glucagon ready-to-use (rtu) for prevention of exercise-induced hypoglycemia during aerobic exercise in adults with t1d

Conditions: Hypoglycemia

Summary: this study is a randomized, placebo-controlled, double-blind, 2-treatment, 2-period, crossover comparison in a clinical research center (crc) setting, followed by a randomized, placebo-controlled, double-blinded, 2-arm parallel comparison with a third open-label arm in an outpatient setting. the purpose of the study is to evaluate the preliminary efficacy and safety of glucagon ready-to-use \[rtu\] to prevent exercise-induced hypoglycemia (eih) in adults with type 1 diabetes mellitus (t1d), who perform regular, moderate-to-high intensity aerobic exercise.

there were 2 phases of this study: crc and outpatient. the initial posting of this study reflected the 3 treatment arms included in the outpatient phase of the study, without including the crc and outpatient phases separately. crc phase: the crc phase was comprised of 2 visits that included daytime exercise sessions at the crc or a comparable setting. subjects were randomized to receive their first treatment at visit 3 and crossed over (2 to 28 day washout) to their second treatment at visit 4. the treatments were a single treatment with 30 microliters of either glucagon rtu (0.15 mg) or placebo with a 50% insulin pump reduction. blood glucose was assessed 15 minutes prior to the start of exercise, at the start of exercise, and then 15, 30, 45, 60, and 75 minutes from the start of exercise. outpatient phase: after completion of the crc phase, subjects entered the 12-week outpatient phase. subjects were to maintain a weekly exercise average of 2 to 3 sessions of at least 30 minutes duration. subjects were assigned randomly in 1:1:1 ratio to administer 30 microliters of one of the following prior to the exercise sessions: glucagon rtu (0.15 mg) with a 50% insulin pump reduction, placebo with a 50% pump reduction or glucagon rtu (0.15 mg) without an insulin pump reduction. blood glucose was assessed 15 minutes prior to the start of exercise, just before exercise, after 30 minutes of exercise, at the end of exercise (if longer than 30 minutes), and 30 minutes post-exercise.

Eligibility criteria:
inclusion criteria: 1. clinical diagnosis of presumed autoimmune type 1 diabetes, receiving daily insulin via continuous subcutaneous insulin infusion. 2. age 18 to \< 65 years. 3. duration of type 1 diabetes ≥ 2 years. 4. random c-peptide \< 0.6 ng/ml (\<198 pmol/l). 5. using insulin therapy by continuous subcutaneous insulin infusion pump for at least 6 months. 6. history of exercise-related hypoglycemia. 7. performs aerobic exercise regularly (2-3 times per week), and desires to exercise per american diabetes association guidelines (150 minutes per week). examples of aerobic exercise include: power walking, hiking, running/jogging, cycling, swimming, cross country skiing, and aerobic fitness classes. 8. will abstain from the use of non-insulin diabetes therapies such as sodium glucose co-transporter 2, glucagon like peptide-1, and metformin for the duration of the study. 9. subject must be willing to adhere to the protocol requirements for the duration of the study. 10. subject has provided informed consent as evidenced by a signed/dated informed consent form completed before any trial-related activities occur. exclusion criteria: 1. frequently experience hyperglycemia with exercise, in the clinical judgement of the investigator. 2. pregnant and/ or nursing: for female subjects of childbearing potential, there is a requirement for a negative urine pregnancy test and for agreement to use contraception and to refrain from breast feeding during the study, and for at least 1 week after the last dose of study drug. acceptable contraception includes birth control pill / patch / vaginal ring, depo-provera, norplant, an intra-uterine device, the double barrier method (the woman uses a diaphragm and spermicide and the man uses a condom), or abstinence. 3. one or more severe hypoglycemic episodes in the past 12 months (as defined by an episode that required third party assistance for treatment). 4. uses inhaled insulin. 5. hemoglobin a1c \> 9.0% at screening. 6. renal insufficiency (serum creatinine greater than 3 mg/dl (0.17 mmol/l)). 7. serum alanine aminotransferase or aspartate aminotransferase equal to or greater than 3 times the upper limit of normal. 8. hepatic synthetic insufficiency as defined as a serum albumin of less than 3 mg/dl (0.17 mmol/l); or serum bilirubin greater than 2 mg/dl (0.11 mmol/l). 9. hematocrit of less than or equal to 30%. 10. mean of triplicate blood pressure (bp) readings at screening where systolic bp \ 150 mm hg, or diastolic bp \ 100 mm hg. 11. clinically significant electrocardiogram abnormalities. 12. use of \> 2.0 u/kg total insulin dose per day. 13. inadequate bilateral venous access in both arms. 14. congestive heart failure, new york heart association class iii or iv. 15. active malignancy within 5 years from screening, except basal cell or squamous cell skin cancers. 16. major surgical operation within 90 days prior to screening, or planned surgical operation during the study. 17. history of seizure disorders. 18. bleeding disorder, treatment with warfarin or any anticoagulants, or platelet count below 50,000 mm3 at screening. 19. history of pheochromocytoma or disorder with increased risk of pheochromocytoma (multiple endocrine neoplasia type 2, neurofibromatosis, or von hippel-lindau disease). 20. history of insulinoma. 21. history of allergies to glucagon or glucagon-like products, or any history of significant hypersensitivity to glucagon or any related products or to any of the excipients (dimethylsulfoxide, mannitol, \& trehalose) in the investigational formulation. 22. history of glycogen storage disease. 23. subject tests positive for human immunodeficiency virus, hepatitis c virus, or active hepatitis b virus infection at screening. 24. any concurrent illness, other than diabetes, that is not controlled by a stable therapeutic regimen. 25. active substance or alcohol abuse, in the opinion of the investigator. subjects reporting active marijuana use or testing positive for tetrahydrocannabinol via rapid urine test will be allowed to participate in the study at the discretion of the investigator. 26. participation in other studies involving administration of an investigational therapeutic agent (drug or device) within 30 days or 5 half-lives, whichever is longer, before screening for the current study and during participation in the current study. 27. any reason the investigator deems exclusionary.

Keywords: exercise glucagon insulin