Intra-nasal Naloxone for Treatment of Impaired Awareness of Hypoglycemia
Phase: PHASE1
Conditions: Hypoglycemia Unawareness, Type 1 Diabetes
Sponsor: University of Minnesota

Clinical Study Protocol 
Intra-nasal naloxone for treatment of impaired awareness of hypoglycemia  
Regulatory Sponsor: 
Amir Moheet 
 
 
 
 
Assistant Professor 
 
 
 
 
 
Study Product: 
 
Naloxone 
Protocol Identifiers: 
CTSI # 22405 
IND Number: 
IND exempt/ IND 129763 
Trial Registration: 
NCT02700048 
Version / Date: 
 
Version 05; Jan 31, 2019 
CONFIDENTIAL 
This document is confidential and the property of the University of Minnesota.  No part of it may be transmitted, reproduced, 
published, or used by other persons without prior written authorization from the study sponsor. 
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Statement of Compliance 
This document is a protocol for a human research study.  This study will be conducted according to US 
and International standards of Good Clinical Practice, applicable government regulations and Institutional 
research policies and procedures.   
All individuals responsible for the design and conduct of this study have completed Human Subjects 
Protection Training and are qualified to be conducting this research prior to the enrollment of any 
subjects.   
As Principal Investigator, I agree to conduct this clinical study in accordance with the design and specific 
provisions of this protocol.  Modifications to the study are acceptable only with an approved protocol 
amendment.  I agree to obtain approval from the IRB and/or regulatory bodies of competent jurisdiction, 
for the protocol and informed consent before initiating the study, to obtain consent from subjects prior to 
their enrollment in the study, to collect and record data as required by this protocol and case report forms, 
to prepare adverse event and study reports as required by this protocol and to maintain study 
documentation for the period of time required. 
________________________________________________ 
_________________ 
Amir Moheet/Assistant Professor 
 
 
 
 
Date 
As a Sub-Investigator, I agree to conduct this clinical study in accordance with the design and specific 
provisions of this protocol.  Modifications to the study are acceptable only with an approved protocol 
amendment.  I agree to obtain approval from the IRB and/or regulatory bodies of competent jurisdiction, 
for the protocol and informed consent before initiating the study, to obtain consent from subjects prior to 
their enrollment in the study, to collect and record data as required by this protocol and case report forms, 
to prepare adverse event and study reports as required by this protocol and to maintain study 
documentation for the period of time required. 
 
 
________________________________________________ 
_________________ 
Lisa Coles/Research Assistant Professor 
 
 
 
Date 
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Version History 
Version #
Version Date
Significant Changes from Previous Version
01
02/03/2016
Original Protocol Version
02
04/25/2016
Added additional justification for sample size
03
06/28/2016
Change randomization for the first 3 subjects to naloxone
04
01/05/2017
Add 8mg dose of naloxone; change randomization for the first 8 
subjects to naloxone
05
01/31/2019
Update study location
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Table of Contents 
List of Abbrevia.ons 
 
.....................................................................................................................................................6
1.0 Study Contact Informa.on 
 
.....................................................................................................................................7
2.0 Introduc.on / Background and Ra.onale ..............................................................................................................8
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Study Summary 
Title
Intra-nasal Naloxone for treatment of impaired awareness of hypoglycemia 
Short Title
Intra-nasal Naloxone for impaired awareness of hypoglycemia 
IRB Number
1603M84961
Study Sponsor
Amir Moheet, MD
Phase
1
Principal Investigator
Amir Moheet, MD
Study Design
Single center, single-blind, randomized, cross-over 
Study Duration
24 months
Study Center(s)
Clinical Research Unit (CRU)
Objectives
Primary Objective: To evaluate intra-nasal Naloxone as a therapy for 
prevention and treatment of impaired awareness of hypoglycemia. 
Secondary Objective: Characterize naloxone pharmacokinetics following 
multiple administrations.
Number of Subjects
18
Main Inclusion Criteria
Males and females between the ages of 18-65 years
Study Product, Dose, 
Route, Regimen
Narcan (naloxone hydrochloride) intranasal spray, 4 mg/nostril repeated 4 
times within 8 hours alternating nostrils.  
Duration of 
Administration
4 doses of 4 mg or 2 doses of 8 mg administered over 1 day.
Endpoints
Primary endpoint will be the within person difference in peak epinephrine 
secretion during the morning episodes of hypoglycemia on days one and 
two; we will compare this difference between the two treatment conditions.   
Secondary endpoint will be naloxone pharmacokinetics including maximum 
concentration (Cmax), time to maximum concentration (Tmax) and area 
under the curve (AUC).
Statistical Methods
We will fit a general linear mixed model with fixed effects for treatment 
(naloxone vs. placebo), treatment order (naloxone first vs. placebo first), and 
period (Part 1 vs. Part 2) and a random effect for participant. We will also 
consider adjustment for important baseline characteristics, such as age and 
sex. Diagnostics will be examined to assess model assumptions. 
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List of Abbreviations  
AE 
 
Adverse Event 
CFR 
 
Code of Federal Regulations 
CRF 
 
Case Report Form 
DSMB  
Data and Safety Monitoring Board 
DSMP  
Data and Safety Monitoring Plan 
FDA 
 
Food and Drug Administration 
GCP 
 
Good Clinical Practice 
HIPAA Health Insurance Portability and Accountability Act of 1996 
ICH 
 
International Conference on Harmonization 
IDS 
 
Investigational Drug Services 
IRB 
 
Institutional Review Board 
PHI 
 
Protected Health Information 
SAE 
 
Serious Adverse Event 
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1.0 
Study Contact Information 
1.
Sponsor and Principal Investigator  
Amir Moheet 
Division of Endocrinology, Diabetes and Metabolism 
420 Delaware St. SE, MMC 101 
Minneapolis, MN 55445 
Phone: 612-624-3209 
E-mail:mohee002@umn.edu 
2.
Sub-Investigators  
Elizabeth Seaquist 
Division of Endocrinology, Diabetes and Metabolism 
420 Delaware St. SE, MMC 101 
Minneapolis, MN 55445 
Phone: 612-624-5150 
E-mail: seaqu001@umn.edu 
Lisa Coles, Ph.D. 
Center for Orphan Drug Research 
College of Pharmacy, University of Minnesota 
LRB/MTRF Mail Code 2873 
2001 6th St SE 
Minneapolis, MN 55455 
Phone: 612-614-1861 
E-mail: durh0016@umn.edu 
3.
Key Study Personnel 
Usha Mishra, M.S. 
Center for Orphan Drug Research 
College of Pharmacy, University of Minnesota 
LRB/MTRF Mail Code 2873 
2001 6th St SE 
Minneapolis, MN 55455 
Phone: 612-614-1864 
E-mail: mishr001@umn.edu 
Anjali Kumar, P.A. 
Division of Endocrinology, Diabetes and Metabolism 
420 Delaware St. SE, MMC 101 
Minneapolis, MN 55445 
Phone: 612-624-0470 
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E-mail:kumar045@umn.edu 
2.0 
Introduction / Background and Rationale 
Iatrogenic hypoglycemia is a common and feared complication of insulin therapy. Recurrent 
exposure to iatrogenic hypoglycemia in patients with insulin treated diabetes can lead to 
development of impaired awareness of hypoglycemia (IAH) (1), a condition that is estimated to 
occur in 20% of patients with type 1 diabetes (T1D) (2). Fear of hypoglycemia can limit the ability 
of patients with diabetes to achieve the glycemic control shown to prevent complications of 
diabetes. Strict avoidance of hypoglycemia has been shown to partially restore awareness of 
hypoglycemia; however it is very difficult to achieve and maintain over the long term (3-5). 
Consequently, there has been great interest in developing therapies that will prevent and/or reverse 
IAH in diabetes.  
One potential therapy to prevent or reverse IAH in diabetes may be opioid receptor antagonists. 
Endogenous opiates have been shown to modulate hormonal responses during hypoglycemia and 
may play a role in the development of IAH (6). Intravenous (IV) administration of naloxone, an 
opioid receptor antagonist, during hypoglycemia has been shown to augment the 
counterregulatory response to hypoglycemia in dogs (7) and humans (8). When infused during 
antecedent hypoglycemia, IV naloxone has been shown to prevent development of defective 
counterregulatory hormone response to subsequent hypoglycemia in healthy humans (9) and in 
patients with T1D (10). However, IV dosing of Naloxone is not feasible for chronic outpatient 
therapy.  The usual alternative of oral dosing is hindered by large first pass effects, low oral 
bioavailability, and high variability.  Intra-nasal (IN) route of administration is a novel approach to 
provide adequate systemic exposure in easy to use delivery route. IN naloxone is currently being 
used for acute management of opioid overuse.  
The long-term goal of this project is to test the hypothesis that IN naloxone therapy in subjects 
with T1D and IAH will improve counter regulatory hormone responses during hypoglycemia and 
increase recognition of hypoglycemia symptoms. The purpose of this project is to evaluate IN 
naloxone as a therapy for the prevention and treatment of IAH. IAH can be reproduced 
experimentally by inducing recurrent hypoglycemia in healthy subjects (11), providing a robust 
investigational model for studying mechanism and treatments for IAH. In this study we will test 
the hypothesis that IN naloxone therapy will prevent the development of IAH in healthy 
subjects who are exposed to experimental hypoglycemia. 
Rationale for route of administration, dose, and regimen:  Intranasal delivery was selected in 
order to non-invasively produce similar naloxone concentrations to those attained from the IV 
dosing used in previous studies which demonstrated the beneficial effects of naloxone (9,10). Two, 
4 mg doses, one to each nostril, administered 1 hr apart are expected to produce similar naloxone 
concentrations as a 0.4 mg/kg/mL dose administered over 90 minutes which was the dose used for 
the IV study (9).  The half-life is reported to be 2.1 hours (Narcan package label) suggesting the 
drug will remain at elevated levels for ~ 4 hours (2 half-lives) after the second dose.  A third 4 mg 
dose will be administered ~4 hrs after the second to remain levels similar to intravenous dosing. 
When a single 8 mg dose was administered to healthy volunteers, adverse events included 
increased blood pressure, musculoskeletal pain, headache, nasal dryness, nasal edema, nasal 
congestion, and nasal inflammation.  These symptoms will be monitored throughout the study.   
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3.0 
Investigational Agent(s) 
3.1 
Description / Indications 
Narcan® (naloxone hydrochloride) intranasal spray (4 mg in 0.1 mL) will be used for this 
study.  Narcan® intransal spray, manufactured by ADAPT Pharma is approved by the FDA 
for the complete or partial reversal of opioid depression, including respiratory depression, 
induced by natural and synthetic opioids.  The placebo will consist of a saline intranasal 
spray (0.09% sodium chloride). 
3.2 
Drug Accountability 
3.2.1 Drug Receipt 
The Narcan® and placebo intranasal sprays will be shipped from different supplier/
distributer directly to Fairview Investigational Drug Services.  For the drug 
product, the same manufacturer and lot will be used for the entire study.   
3.2.2 Packaging  
The subjects will receive four 4 mg doses  or two 8 mg doses of IN naloxone or 
placebo which will be dispensed by Fairview Investigational Drug Services, 
prepared by the Investigators and given to the subject on site.  No packaging will 
be necessary, as no study drug will leave the site. 
3.2.3 Storage  
Naloxone hydrochloride and placebo intranasal solutions can be stored at room 
temperature 15C to 25° C.   
3.2.4 Return or Destruction of Study Drug 
 
Unused drug will be returned to IDS where it will be destroyed under standard 
operating procedures.   
4.0 
Study Objectives 
4.1 
Primary Objective 
Primary endpoint will be the within person difference in peak epinephrine secretion during 
the morning episodes of hypoglycemia on days one and two; we will compare this 
difference between under the two treatment conditions (parts 1 and 2).  Epinephrine 
secretion during hypoglycemia is assessed by collecting blood samples for measurement of 
epinephrine concentrations at baseline and every 15 minutes during the period of 
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hypoglycemia (starting at point where blood glucose is first < 55 mg/dl) in the clamp 
studies done in the mornings of days 1 and 2 of both parts 1 and 2.  
4.2 
Secondary Objective 
 
Characterize naloxone pharmacokinetics following multiple intranasal administrations.  
  
5.0 
Study Design 
5.1 
Overview of Study Design 
This is a single center, single-blind randomized cross over design trial that will compare 
the impact of intra-nasal naloxone vs. intra-nasal placebo administration during 
experimental hypoglycemia on day one vs. day two. We intend to enroll 18 individuals to 
obtain the complete data sets from 15 participants.  Initially up to 8 of these subjects will 
receive intra-nasal naloxone first prior to placebo in order to evaluate tolerability and to 
ensure that the desired drug concentrations are achieved. Double-blinding is not possible 
because we will not be able to replicate for the placebo (placebo) the same delivery device 
as is being provided by the manufacturer for the naloxone; the manufacturer is unable to 
provide placebo-charged devices for us to use as placebo. Our own labeling will be put 
over both naloxone and placebo devices in order to obscure any device labeling that would 
break the blind for the participant. Expected duration of subject participation is 10-12 
weeks. This study will consist of two 2-day intervention visits separated by approximately 
8 weeks. 
5.2 
Anticipated Duration of the Clinical Investigation 
We anticipate the entire duration of the investigation to be 24 months. 
5.3 
Evaluation Criteria 
5.3.1 Primary Clinical Endpoint 
Primary endpoint will be the within person difference in peak epinephrine secretion 
during the morning episodes of hypoglycemia on days one and two; we will 
Dates
Goal
Responsible party(ies)
Month 1-2
Application for FDA approval , response to 
stipulations, and approval by University of Minnesota 
d C S
Moheet, Coles, 
Seaquist
Month 3-18
Recruitment and screening of subjects
Moheet, Coles, Kumar
Months 3-18
Performing the experiments, laboratory analysis of 
plasma hormone and naloxone concentrations. 
Moheet, Coles, Kumar, 
Mishra
Month12-24
Preparation of manuscript and abstracts for 
presentation to national medical societies and for 
publication in peer reviewed journals
Moheet, Coles, 
Seaquist
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compare this difference between the two treatment conditions (parts 1 and 2). 
Epinephrine secretion during hypoglycemia is assessed by collecting blood samples 
for measurement of epinephrine concentrations at baseline and every 15 minutes 
during the period of hypoglycemia (starting at point where blood glucose is first < 
55 mg/dl) in the clamp studies done in the mornings of days 1 and 2 of both parts 1 
and 2. 
5.3.2 Secondary Clinical Endpoint 
To characterize the pharmacokinetic parameters of intranasal naloxone which will 
include Cmax (ng/ml), Tmax (minutes), half-life (hours), AUC (0-> infinity), 
clearances (CL), and volume of distributions (V).  Please refer to Section 6.4.3 for 
parameter definitions. 
5.4 
Study Population 
18 subjects 18-65 years of age will be enrolled in the study.  The investigators will recruit 
and screen subjects.  
5.4.1 Sample Size 
We plan to enroll 18 subjects.   
We propose a two-period two-treatment cross-over study, where each participant 
gets intra-nasal naloxone and intra-nasal placebo, in randomized order. Primary 
endpoint will be the within person difference in peak epinephrine secretion during 
the morning episodes of hypoglycemia on days one and two; we will compare this 
difference between under the two treatment conditions.  Thus each participant will 
have two observations: one epinephrine response from their naloxone experiment 
and one epinephrine response from their placebo experiment. We expect to recruit 
18 individuals in order to complete 15 studies. Additional participants will be 
recruited if needed to have 15 completed studies. If naloxone prevents IAH, then 
the epinephrine response during the third hypoglycemic clamp after naloxone 
infusion will still be high, while the epinephrine response during the third 
hypoglycemic camp after placebo infusion will be blunted. Therefore this within-
person difference in epinephrine response will be large and positive. If naloxone 
does not prevent IAH, then this within-person difference will be close to zero. 
In a previous study between healthy controls and subjects with T1D and impaired 
awareness of hypoglycemia, participants underwent a hyperinsulinemic 
hypoglycemic clamp (the same clamp procedure as proposed here) and the 
epinephrine response (the difference in peak epinephrine between euglycemia and 
hypoglycemia) was 121 ± 168 pg/ml in the subjects with T1D vs. 278 ± 134 pg/ml 
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in controls. We have powered this study to achieve a similar magnitude of 
difference between naloxone and placebo (a paired comparison) as was seen 
previously between controls and diabetics (a two-sample comparison). Assuming 
15 completers, a one-sided type I error of 5%, and a power of 85%, a paired 
difference between naloxone epinephrine response and placebo epinephrine 
response of at least 157 pg/ml is statistically detectable if the between-person 
standard deviation of the paired naloxone vs. placebo difference is no more than 
216 pg/ml.  
This standard deviation of the paired difference is a function of the standard 
deviation of the epinephrine response and the within-person correlation between the 
two epinephrine responses (one after naloxone, one after placebo). As can be seen 
from the Table below, we are conservatively powered, as our preliminary data 
suggest that our observed standard deviation will be smaller than 216 pg/ml. 
Table. Estimated standard deviation (SD) of the paired difference between naloxone epinephrine 
response and placebo epinephrine response when the within-person correlation is ρ 
5.4.2 Subject Recruitment 
Healthy participants will be recruited from IRB-approved public notices.  Dr. 
Moheet, Dr. Coles or Anjali Kumar will make initial contact with subjects 
potentially interested and will discuss the investigation and conduct the informed 
consent discussion at least 24 hours before study medication is to be given.   
5.4.3 Subject Screening 
Drs. Moheet or Coles will complete a phone screen with each participant. Subjects 
will sign the consent form on the study visit, and will have a medical history and 
current medications recorded. A routine physical, and pregnancy test (if relevant), 
will be completed on the study visit. 
5.4.4 Prior and Concomitant Therapy 
Neither prescribed, other than hormonal birth control, nor over-the counter 
medications will be allowed for 48 hours (two days) prior to, nor for 24 hours after, 
receiving naloxone. 
ρ = 0.2
ρ = 0.4
ρ = 0.6
ρ = 0.8
SD in epi response = 135
171
148
121
85
SD in epi response = 170
215
186
152
108
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5.4.5 Inclusion Criteria 
Subjects will be eligible to participate in the study if all of the following conditions 
exist: 
1. Males and females between the ages of 18-65 years. 
2. Subjects are capable of giving informed consent. 
3. Female subjects must be post-menopausal for at least 1 year, or surgically 
incapable of bearing children, or practicing at least one or more of the 
following methods of contraception for three months prior to, and during 
the study: hormonal, intrauterine device (IUD), or barrier method in 
combination with a spermicide. 
4. Subject should be medication free, other than hormonal birth control, for 48 
hours before through 24 hours after study drug administration. If the need 
for medication is identified during this time period, it will be discussed with 
and approved by the PI.    
5.4.6 Exclusion Criteria 
Subjects will be excluded from participation in the study if any of the following 
conditions exist: 
1. Women who are pregnant. 
2. Women who are breastfeeding. 
3. Subject has a known hypersensitivity to naloxone. 
4. Subject with hypertension  
5. Subject has a significant history of cardiac, neurologic, psychiatric, 
oncologic, endocrine (including diabetes type I or type II), metabolic, renal 
or hepatic disease 
6. Subject has taken or used any investigational drug or device in the 30 days 
prior to screening. 
7. Subject has taken either prescribed or over the counter medication for 48 
hours prior to study drug administration on either of the study days, other 
than hormonal birth control. 
8. History of narcotic or heroin abuse.  
5.4.7 Exit/Discontinuation Criteria 
Subjects will exit the study if any of the following conditions exist: 
1. Subject voluntarily withdraws from the study. 
2. Subject death. 
3. Subject acquires any of the listed exclusion criteria. 
4. Subject completes the protocol. 
5. Subject is non-compliant with the protocol (See Section 6.7 for definition of 
non-compliance) 
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6. Subject’s well-being, in the opinion of the Investigator, would be 
compromised by study continuation. 
7. Subject experiences concurrent illness. 
8. Subject experiences a serious adverse event. 
9. IRB recommendation 
Even if subjects who received study drug exit the study, they will be followed for 
24 hours to ascertain if any Adverse Event occurs. 
6.0 
Study Procedures 
6.1 
Informed Consent 
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.  The 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 IRB-
approved consent form, must be obtained before that subject participates in any study 
procedure.  This consent form must be signed by the subject, and the investigator-
designated research professional obtaining the consent.  A blank copy of the IRB-approved 
form must be kept on-site and by the sponsor-investigator.   
6.2 
Randomization Scheme 
The investigational pharmacy at the University of Minnesota will be responsible for 
implementing the randomization order in which participants are given naloxone or placebo, 
prepared by the study statistician. 
6.3 
Laboratory Testing Procedures 
6.3.1 Frequency of Blood Draws 
Three to five milliliter blood samples will be collected for determination of plasma 
naloxone concentrations prior to dosing, at 5 ± 1, 15 ± 2, 30 ± 3 minutes, and at 
1.08 ± 5, 1.5 ± 5, 2, 3, 4, and 6 hours after completion of the first IN dose.   The 
actual blood collection times for hours 2 through 6 may deviate by ± 10 minutes 
from the specified times.  In all cases, the actual time of the blood draw will be 
recorded.  Missed samples or breakage of a sample will be recorded. 
Baseline blood samples will be drawn for glucose, glucagon, epinephrine, 
norepinephrine and cortisol before the dose of Naloxone or placebo and before the 
start of the insulin clamp. During the morning study on day 1, blood samples will 
be collected every 5 minutes for monitoring of blood glucose levels and every 15 
minutes during the last 90 minutes of the clamp, for later measurement of serum 
glucagon, epinephrine, norepinephrine and cortisol. Afternoon clamp on day 1 will 
proceed as in the morning except that no serum or plasma will be collected except 
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for the monitoring of glucose and collection of samples for subsequent 
measurement of naloxone. On day 2 blood samples will be collected as on the 
morning of day 1.  
6.3.2 Specimen Preparation, Specimen Handling and Storage 
Whole blood will be collected and centrifuged at 2000 rpm for 10 minutes to 
separate plasma.  Plasma will be frozen and stored at -20° C or lower until analysis. 
6.3.3 Specimen Shipment 
Naloxone samples will be transported in an ice packed Styrofoam container directly 
from CRU to our research lab (LRB/MTRF) by study personnel.  At that point, they 
will be analyzed.  Leftover samples will be stored in the freezer until all analysis is 
complete, then discarded. Counter regulatory hormones samples including 
glucagon, epinephrine, norepinephrine, and cortisol would be sent to the Vanderbilt 
Diabetes Research and Training Center Core Laboratory for analysis. 
6.4 
Clinical Procedures 
6.4.1 Treatment Regimen 
This study will consist of two 2-day intervention visits separated by approximately 
8 weeks. 
Subjects will be asked to report to the research center by 7 am on the first day of 
the study after fasting overnight. On arrival, intravenous lines will be placed in 
each arm (one will be used for infusions and the other for blood sampling).  A 
minimum of 30 minutes after the IVs are placed, baseline blood samples will be 
drawn for later measurement of glucose, glucagon, epinephrine, norepinephrine, 
and cortisol. Subjects will then be given a 4 mg (0.1 ml) or 8 mg dose  (0.2 mL of 
IN naloxone or a similar volume  of IN placebo..  After naloxone or placebo dose, a 
hyperinsulinemic (2.0 mu/kg/min) hypoglycemic (target = 50 mg/dl) clamp 
protocol will be started. The clamp will be maintained for 2 hours. Blood samples 
will be collected every 5 minutes for monitoring of blood glucose levels and every 
15 minutes during the last 90 minutes for later measurement of serum glucagon, 
epinephrine, norepinephrine and cortisol. If the subject received 4mg dose of IN 
naloxone or placebo, a second dose of 4 mg IN naloxone or placebo will be given 
at +30 min after the start of insulin clamp. Every 15 minutes during the last 90 
minutes minutes of the morning clamp, subjects will be asked to quantitate their 
hypoglycemia related symptoms using a standardized questionnaire (12). At the 
completion of the morning clamp, glucose will be given to return the participant to 
normal glucose. 2 hours after the end of the morning clamp, a second 2 hour 
hyperinsulinemic (2.0 mu/kg/min) hypoglycemic (target = 50 mg/dl) clamp 
protocol will be started. At the start of this afternoon clamp study, a dose of 4 mg or 
8 mg of IN naloxone or placebo will be given.  Afternoon clamp will proceed as in 
the morning except that no serum or plasma will be collected except for the 
monitoring of glucose and collection of samples for subsequent measurement of 
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naloxone. If the subject received 4 mg dose of intra-nasal naloxone or placebo, a 
second dose of 4 mg intra-nasal naloxone or placebo will be given after 30 minutes. 
After the completion of the afternoon clamp, subjects will be returned to 
euglycemia and fed a meal.  They will then be allowed to leave the research center 
with instructions to return the next morning after an overnight fast. At 7 AM on day 
2 they will undergo a single 2 hour hyperinsulinemic hypoglycemic clamp (target 
blood glucose 50 mg/dl) during which blood samples will be collected as on the 
morning of day 1. Symptom scores will be collected every 15 minutes during the 
last 90 minutes of the clamp.  At the end of the study, infusions will be stopped, and 
participants will be fed a meal and then sent home after they are scheduled to return 
for Part 2 in 8 weeks. This timing is selected to ensure that female participants are 
studied at the same phase of the menstrual cycle; males will return for Part 2 in 8±2 
weeks. During Part 2 they will receive the treatment not provided during Part 1. 
The rest of the study protocol will be the same as in Part 1. 
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A description of the study visits is below: 
6.4.2 Clinical Assessments During Study 
Blood Pressure & Pulse:  A CRU staff member will check and record blood pressure and 
pulse prior to, and then approximately 30 minutes following, each dose and prior to 
discharge.  
Other Side Effects/Tolerability:  Side effects and tolerability of the IN administration will 
be collected as self-reports by subjects during both part 1 and part 2. 
Assessment of Safety:  Safety assessments include adverse events during the 6-hour period 
of observation. 
6.4.3  Drug Assay and Pharmacokinetic Analyses 
A validated, liquid chromatography-mass spectroscopy assay will be used to measure 
naloxone concentrations.   
Non-compartmental Pharmacokinetics Analysis:  Tmax and Cmax will be determined from 
visual inspection of the naloxone concentration-time plots.  Pharmacokinetic analysis will 
be performed with WinNonLin (Certara, Princeton, NJ, USA), a pharmacokinetic data 
V
i
s
i
t 
description
Expected activities
Part 1 Day 1
• Randomization 
• Morning (8 – 10 AM) hyperinsulinemic hypoglycemic clamp study with two, 4 
mg doses of naloxone or placebo depending on randomization assignment, 
collection of counterregulatory hormones and hypoglycemia symptom scores. 
• Afternoon (1 – 3 PM) hyperinsulinemic hypoglycemic clamp study with single 
4 mg dose of naloxone  or placebo depending on randomization assignment 
• Meal 
Part 1 Day 2
• Hyperinsulinemic hypoglycemic clamp study with collection of 
counterregulatory hormones and hypoglycemia symptom scores 
• Lunch
8 week wash out 
period
• Usual activities
Part 2 Day 1
• Morning (8 – 10 AM) hyperinsulinemic hypoglycemic clamp study with two 4 
mg doses of naloxone or placebo depending on randomization assignment, 
collection of counterregulatory hormones and hypoglycemia symptom scores 
• Afternoon (1 – 3 PM) hyperinsulinemic hypoglycemic clamp study with single 
4 mg dose of naloxone or placebo depending on randomization assignment 
• Meal
Part 2 Day 2
• Hyperinsulinemic hypoglycemic clamp study with collection of 
counterregulatory hormones and hypoglycemia symptom scores. 
• Lunch
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analysis package, and will include calculation of the area under the concentration-time 
curve (AUC) as well as other parameters as detailed below. Descriptive statistics will be 
used to summarize the data from this study. Descriptive statistics will include numbers of 
subjects (n), mean, median, standard deviation (SD), minimum, and maximum for 
continuous data and frequencies and percentages for categorical data. For each subject, the 
following pharmacokinetic parameters will be determined: 
•
Cmax: maximum observed plasma concentration 
•
Tmax: time to Cmax  
•
AUC0-t: area under the plasma concentration-versus-time curve from time zero to the 
last sampling time at which concentrations were at or above the limit of 
quantification, calculated by the linear trapezoidal rule  
•
AUC0-12hr: area under the plasma concentration-versus-time curve from time zero to 
12 hours post-dose  
•
AUC0-∞; area under the plasma concentration-versus-time curve from time zero to 
infinity, calculated from AUC0-t + (Ct/λz), where Ct is the last observed quantifiable 
concentration 
•
λz: apparent terminal rate constant λz obtained from the slope of the line, fitted by 
linear least squares regression, through the terminal points of the natural log of the 
concentration-versus-time plot of these points  
•
t1/2: apparent terminal half-life, calculated from (loge 2)/λz  
•
CL: clearance 
•
Vd: volume of distribution 
Plasma naloxone concentrations below the limit of quantification (BLQ) of the assay will 
be taken as zero for all calculations.  All calculations will be made using raw data. 
Compartmental Analysis:  Naloxone concentration-time data will also be analyzed using 
compartmental pharmacokinetic modeling (Phoenix Software, Certara, Princeton, NJ).  In 
addition, a nonlinear mixed-effects model will be employed to determine the population 
pharmacokinetic parameters of interest using NONMEM, a pharmacokinetic software 
application.  Initially, one- and two-compartment pharmacokinetic models with first-order 
absorption will be explored.  Standard diagnostic plots and goodness of fit parameters will 
be examined at several key stages to guide the choice of the most appropriate structural 
and statistical components of the model.  The final model will be used to simulate 
naloxone concentrations using varying doses and dosing regimens. 
6.5 
Follow-Up Procedures and Therapy Transitions 
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Subjects may contact study personnel after completion of the study with concerns or 
questions. 
6.6 
Study Timetable / Schedule of Events 
 
See above section 6.4.1 
6.7 
Study Protocol Compliance / Treatment Adherence 
Safety and tolerability will be evaluated in all subjects who receive study drug whether or 
not they complete the study.  Subjects are required to stay at CRU research facility for 3 
hours after the last dose of study drug administration.  If they do not complete the study; a 
new subject will be recruited to ensure a final sample size of 15 completers.  
6.8 
Protocol Amendments after Study Initiation 
 
Should changes in the study plan or protocol become necessary in the course of the clinical 
trial, those specific changes will be discussed and agreed upon by the Investigators, and 
appropriate IRB approval obtained before the changes are implemented.  All changes must 
be documented as protocol amendments.   
6.9 
Deviations from the Clinical Protocol 
 
When a deviation from the protocol is necessary for an individual subject, the investigator 
must complete a description of the deviation from the protocol and justification on the 
Protocol Deviation Form.   
6.10 
Subject Compensation 
Subjects will be compensated $150 for each day of the study. Total compensation will be 
$600 if they complete the entire study. 
7.0 
Data Collection and Analysis 
7.1 
Subject Population(s) for Analysis 
In this study we intend to enroll normal volunteers.  Previously our group has had no 
trouble enrolling volunteers to participate in studies in which they were asked to 
experience several periods of hypoglycemia.  This is a proof of principle study in which 
the impact of IN naloxone on hypoglycemia induced blunting of the counterregulatory 
response will be measured.  Normal volunteers who participate in this protocol are 
expected to have the same degree of hypoglycemia induced blunting in their 
counterregulatory response as patients with type 1 diabetes and normal awareness of 
hypoglycemia.  Therefore, this design will allow us to determine if naloxone works under 
controlled conditions.  If it does, it will provide rationale to use in patient populations in 
the future.  
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7.2 
Statistical Methods 
 Our primary outcome is the peak epinephrine response during the third hypoglycemic 
clamp of each infusion experiment, thus each participant will have two observations: one 
from their naloxone experiment and one from their placebo experiment. We will fit a 
general linear mixed model with fixed effects for treatment (Naloxone vs. placebo), 
treatment order (Naloxone first vs. placebo first), and period (Part 1 vs. Part 2) and a 
random effect for participant. We are confident that our study design, with a washout 
period of 8 weeks between Parts 1 and 2, has minimized the possibility of a treatment 
effect from Part 1 that lingers into Part 2. We will also consider adjustment for important 
baseline characteristics, such as age and sex. Diagnostics will be examined to assess model 
assumptions.  
8.0 
Safety and Adverse Events 
8.1 
Definitions 
Adverse Event (AE) 
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 injuries will 
be regarded as adverse events.  Abnormal results of laboratory or diagnostic procedures 
are 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. 
Adverse Reaction 
An adverse reaction is any adverse event caused by a drug.  Adverse reactions are a 
subset of suspected adverse reactions. 
Suspected Adverse Reaction 
A suspected adverse reaction is an adverse event for which there is a reasonable 
possibility that the drug caused the adverse event. 
Serious Adverse Event (SAE) 
A serious adverse event (SAE) is any adverse event that is: 
•
Fatal 
•
Life-threatening 
•
Requires or prolongs a hospital stay 
•
Results in persistent or significant disability or incapacity 
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•
Results in a congenital anomaly or birth defect 
Important medical events are events that may not be immediately life-threatening, but 
are clearly of major clinical significance, may be SAEs.  They may jeopardize the 
subject, and may require intervention to prevent one or the other serious outcomes noted 
above.   
Attribution 
The relationship of the adverse event and the drug or intervention will be classified as 
follows: 
•
Unrelated:  The AE is clearly NOT related to the intervention 
•
Unlikely:  The AE is doubtfully related to the intervention 
•
Possible:  The AE may be related to the intervention 
•
Probable:  The AE is likely related to the intervention 
•
Definite:  The AE is clearly related to the intervention. 
Hospitalization  
Hospitalization shall include any initial admission (even if less than 24 hours) to a 
healthcare facility as a result of a precipitating clinical adverse effect; to include transfer 
within the hospital to an intensive care unit.  Hospitalization or prolongation of 
hospitalization in the absence of a precipitating, clinical adverse effect (e.g., for a 
preexisting condition not associated with a new adverse effect or with a worsening of 
the preexisting condition; admission for a protocol-specified procedure) is not, in itself, 
a serious adverse effect. 
Expected Adverse Event 
Expected adverse events are those that are known to be associated with or have the 
potential to arise as a consequence of participation in the study. 
Unexpected Adverse Event 
An adverse event or suspected adverse reaction is considered unexpected if it is not 
listed in the Investigator Brochure or Protocol at the specificity or severity that has been 
observed. 
Unanticipated Problems Involving Risk To Subjects or Others (UPIRTSO) 
An adverse event that in the opinion of the Principal Investigator is unexpected, related 
to the drug, and serious. 
8.2 
Recording of Adverse Events 
At each contact with the subject, the investigator must seek information on adverse events 
by specific questioning and, as appropriate, by examination.  Information on all adverse 
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events should 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 should be recorded in the source document, 
though should be grouped under one diagnosis. 
All adverse events occurring during the study period must be recorded.  The clinical course 
of each event should be followed until resolution, stabilization, or until it has been 
determined that the study treatment or participation is not the cause.  Serious adverse 
events that are still ongoing at the end of the study period must 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 should 
be recorded and reported immediately. 
8.3 
Repor6ng of Serious Adverse Events 
8.3.1 Study Sponsor Notification by Investigators 
A serious adverse event must be reported to the study sponsor by telephone or fax 
(preferred) within 24 hours of the event.  A Serious Adverse Event (SAE) Form 
must be completed by the investigator and faxed to the study sponsor within 24 
hours.  The investigator will keep a copy of this SAE form on file at the study site. 
Report serious adverse events by phone and fax to: 
Amir Moheet   (phone) 612-624-3209 
 
 (pager) 612-899-2840 
 
 (fax) 612- 626-3133 
At the time of the initial report the following information should be provided: 
Within the following 48 hours, the Investigator must provide further information on 
the serious adverse event in the form of a written narrative.  This should include a 
•
Study Identifier
•
Whether study treatment was 
discontinued
•
Study Center
•
Subject Number
•
The reason why the event is 
classified as serious
•
A description of the event
•
Date of onset
•
Investigator assessment of the 
association between the event and 
study treatment
•
Current Status
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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 should be provided promptly to the 
study sponsor. 
8.3.2 IRB Notification by Investigators 
Reports of all serious adverse events (including follow-up information) must be 
submitted to the IRB within 10 working days if it falls under the UPIRTSO 
guidelines.  Copies of each report and documentation of IRB notification and 
receipt will be kept in the Clinical Investigator’s binder. 
8.3.3 FDA Notification by Sponsor 
The study sponsor shall notify the FDA by telephone or by facsimile (preferred) 
transmission of any unexpected fatal or life-threatening experience associated with 
the use of the drug as soon as possible but no later than 7 calendar days from the 
sponsor’s original receipt of the information. 
If a previous adverse event that was not initially deemed reportable is later found to 
fit the criteria for reporting, the study sponsor will submit the adverse event in a 
written report to the FDA as soon as possible, but no later than 15 calendar days 
from the time the determination is made. 
8.3.4 UPIRTSO Events 
Investigators are required to submit a report of UPIRTSO events to the IRB within 
10 working days of first learning of the event.  
8.4 
Safety Monitoring Plan 
 
8.4.1 Anticipated Risks / Risk Mitigation 
All CRU Research staff members are trained in BLS.  During dosing an MD will be 
present on site.  A complete crash cart and AED are available at CRU, and 
emergency standing orders are in place.  911 will be called for transport if needed.   
Study Procedure
Anticipated Risks
Risk Mitigation
Blood draws, IV 
drug administration
Infection, pain at injection 
site
Aseptic technique and use of trained 
personnel at CRU.
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8.4.2 Medical Monitoring for Participant Safety  
A Data Safety Monitoring Board (DSMB) will be assembled at the start of the 
study to regularly monitor patient safety and study documentation of adverse and 
serious adverse events. This board will consist of 3 members listed below: 
1.  Lisa Chow, MD. Associate Professor of Medicine, Department of Medicine, 
University of Minnesota 
IN naloxone 
administration
Increased blood pressure, 
musculoskeletal pain, 
headache, nasal dryness, 
nasal edema, nasal 
congestion, and nasal 
inflammation.   
The risks of IN naloxone will be minimized 
by excluding individuals who are sensitive 
to naloxone hydrochloride and those with 
high blood pressure.   
We will also use a standardized form to ask 
subjects about symptoms of musculoskeletal 
pain, headache, nasal dryness, nasal edema, 
nasal congestion, and nasal inflammation. 
blood pressure will be checked 
approximately 30 minutes following each 
dose and prior to discharge  
If symptoms develop the study may be 
stopped depending on severity and the 
doctor will monitor the subject until the 
symptoms are gone.   
IN placebo 
administration
There are no reported 
adverse events of IN 
placebo administration
Hypoglycemia
Sweating, shakiness, 
confusion, increased 
heartbeat and feeling 
"low". If the blood sugar 
drops below 20 mg/dl, 
confusion, seizures, coma 
or abnormalities in heart 
rhythm can occur.
 The risks of hypogycemia will be 
minimized by monitoring the blood glucose 
every 5 minutes and provide glucose as 
needed to achieve the target level of 
glycemia. Subjects will also wear a pulse 
oximeter during the study so we can monitor 
their heart rate.   If we become unable to 
monitor the glucose during the study or if 
the develop a serious arrhythmia (as defined 
by the MD or PA present), the study will be 
stopped and glucose will be given to 
normalize the blood sugar.  Study MD or PA 
will be present thoughtout the study to 
Study Procedure
Anticipated Risks
Risk Mitigation
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2. Tasma Harindhanavudh, MD. Assistant Professor of Medicine, Department of 
Medicine, University of Minnesota 
3. Lynn Eberly, PhD. Associate Professor Division of Biostatistics, School of 
Public Health, University of Minnesota 
Dr. Lisa Chow will chair the committee. Drs. Lisa Chow and Lynn Eberly both 
have prior experience of serving on other DSMB. Drs. Lisa Chow and Tasma 
Harindhanavudh are endocrinologist and have clinical expertise in this area of 
research and are both independent of the study team. Dr. Lynn Eberly is the study 
the study statistician. DSMB members will be unblinded to treatment assignments. 
They will review (1) incidence of early stopping of a study and (2) incidence of any 
adverse or serious adverse events, after 5, 10, and 15 randomizations and again at 
completion of recruitment. After an experiment where the study was stopped early 
and an adverse or serious adverse event was reported, they will review that 
experiment’s data within two weeks. 
The DSMB will be informed of all adverse events-serious adverse events within 48 
hours and others within 7 days. The Principal Investigator will oversee the safety of 
the study, including careful assessment and appropriate reporting of adverse events 
as outlined in Section 7.4.   
DSMB members will not receive any honorarium for serving on this committee.   
8.4.3 Study Stopping Rules 
If an SAE occurs in any participant, we will ask the DSMB to determine whether 
the adverse event was due to study medication.  If it is deemed probably due to 
study medication, no further subjects will be given IN naloxone.    
8.4.4 
Repor6ng of Pregnancy 
The outcome of any pregnancy (e.g., any premature terminations, elective or 
therapeutic, and any spontaneous abortions or stillbirths, as well as the health status 
of the mother and child including date of delivery and infant’s gender and weight) 
will be reported.  Pregnancies will be followed until birth or outcome is known 
pending the subject’s permission. 
9.0 
Data Handling and Record Keeping 
9.1 
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 
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•
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 should 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. 
9.2 
Source Documents 
Source Data are the clinical findings and observations, laboratory and test data, and other 
information contained in Source Documents.  Source Documents are the original records 
(and certified copies of original records); including, but not limited to, hospital medical 
records, physician or office charts, physician or nursing notes, subject diaries or evaluation 
checklists, pharmacy dispensing records, recorded data from automated instruments, x-
rays, etc.  When applicable, information recorded on the CRF shall match the Source Data 
recorded on the Source Documents.   
9.3 
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 should be printed legibly in black ink.  If any entry error has been made, to correct 
such an error, draw a single straight line through the incorrect entry and enter the correct 
data above it.  All such changes must be initialed and dated.  DO NOT ERASE OR 
WHITE OUT ERRORS.  For clarification of illegible or uncertain entries, print the 
clarification above the item, then initial and date it. 
A Case Report Form will be completed for each subject enrolled into the clinical study. 
The investigator-sponsor will review, approve and sign/date each completed CRF; the 
investigator-sponsor’s signature serving as attestation of the investigator-sponsor’s 
responsibility for ensuring that all clinical and laboratory data entered on the CRF are 
complete, accurate and authentic.   
We will record the time and amount of blood draws; the time, amount, and route of drug 
administration; all vital signs (BP, HR, RR);hypoglycemia symptom scores; any side 
effects reported from study drugs.  
9.4 
Clinical Reports 
 
 
 
 
 
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An annual progress report will be submitted to the FDA and the IRB.  Investigators will 
submit a final report of the clinical study to the sponsor and reviewing IRB within 3 
months of termination or completion of the clinical study or the Investigator’s part of the 
clinical study. 
 
9.5 
Records Retention 
 
 
 
 
 
The investigator-sponsor will retain the specified records and reports for up to 2 years after 
the marketing application is approved for the investigational drug; or, if a marketing 
application is not submitted or approved for the investigational drug, until 2 years after 
investigations under the IND have been discontinued and the FDA so notified.  
10.0 
Study Monitoring, Auditing, and Inspecting 
This study will be monitored according to FDA/GCP guidelines.  The Investigator will allocate 
adequate time for such monitoring activities.  The Investigator will also ensure that the monitor or 
other compliance or quality assurance reviewer is given access to all study-related documents and 
study related facilities (e.g. pharmacy, diagnostic laboratory, etc.), and has adequate space to 
conduct the monitoring visit. 
10.1 
Study Monitoring Plan 
 
 
 
 
 
Independent monitoring of the clinical study for clinical protocol and IND application 
compliance will be conducted periodically (i.e., at a minimum of annually) by the Clinical 
and Translational Science Institute, Clinical Trial Monitoring Service, according to the 
attached monitoring plan. 
10.2 
Auditing and Inspection 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, 
the sponsor, government regulatory bodies, and University compliance and quality 
assurance groups 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.). 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality 
assurance offices. 
11.0 
Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical 
Practice (21 CFR 312 and International Conference on Harmonization guidelines), applicable 
government regulations and Institutional research policies and procedures. 
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This protocol and any amendments will be submitted to a properly constituted independent 
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.   
12.0 
Study Finances  
12.1 
Funding Source 
This study is supported by funds from University of Minnesota Foundation and we are also 
applying for additional funds through other funding sources. 
 
 
12.2 
Conflicts of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, 
or financial gain greater than the minimum allowable by their institution, etc.) must refer to 
the Regents Policies on Individual Conflict of Interest Policy or Institutional Conflict of 
Interest Policy. These policies require University Faculty and staff to report external 
professional activities and business and significant financial interests related to his or her 
University activities by submitting a REPA (Report of External Professional Activities) at 
least once per year. Faculty and staff should also file a REPA when substantial changes in 
business or financial interests occur, when an activity that presents a potential conflict of 
interest is anticipated, or when submitting an application for research support or 
technology transfer, submitting research protocols to the IRB, or receiving financial 
contributions. All University of Minnesota investigators will follow the University conflict 
of interest policy. 
13.0 
Publications Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, nor 
any of the information provided by the sponsor for the purposes of performing the study, will be 
published or passed on to any third party without the consent of the study sponsor.  Any 
investigator involved with this study is obligated to provide the sponsor with complete test results 
and all data derived from the study. 
14.0 
References 
1. Cryer PE. Mechanisms of hypoglycemia-associated autonomic failure and its component 
syndromes in diabetes. Diabetes 2005;54:3592-601 
2. Geddes J, Schopman JE, Zammitt NN, Frier BM. Prevalence of impaired awareness of 
hypoglycaemia in adults with Type 1 diabetes. Diabetic Med 2008;25:501-4 
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3. Fanelli C, Pampanelli S, Epifano L, et al. Long-term recovery from unawareness, deficient 
counterregulation and lack of cognitive dysfunction during hypoglycemia, following 
institution of rational, intensive insulin therapy in IDDM. Diabetologia.1994; 37:1265-1276 
4. Leelarathna L, Little SA, Walkinshaw E, et al. Restoration of Self-Awareness of 
Hypoglycemia in Adults with Long-Standing Type 1 Diabetes Hyperinsulinemic-
hypoglycemic clamp substudy results from the HypoCOMPaSS trial. Diabetes care 
2013;36:4063-70 
5. Dagogojack S, Rattarasarn C, Cryer PE. Reversal of hypoglycemia unawareness, but not 
defective glucose counterregulation, in IDDM. Diabetes.1994; 43:1426-1434 
6. McCrimmon RJ. The Response to Hypoglycemia: A Role for the Opioid System? J Clin 
Endocrinol Metab .2011; 96:3357-3359 
7. Eltayeb KMA, Brubaker PL, Lickley HLA, Cook E, Vranic M. Effect of opiate-receptor 
blockade on normoglycemic and hypoglycemic glucoregulation. Am J Physiol .1986; 
250:E236-E242 
8. Caprio S, Gerety G, Tamborlane WV, et al. Opiate blockade enhances hypoglycemic 
counterregulation in normal and insulin-dependent diabetic subjects. Am J Physiol.1991; 
260:E852-E858 
9. Leu J, Cui MH, Shamoon H, Gabriely I. Hypoglycemia-Associated Autonomic Failure Is 
Prevented by Opioid Receptor Blockade. J Clin Endocrinol Metab.2009;94:3372-3380 
10. Vele S, Milman S, Shamoon H, Gabriely I. Opioid Receptor Blockade Improves 
Hypoglycemia-Associated Autonomic Failure in Type 1 Diabetes Mellitus. J Clin Endocrinol 
Metab .2011; 96:3424-3431 
11. Moheet A, Kumar A, Eberly LE, Roberts KR, Seaquist ER. Hypoglycemia-Associated 
Autonomic Failure in Healthy Humans: Comparison of Two vs Three Periods of 
Hypoglycemia on Hypoglycemia-Induced Counterregulatory and Symptom Response 5 Days 
Later. 
12. Towler D, Havlin C, Craft S, Cryer P. Mechanism of awareness of hypoglycemia—perception 
of neurogenic (predominantly cholinergic) rather than neuroglycopenic symptoms. Diabetes. 
1993;42:1791–1798. 
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