 cohorts, 
if discontinuation of intravenous dextrose is achieved in 2 out of the 
3 subjects up to three additional patients (at least 2 with diffuse 
disease, as defined by PET scan and/or genetics) may be enrolled 
in order to meet the Success Stopping Criteria (see 11a below).  
b. Cohorts 3- 4: four subjects, with at least 2 subjects with diffuse 
disease. If discontinuation of intravenous dextrose is achieved in 1 
or 2 of the 4 subjects, an additional subject with diffuse may be 
enrolled in order to meet the Success Stopping Criteria (see 11a 
below). 

 
 
18
c.  The dose will be increased in ½ log increments between cohorts as 
specified below: 
 
Group Dose Scheme 
(mg/kg/hr for 9 hours) 
Total Dose (mg/kg) Number of 
Subjects 
1 
0.2 
1.8 
3-6 
2 
0.6 
5.4 
3-6 
3 
2 
18 
3-5 
4 
6 
54 
4-6 
 
11. Stopping Criteria:  
a. Success Stopping Criteria: the dose escalation will be stopped if in 
a cohort at least 2 subjects with diffuse disease are able to have 
dextrose infusion discontinued for the final 2 hours of the study 
period.  
b. Safety Stopping Criteria: if an exaggerated pharmacology effect is 
observed (blood glucose greater than 200 mg/dL for 2 hours off 
dextrose infusion) dose escalation will be stopped and the dosing 
algorithm will be modified to proceed with a dose that is 2 fold 
higher the previous level observed to be safe. Dosing will be 
stopped if any severe adverse event is observed.  
12. Calculation of glucose infusion rate. Glucose infusion rate over the last 2 
hours of the treatment period will be calculated by adding the total amount 
of intravenous glucose (in mg) received over 2 hours divided by the weight 
in Kg and by time (120 min). 
13. Determination of therapeutic plasma levels, plasma half-life and 
pharmacokinetics of exendin-(9-39). During the infusion with exendin-(9-
39) blood samples will be obtained at 1,  5, and 9 hours, and at 1 and 3 
hours after the infusion ends. Should there be difficulty in establishing 
blood drawing lines to obtain samples of the secondary outcome variables 
the study will proceed with collection of the primary outcome variable only 
(glucose infusion rate). Plasma levels of exendin-(9-39) will be determined 
by mass spectometry.  
14. Determination of plasma insulin, blood glucose, and betahydroxybutyrate 
levels: Venous samples for determination of plasma insulin and plasma 
glucose will be obtained at 0, 1, 5 and 9 hours during the study period. 
Betahydroxybutyrate will be obtained hourly by heel stick during the study 
period. For subjects in whom the dextrose infusion has been discontinued 
by the end of the study infusion betahydroxybutyrate will be obtained 
every hour until 3 hours post-dose (or when blood glucose < 70 mg/dL, 
whichever comes first).  In these subjects an additional sample will be 
obtained at the end of 3 hours (or when blood glucose < 70 mg/dL, 
whichever comes first) for plasma glucose and insulin. Should there be 

 
 
19
difficulty in establishing peripheral blood drawing lines to obtain samples 
of the secondary outcome variables, (Insulin, exendin-(9-39) levels) the 
study will proceed with collection of the primary outcome variable only 
(glucose infusion rate). Capillary and venous blood glucose will be 
measured using the Nova StatStrip point-of-care glucose monitor (Nova 
Biomedical Corporation, Waltham, MA, USA). Betahydroxybutyrate will be 
measured at the bedside using a ketone meter (PrecisionXtra, Abbott 
Laboratories). Blood samples for plasma glucose, insulin and 
betahydroxybutyrate levels will be sent to the hospital chemistry laboratory 
for processing.  
3.5. Sample Size and Data Analysis.  
The goal of this study is to find the intravenous dose of exendin-(9-39) (and the 
plasma concentration) that is necessary to completely abolish the need for 
exogenous glucose administration to maintain normal blood glucose in children 
with congenital hyperinsulinism. The sample size of three for each dosing 
regimen is a sample of convenience and not based on statistical considerations. 
However, we offer the following considerations based on our previous studies: for 
the first 9 subjects studied under this protocol the mean ± standard deviation 
(SD) baseline glucose infusion rate (GIR) was 13.2 ± 4.8 mg/kg/min.  Our 
hypothesis is that exendin-(9-39) will decrease the glucose infusion rate required 
to maintain blood glucose > 70 mg/dL.  A paired test is called for to compare the 
two conditions – exendin-(9-39) and vehicle; however, since we do not actually 
know the SD of differences, our sample size calculation is based on the more 
conservative t-test for independent samples, and we use the SD of 4.8 as an 
estimate of the common SD; using a two group t-test with a 0.05 two-sided 
significance level.  
 
Reduction in GIR  
Sample size for 80% 
power 
Sample size for 90% 
power 
25% 
34 
45 
50% 
9 
12 
100% 
3 
4 
 
3.5.1. Data Analysis 
The pharmacometric and statistical analyses of the data obtained from this study 
will be conducted by the investigators and study statistician. 
3.5.2. Variables and time points 
Pharmacodynamics (Primary Variable): Glucose infusion rate during the last 2 
hours (hours 7-9) of infusion of exendin-(9-39) versus vehicle is the primary 
pharmacodynamic variable of interest, although blood glucose measurements over 
time will be utilized in exploratory PK/PD analyses.  
Pharmacokinetics (Primary Variables): The pharmacokinetic variables of interest 
include AUC0-∞, AUC0-t, maximal concentration (Cmax), time to maximal 

 
 
20
concentration (Tmax), concentration at end of infusion (Ceoi), steady state volume of 
distribution (Vss), clearance (CL) and half-life (t1/2) of exendin-(9-39). These will be 
derived through both non-compartmental and model-based methods. 
Safety (Secondary Variables): Primary safety endpoints will include all types of 
adverse experiences, in addition to laboratory safety tests (hematology, chemistry, 
and urinalysis). 12-lead electrocardiograms (ECGs), vital signs and physical 
examinations will also be recorded.  
Secondary Variables: Plasma insulin, blood glucose and betahydrodybutyrate 
levels. 
3.5.3. Approach to analysis 
The following populations are defined for the analysis and reporting of data.  
All Subjects as Treated (AST): All subjects who received any dose of the 
investigational drug. This population will be used for assessment of safety and 
tolerability. 
Per-Protocol (PP): All subjects who received protocol procedures sufficiently to 
ensure that these data will be likely to exhibit the effects of treatment, according to 
the underlying scientific model.  
3.5.4. Statistical Methods 
Analysis Overview: Each subject will undergo two experiments (i.e., either 
infusion of exendin-(9-39) or infusion of vehicle in random order.  A two-
treatment, two-period crossover design will be employed, with two sequence 
groups (i.e., vehicle infusion first followed by exendin-(9-39) infusion vs. exendin-
(9-39) infusion first followed by vehicle infusion).  Subjects will be randomly 
assigned to one or the other of the two sequence groups.  The primary aim of the 
study is to evaluate the effect of exendin-(9-39) vs. vehicle on glucose infusion 
rate in subjects with congenital hyperinsulinism, and to measure PK parameters 
for exendin-(9-39), and PK/PD relationships between glucose infusion rate, blood 
glucose and exendin-(9-39) exposure. Descriptive statistics will be used to 
characterize demographic, baseline, and outcome measures in subjects.  Means, 
SDs, 95% confidence intervals (CIs), medians, and minimum and maximum 
values will be tabulated and reported for all continuous variables, by infusion 
condition.  Histograms will be used to determine extent of skewness, and 
transformations (e.g. logarithmic) will be considered for seriously skewed data.  
Frequency counts and percentages will be used for categorical variables (e.g., 
gender, race, adverse events).  
Pharmacodynamics: To assess the effect of exendin-(9-39) on glucose infusion 
rate, glucose infusion rate (GIR) over the last 2 hours of the treatment period will 
be calculated by adding the total amount of intravenous glucose (in mg) received 
over 2 hours divided by the weight in Kg and by time (120 min) during infusion of 
vehicle and exendin-(9-39). Comparison between the two infusions of GIR will be 
made using the linear mixed effects models. Similarly, the plasma concentration 
of insulin, glucose and betahydroxybutyrate will be analyzed as above. Each of 
the outcome parameters will be analyzed separately using linear mixed effects 

 
 
21
models (92), which are ideally suited for the cross-over design, as this design 
includes both fixed effects (treatment, period, carry-over) and random effects (the 
subjects).  Moreover, software for linear mixed models (e.g., SAS proc MIXED) 
allows flexible modeling of the covariance structure, deals with unbalanced or 
missing data, and allows use of covariates that change both at the within and 
among-individual level.   
In the event that certain of the outcomes are not suitable for linear mixed effects 
modeling, then a series of three-sample t-tests (or Mann-Whitney tests) will be 
used.  The first test will analyze the equality of the carry-over effects by applying 
the test to the subject totals.  If the carry-over effects are statistically non-
significant, we will proceed to the second test, which will determine the effect of 
time period by applying the test to the time period differences.  Finally, provided 
that there are no statistically significant carry-over or time period effects, we will 
proceed to the third test, analyzing the treatment effects by applying the test to 
the cross-over differences.   
Dose-response and concentration-effect relationships will be examined between 
blood glucose and exendin-(9-39), as well as between safety endpoints and 
exendin-(9-39).  
Pharmacokinetics: Exendin-(9-39) plasma concentration-time data will be analyzed 
using a moment-based, non-compartmental approach (NCA) with WinNonlin 
(version 5.1, Pharsight Corporation). Basic PK metrics including Cmax, Ceoi, Tmax, 
and AUC0-∞, and AUC0-t will be calculated in addition to derived parameters such 
as elimination half-life. A model-based approach will be utilized in parallel to 
describe the individual pharmacokinetic parameters including exendin-(9-39) 
clearance (CL) and volume of distribution (VD) once the appropriate structural 
model (e.g., one or two-compartment) has been determined. Sources of variability 
will be described and the contribution of patient-specific covariates to explain 
sources of variation will be examined via a rigorous covariate analysis using 
nonlinear mixed effect modeling and the NONMEM (version 6) algorithm. Briefly, 
covariates will be included in the model if deemed significant (p<0.05) observed as 
a reduction in the objective function value (OFV) greater than 3.84 (χ2 distribution, 
df=1). Subsequently, covariates will be retained in the model if fixing their value to 
zero results in greater than 10.84 (χ2 distribution, df=1) increase in the OFV, at a 
higher level of stringency (p<0.001). Ultimately, the final model will be selected 
using a combination of goodness-of-fit criteria including diagnostic scatter plots, 
convergence with at least 3 significant digits, reasonable parameter estimates and 
precision of parameter estimates. Diagnostic plots of the base model will evaluate 
the correlation between PK parameters (clearance, volume) with indices of body 
size (e.g., bodyweight) and, if so, an allometric model will be considered during 
model development. The underlying basis for this type of model has been 
previously described as useful in pediatrics in that it incorporates known 
physiologic relationships in the covariate-parameter model (93). The effects of 
categorical covariates will be modeled using normalized power model. 
Safety: Summary statistics and plots will be generated for the change from 
baseline values in the vital signs, ECG parameters, and selected laboratory safety 
parameters, as deemed clinically appropriate. Depending on the safety parameter, 

 
 
22
the difference from baseline will either be computed on the original scale (raw 
change from baseline) or on the log scale and back-transformed for reporting 
(percent change from baseline). Summary statistics for the raw laboratory safety 
tests, ECGs, and/or vital signs may also be computed, as deemed clinically 
appropriate.  
 
4. Subject Selection and Withdrawal 
4.1. Inclusion and Exclusion Criteria 
Inclusion Criteria: 
 Confirmed diagnosis of congenital hyperinsulinism (based on clinical 
criteria: insulin, beta hydroxybutyrate, and/or free fatty acid plasma levels 
at the time of hypoglycemia, and/or glycemic response to glucagon at the 
time of hypoglycemia) 
 Age: from birth to 12 months 
 Failure to respond to diazoxide (defined as the failure to maintain blood 
glucose > 70 mg/dL without supraphysiologic rates of glucose infusion:> 
4-5 mg/Kg/min) 
 
Exclusion Criteria: 
 Evidence of a medical condition that might alter results, including active 
infection, kidney failure, severe liver dysfunction, severe respiratory or 
cardiac failure 
 Current therapy at the time of initiation of study procedures with 
medications that affect glucose metabolism, such as high dose 
glucocorticoids, ß-agonists, glucagon, diazoxide and octreotide. Subjects 
will be eligible to participate 4 hours after glucagon discontinuation, 24 
hours after the last dose of octreotide and 72 hours after last dose of 
diazoxide 
 Subjects with suspected Beckwith-Wiedemann syndrome or other 
syndromic forms of congenital hyperinsulinism 
4.2. Rationale for Using Neonates and Children 
Congenital hyperinsulinism is a genetic disorder of insulin regulation, most 
commonly due to mutations in the KATP channel. Affected individuals present 
shortly after birth with severe hypoglycemia and require high glucose infusion 
rates through a central line to maintain safe blood glucose levels, as they are 
unresponsive to available medical therapy. The majority of these children require 
a near-total pancreatectomy to ameliorate the hypoglycemia. Approximately 50% 
of these children will require some medical intervention (frequent or continuous 
enteral feedings and/or octreotide) after surgery. The severity of the disorder 
seems to ameliorate with age, as many of the affected adult individuals who did 
not undergo a pancreatectomy as infants followed by our team have a safe 
fasting tolerance. Therefore, it is important to perform these studies in the 

 
 
23
population more severely affected: infants and children. Studying the effect of the 
GLP-1 receptor antagonist, exendin-(9-39), on glucose metabolism of these 
subject population will provide information that can be used to improve their 
management and in the developing of new therapies. 
4.3. Subject Recruitment 
Subjects will be recruited from the Hyperinsulinism Center at The Children’s 
Hospital of Philadelphia, the largest center in this country caring for children with 
disorders of insulin regulation. Every year our center treats approximately 30 
children with medically unresponsive hyperinsulinism that require 
pancreatectomy. Currently we have approximately 1200 in-patient days a year. 
This put us in a unique position to conduct research directed to develop new 
therapies for this disorder.  
The study will be advertised in the center’s website. Additional study information 
will be posted to the Pediatric Endocrine Society (PES) website.  This web page 
lists clinical research studies that are recruiting pediatric endocrine subjects 
across the United States and Canada. The purpose of the web page is to inform 
the pediatric endocrinology community about clinical research studies, and to 
allow providers and patients/families to identify clinical research studies that may 
be of interest. Access to the page is unrestricted.  
 
 
 
4.4. Early Withdrawal of Subjects 
4.4.1. When and How to Withdraw Subjects 
Subjects will be withdrawn from the study if the test of hypersensitivity is positive 
upon admission before the initiation of the study protocol. Subjects will be 
withdrawn at any time during the study if an unexpected severe adverse event 
occurs. There are not expected safety concerns for abrupt termination of the 
study protocol. 
4.4.2. Data Collection and Follow-up for Withdrawn Subjects 
In the event of withdrawal before completion of the study protocol, data obtained 
until the time of withdrawal will be collected and used in the final analysis.  
 
5. Safety and Adverse Events 
5.1. Definitions 
 Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops 
or worsens in severity during the course of the study.  Intercurrent illnesses or 

 
 
24
injuries will be regarded as adverse events.  Abnormal results of diagnostic 
procedures will be considered to be adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
Serious Adverse Event 
Adverse events will be classified as serious or non-serious.  A serious adverse 
event is any AE that is:  
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, 
but are clearly of major clinical significance.   They may jeopardize the subject, 
and may require intervention to prevent one of the other serious outcomes noted 
above.  For example, drug overdose or abuse, a seizure that did not result in in-
patient hospitalization, or intensive treatment of bronchospasm in an emergency 
department would typically be considered serious.  
 
All adverse events that do not meet any of the criteria for serious should be 
regarded as non-serious adverse events.  
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally 
defined as the period from the initiation of any study procedures to the end of the 
study treatment follow-up.  For this study, the study treatment follow-up is defined 
by the half-life of the drug and will be 24 hrs after the end of infusion.  
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A 
preexisting condition will be recorded as an adverse event if the frequency, 
intensity, or the character of the condition worsens during the study period. 
General Physical Examination Findings 
At screening, any clinically significant abnormality will be recorded as a 
preexisting condition.  At the end of the study, any new clinically significant 
findings/abnormalities that meet the definition of an adverse event will also be 
recorded and documented as an adverse event.  
Post-study Adverse Event 
All unresolved adverse events will be followed by the investigator until the events 
are resolved, the subject is lost to follow-up, or the adverse event is otherwise 
explained.  At the last scheduled visit, the investigator will instruct each subject to 

 
 
25
report any subsequent event(s) that the subject, or the subject’s personal 
physician, believes might reasonably be related to participation in this study.  The 
investigator will notify the IRB, CTRC, and the FDA (per the IND) of any death or 
adverse event occurring at any time after a subject has discontinued or 
terminated study participation that may reasonably be related to this study.  
These agencies will also be notified if the investigator should become aware of 
the development of cancer or of a congenital anomaly in a subsequently 
conceived offspring of a subject that has participated in this study.  
Abnormal Laboratory Values 
A laboratory test abnormality considered clinically relevant by the investigator 
(e.g. the abnormality suggests a disease and/or organ toxicity, or is of a degree 
that requires active management such as change of dose, discontinuation of the 
drug, more frequent follow-up assessments, or further diagnostic investigation) 
should be documented as an adverse event.  
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization will 
be documented and reported as a serious adverse event unless specifically 
instructed otherwise in this protocol.  Any condition responsible for surgery will be 
documented as an adverse event if the condition meets the criteria for and 
adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery will 
be reported as an adverse event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective 
surgical procedures for a preexisting condition.  Surgery will not be 
reported as an outcome of an adverse event if the purpose of the 
surgery was elective or diagnostic and the outcome was uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy 
measurement for the study. 
• Hospitalization or prolonged hospitalization for therapy of the target 
disease of the study, unless it is a worsening or increase in frequency 
of hospital admissions as judged by the clinical investigator. 
5.2. Recording of Adverse Events 
At each contact with the subject, the investigator will seek information on adverse 
events by specific questioning and, as appropriate, by examination.  Information 
on all adverse events will be recorded immediately in the source document, and 
also in the appropriate adverse event module of the case report form (CRF).  All 
clearly related signs, symptoms, and abnormal diagnostic procedures results will 
be recorded in the source document, grouped under one diagnosis when 
appropriate. 
 
All adverse events occurring during the study period will be recorded.  The 
clinical course of each event will be followed until resolution, stabilization, or until 
it has been determined that the study treatment or participation is not the cause.  

 
 
26
Serious adverse events that are still ongoing at the end of the study period will be 
followed up to determine the final outcome.  Any serious adverse event that 
occurs after the study period and is considered to be possibly related to the study 
treatment or study participation will be recorded and reported immediately. 
 
*Adverse events will be reported to The Children’s Hospital of Philadelphia IRB 
(215-590-2830) and CTRC (215-590-2215), and the FDA (in writing only) 
annually at the time of continuing review.  
 
Any action resulting in a temporary or permanent suspension of this study (e.g. 
FDA actions, IRB actions, or actions by a commercial sponsor or by the 
investigators or co-investigators) will be reported to BioMarin, Pharmaceutical 
Inc. 
5.3. Reporting of Serious Adverse Events 
5.3.1. Study Sponsor Notification by Investigator 
An adverse event that is serious, related and unexpected, will be reported to the 
agencies cited previously by telephone or MEMO within 24 hours of the event.  A 
Serious Adverse Event (SAE) form will be completed by the sponsor-investigator 
and faxed to the above agencies/regulatory bodies, according to current reporting 
requirements. The investigator will keep a copy of this SAE form on file at the study 
site.  Report serious adverse events by phone and facsimile to: 
 
The Children’s Hospital of Philadelphia IRB (215-590-2830)  
The Children’s Hospital of Philadelphia CTRC (215-590-2215) 
FDA (in writing only) 
 
At the time of the initial report, the following information will be provided: 
• Study identifier 
• Subject number 
• A description of the event 
• Date of onset 
• Current status 
• Whether study treatment 
was discontinued 
• The reason why the event is 
classified as serious 
• Investigator assessment of 
the association between the 
event and study treatment 
 
Within the following 48 hours, the investigator will provide further information on 
the serious adverse event in the form of a written narrative.  This will include a 
copy of the completed Serious Adverse Event form, and any other diagnostic 
information that will assist the understanding of the event.  Significant new 
information on ongoing serious adverse events will be provided promptly to the 
agencies cited. 

 
 
27
5.4. Dose Escalation Decisions 
Treatment cohorts will be dosed in escalating order as outlined above (section 
3.4). Dose escalation decisions will be made by the investigator only after the 
safety of the previous dose level has been established. Subsequent cohorts will 
not be dose until safety data are obtained from all subjects in the previous cohort. 
Safety will be evaluated based on the incidence and severity of adverse events 
(AEs), clinical laboratory test results, ECGs, and other relevant clinical findings 
(e.g., heart rate, blood pressure, respiratory rate and temperature). Decisions to 
dose escalate or halt dose escalation will be based on review of these data by 
the investigator, the Safety Officer and the pharmacologist. 
5.5. Stopping Rules  
Subject Specific Stopping Rules 
All subjects will be monitored during administration of the investigational product 
and if any of the events below occur the subject will be discontinued from 
treatment and followed clinically. 
1.    Subjects who have a wheal and flare reaction in the 30 minutes 
following peptide injection for the Hypersensitivity Test will be 
withdrawn from further investigation due to a positive 
hypersensitivity test and any further research procedures will 
be canceled. 
2.    Peptide stopping rules: Should any of the following events 
occur during administration of the investigational agent, in the 
setting of a serious adverse event or adverse event that is 
possibly related to exendin-(9-39), the subject’s treatment will 
be discontinued and the subject will be followed clinically.  
                                          i.    Blood pressure instability 
                                         ii.    Pulse instability 
                                        iii.    Fever 
  
Trial stopping rules: 
If 2 subjects experience serious adverse events thought to be probably or 
definitely related to study procedures or medications we will place the study on a 
voluntary hold to evaluate safety and study design.  The IRB, FDA, and the 
Safety Officer will be informed and consulted as appropriate and per local and 
federal regulations. 
  
Potential study related SAEs include the following: 
1.    Anemia requiring hospitalization as a consequence of the 
amount of blood being collected in study procedures 
2.    Severe hypersensitivity reaction requiring hospitalization 
 
Surveillance of subjects will be performed to permit early detection of adverse 
events as discussed in the Data and Safety Monitoring Plan. 

 
 
28
5.6. Medical Monitoring 
It will be the responsibility of the Principal Investigator to oversee the safety of the 
study at this site.  This safety monitoring will include careful assessment and 
appropriate reporting of adverse events as noted above, as well as the 
construction and implementation of a site data and safety-monitoring plan.  Medical 
monitoring will include a regular assessment of the number and type of serious 
adverse events. 
5.6.1. Data and Safety Monitoring Board 
Given the nature of the study a Data and Safety Monitoring Board (DSMB) is not 
necessary. The attached data safety and monitoring plan include the 
establishment of a Safety Officer. The safety of the subjects enrolled on the study 
will be assessed by the Safety Officer. All SAE ‘s will be reviewed as they occur. 
Reporting requirements to the IND will be strictly adhered to. If more than one 
unexpected or previously undescribed serious adverse event attributable to 
exendin-(9-39) is observed, accrual to the protocol will be suspended. The Safety 
Officer will assess the risk to the subject, and a recommendation to continue with 
the study or close it will be made to the IRB for review. Should the decision be 
made to continue with the study, the modifications to the protocol, the updated 
assessment of risks and benefits, and a modified informed consent will be 
submitted to the IRB and FDA for consideration.  
6. Data Handling and Record Keeping 
6.1. Confidentiality 
Information about study subjects will be kept confidential and managed according 
to the requirements of the Health Insurance Portability and Accountability Act of 
1996 (HIPAA).  Those regulations require a signed subject authorization 
informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in 
this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of 
their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the 
investigator, by regulation, retains the ability to use all information collected prior 
to the revocation of subject authorization.  For subjects that have revoked 
authorization to collect or use PHI, attempts will be made to obtain permission to 
collect at least vital status (i.e. that the subject is alive) at the end of their 
scheduled study period. 

 
 
29
6.2. Source Documents 
Source data are all information, original records of clinical findings, observations, 
or other activities in a clinical trial necessary for the reconstruction and evaluation 
of the trial.  Source data are contained in source documents   Examples of these 
original documents, and data records include: hospital records, clinical and office 
charts, laboratory notes, memoranda, subjects’ diaries or evaluation checklists, 
pharmacy dispensing records, recorded data from automated instruments, copies 
or transcriptions certified after verification as being accurate and complete, 
microfiches, photographic negatives, microfilm or magnetic media, x-rays, subject 
files, and records kept at the pharmacy, at the laboratories, and at medico-
technical departments involved in the clinical trial. 
6.3. Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the 
study.  All data requested on the CRF must be recorded.  All missing data must be 
explained.  If a space on the CRF is left blank because the procedure was not done 
or the question was not asked, write “N/D”.  If the item is not applicable to the 
individual case, write “N/A”.  All entries will be printed legibly in black ink.  If any 
entry error has been made, to correct such an error, we will draw a single straight 
line through the incorrect entry and enter the correct data above it.  All such 
changes will be initialed and dated.  WE WILL NOT ERASE OR WHITE OUT 
ERRORS.  For clarification of illegible or uncertain entries, we will print the 
clarification above the item, then initial and date it. 
6.4. Records Retention 
It will be the investigator’s responsibility to retain study essential documents for at 
least 2 years after study completion. These documents will be retained for a 
longer period if required by an agreement with the agencies cited above.  In such 
an instance, it will be the responsibility of the agency to inform the investigator as 
to when these documents no longer need to be retained.  
7. Study Monitoring, Auditing, and Inspecting 
7.1. Study Monitoring Plan 
This study will be monitored according to the monitoring plan in Attachment.  The 
investigator will allocate adequate time for such monitoring activities.   
7.2. Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by 
the IRB, CTRC, Biomarin, and government regulatory bodies (FDA) of all study 
related documents (e.g. source documents, regulatory documents, data 
collection instruments, study data etc.).  The investigator will ensure the 
capability for inspections of applicable study-related facilities (e.g. pharmacy, 
diagnostic laboratory, etc.). 
 

 
 
30
Participation as an investigator in this study implies acceptance of potential 
inspection by government regulatory authorities and applicable University 
compliance and quality assurance offices. 
8. Ethical Considerations 
This study is to be conducted according to US and international standards of 
Good Clinical Practice (FDA Title 21 part 312 and International Conference on 
Harmonization guidelines), applicable government regulations and Institutional 
research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted 
Institutional Review Board (IRB), in agreement with local legal prescriptions, for 
formal approval of the study conduct.  The decision of the IRB concerning the 
conduct of the study will be made in writing to the investigator and a copy of this 
decision will be provided to the sponsor before commencement of this study.  
The investigator will provide a list of IRB members and their affiliate if requested. 
 
All subjects for this study will be provided a consent form describing this study 
and providing sufficient information for subjects to make an informed decision 
about their participation in this study. This consent form will be submitted with the 
protocol for review and approval by the IRB for the study.  The formal consent of 
a subject, using the EC/IRB-approved consent form, will be obtained before that 
subject is submitted to any study procedure.  This consent form will be signed by 
the subject or legally acceptable surrogate, and the investigator-designated 
research professional obtaining the consent.  
9. Study Finances 
9.1. Funding Source 
This study will be financed, in part, through a grant from BioMarin 
Pharmaceutical Inc.  
9.2. Conflict of Interest 
All investigators will follow the Children’s Hospital of Philadelphia conflict of 
interest policy. 
9.3. Subject Stipends or Payments 
Subjects will not be reimbursed for participation in this study.  
10. Publication Plan 
The investigators hold the primary responsibility for publication of the any results 
of the study.   
 
 

 
 
31
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