Patient case (clinical description): A 50-year-old woman comes to the clinic with intermittent ear discharge and sense of hearing loss on her left ear.  Past medical history is significant for obesity, hyperlipidemia, and diabetes mellitus.  Her medications include Metformin, Atorvastatin and Vit D supplement. Vital signs are normal. BMI is 37. Otoscopy shows a small perforation in the left tympanic membrane and a pearly mass behind the membrane.  Conduction hearing loss is noted in the left ear.  The remainder of the ear, nose, and throat examination is normal.

Patient's own account: I went to the clinic the other day because I had some fluid in my ear and I felt like I could not hear as well as I used to in my left ear. I'm a 50-year-old woman, and I have been obese for a while now. I have diabetes and cholesterol. I take some medication. I take metformin, atorvastatin, and vitamin D supplements. When I was admitted, my vitals were normal. My BMI is 37. When they looked into my ears, they said that my left tympanic membrane was broken and there was some fluid behind the membrane. During the hearing test, they could assess that my left ear suffers from hearing loss. They also performed ear, nose, and throat examinations that turned out to be normal.

Clinical trial: A Study of Single and Multiple Doses of Oral Insulin or Placebo in Subjects With Type 2 Diabetes Mellitus

Eligibility criteria:
Inclusion Criteria:

          -  Male or female subjects, age 20 to 75 years, inclusive with type 2 diabetes mellitus.

          -  At Visit 2/Period 1/Day 1, subjects will have been treated for their diabetes by
             metformin (≥1000 mg/day; any type and regimen), metformin and a DPP-4 inhibitor (
             Dipeptidyl-Peptidase)-4), metformin and an SGLT-2 (Sodium-glucose co-transporter 2)
             inhibitor, metformin and TZD (Thiazolidinediones), or metformin and sulfonylurea.
             Subjects will have been on a stable regimen of metformin (defined as the same
             metformin dose and type) and other treatments for at least 8 weeks prior to Visit
             2/Period 1/Day 1.

          -  Body Mass Index (BMI) between 25 and 40 kg/m2, inclusive, at Screening.

          -  Hemoglobin A1c (HbA1c) between ≥7.5 and ≤10.5% at Screening.

          -  Fasting serum glucose greater than or equal to 126 mg/dL at Screening.

          -  Females of childbearing potential must have a negative serum pregnancy test result at
             Screening and a negative urine pregnancy test at Visit 2/Day 1 for all study Periods.

          -  Females who are not of childbearing potential are defined as:

             i. Postmenopausal (defined as at least 12 months with no menses in women ≥45 years of
             age) ii. Has had a hysterectomy and/or bilateral oophorectomy, bilateral
             salpingectomy, or bilateral tubal ligation/occlusion at least 6 weeks prior to
             screening; OR iii. Has a congenital or acquired condition that prevents childbearing.

          -  Females of childbearing potential agree to avoid becoming pregnant while receiving
             study treatment and for 14 days after the last dose of study treatment by complying
             with one of the following:

             i. practice abstinence† from heterosexual activity OR ii. Use (or have her partner
             use) acceptable contraception during heterosexual activity.

        Exclusion Criteria:

          -  Usage of anti-diabetic agents other than metformin, sulfonylurea, SGLT-2 inhibitors,
             TZD, or DPP-4 inhibitors within 6 weeks prior to Visit 2/Period 1/Day 1.

          -  Presence of any clinically significant endocrine disease according to the Investigator
             (euthyroid subjects on replacement therapy will be included if the dosage of thyroxine
             is stable for at least six weeks prior to Screening).

          -  Clinical diagnosis of type 1 diabetes.

          -  Fasting serum glucose >300 mg/dL at Screening; a single repeat test is allowable.

          -  Evidence of unawareness of hypoglycemia, a documented plasma glucose ≤50 mg/dL in the
             absence of symptoms of hypoglycemia at Screening.

          -  Presence of any clinically significant condition (in the opinion of the Investigator)
             that might interfere with the evaluation of study medication, such as significant
             renal, hepatic, gastrointestinal (GI), cardiovascular (CV), immune disease, blood
             dyscrasias or any disorders causing hemolysis or unstable red blood cells, or
             clinically important hematological disorders (i.e. aplastic anemia, myeloproliferative
             or myelodysplastic syndromes, thrombocytopenia) at Screening.

          -  Presence or history of cancer within the past 5 years of Screening, with the exception
             of adequately-treated localized basal cell skin cancer or in situ uterine cervical
             cancer.

               1. A subject with a history of malignancy >5 years prior to Screening should have no
                  evidence of residual or recurrent disease.

               2. A subject with a history of melanoma, leukemia, lymphoma, or renal carcinoma is
                  excluded.

          -  Laboratory abnormalities at Screening including:

               1. C-peptide < 1.0 ng/mL;

               2. Positive pregnancy test in females of childbearing potential (at Screening and
                  Visit 2/Periods 1-3/Day 1);

               3. Abnormal serum thyrotropin (TSH) levels below the lower limit of normal or >1.5X
                  (1.5 times) the upper limit of normal

               4. Elevated liver enzymes (alanine transaminase (ALT), alanine aminotransferase
                  (AST), alkaline phosphatase) >2X the upper limit of normal.

               5. Very high triglyceride levels (>600 mg/dL); a single repeat test is allowable.

               6. Any relevant abnormality that would interfere with the efficacy or the safety
                  assessments during study treatment administration.

          -  Positive history of active liver disease (other than non-alcoholic hepatic steatosis),
             including chronic hepatitis B or C, primary biliary cirrhosis, or active symptomatic
             gallbladder disease.

          -  Positive history of HIV.

          -  Use of the following medications:

               1. History of use of insulin for more than 1 week within 6 months prior to and none
                  within 6 weeks prior to Visit 2/Period 1/Day 1.

               2. History of use of aprotinin at any time prior to Screening (e.g., Trasylol, any
                  type or dose).

               3. Administration of thyroid preparations or thyroxine (except in subjects on stable
                  replacement therapy) within 6 weeks prior to Screening.

               4. Administration of systemic long-acting corticosteroids within two months or
                  prolonged use (more than one week) of other systemic corticosteroids or inhaled
                  corticosteroids (if daily dosage is > 1,000 μg equivalent beclomethasone) within
                  30 days prior to Screening. Intra-articular and/or topical corticosteroids are
                  not considered systemic.

               5. Use of medications known to modify glucose metabolism or to decrease the ability
                  to recover from hypoglycemia such as oral, parenteral, and inhaled steroids (as
                  discussed above), and immunosuppressive or immunomodulating agents.

          -  Subject is on a weight loss program and is not in the maintenance phase, or subject
             has started weight loss medication (e.g., orlistat or liraglutide), within 8 weeks
             prior to Screening. Subjects who have had bariatric surgery are also excluded.

          -  Subject is pregnant or breast-feeding.

          -  Subject has a Screening systolic blood pressure ≥165 mmHg or diastolic blood pressure
             ≥100 mmHg. Subjects will be allowed to take a BP rescue medication.

          -  Subject is a user of recreational or illicit drugs or has had a recent history (within
             1 year of Screening) of drug or alcohol abuse or dependence. (Note: Alcohol abuse
             includes heavy alcohol intake as defined by >3 drinks per day or >14 drinks per week,
             or binge drinking) at Screening.

          -  Any clinically significant ECG abnormality at Screening or cardiovascular disease.
             Clinically significant cardiovascular disease will include:

               1. History of stroke, transient ischemic attack, or myocardial infarction within 6
                  months prior to Screening,

               2. History of or currently have New York Heart Associate Class II-IV heart failure
                  prior to Screening, or

          -  One or more contraindications to metformin.

          -  At the Principal Investigator's discretion, any condition or other factor that is
             deemed unsuitable for subject enrollment into the study.
No condition on gender to be admitted to the trial.
No healthy subjects accepted to join the trial.
Subject must be at least 20 Years old.
Subject must be at most 75 Years

Eligibility (NLI label): Entailment