Clinical trial NCT02104739
Conditions: Prediabetes Obesity
Keywords: prediabetes diabetes mellitus type 2 exenatide saxagliptin exenatide ER
Sponsor: The University of Texas Health Science Center, Houston
Start date: 2014-04-01; Completion date: 2017-03-01
Enrollment: 21 participants; Allocation: RANDOMIZED; Intervention model: CROSSOVER

Brief summary:
This project addresses cardiovascular disease risk in patients with prediabetes. Levels of lipids after eating a meal ("postprandial lipids") are strong independent predictors of cardiovascular risk. Newer anti-diabetic agents - exenatide and saxagliptin - impact lipid metabolism. These medications will be studied for their effect in reducing both postprandial lipid levels and arterial dysfunction.

Detailed description:
It is a paradox that medical efforts to control blood glucose in type 2 diabetes mellitus have not decreased the risk of cardiovascular disease. Postprandial lipid concentrations are a strong predictor of cardiovascular risk, independent of traditional cardiovascular risk factors. The new classes of antidiabetic medications - GLP-1 agonists and DPP-IV inhibitors - affect lipid as well as glucose metabolism. This study will investigate the efficacy of these medications in reducing postprandial hyperlipidemia, disrupting the concurrent proinflammatory free fatty acid signaling, and ameliorating endothelial dysfunction in individuals with prediabetes. This will consist of a single center, randomized, crossover, placebo-controlled double-blinded prospective trial involving three study arms representing the aforementioned medications: exenatide (GLP-1 agonist), saxagliptin (DPP-IV inhibitor), and placebo (control arm). Each subject will participate in each of the three arms, which are three separate, daylong outpatient studies. For each study arm, subjects will eat a standardized atherogenic high-fat test lunch. Venous blood draws and measurements of forearm blood flow will be done prior to the meal and periodically during a 6-hour period after the meal. Forearm blood flow measurements will assess for changes in endothelial function. The blood will be analyzed for multiple markers of hyperlipidemia and free fatty acid signaling. After completing the three randomized study visits, subjects are invited to participate in an optional, nonrandomized extension study. For the extension study, subjects will take exenatide ER (extended-release exenatide) weekly for total of six weeks. Then subjects return to eat a standardized atherogenic high-fat test lunch. Venous blood draws and measurements of forearm blood flow will be done prior to the meal and periodically during a 4-hour period after the meal, for the same analyses described before. The results will provide new insights into the anti-inflammatory effects of multiple antidiabetic medications via the mechanisms of postprandial hyperlipidemia, free fatty acid signaling, and endothelial function in prediabetic individuals.

Arms: arm 1: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablets and Placebo (normal saline) injections arm 2: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablets and Placebo (normal saline) injections arm 3: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablets and Placebo (normal saline) injections arm 4: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablets and Placebo (normal saline) injections arm 5: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablets and Placebo (normal saline) injections arm 6: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablets and Placebo (normal saline) injections arm 7: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablet and Placebo (normal saline) injection; Subcutaneous injection (2mg) weekly for 6 weeks arm 8: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablet and Placebo (normal saline) injection; Subcutaneous injection (2mg) weekly for 6 weeks arm 9: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablet and Placebo (normal saline) injection; Subcutaneous injection (2mg) weekly for 6 weeks arm 10: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablet and Placebo (normal saline) injection; Subcutaneous injection (2mg) weekly for 6 weeks arm 11: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablet and Placebo (normal saline) injection; Subcutaneous injection (2mg) weekly for 6 weeks arm 12: Exenatide Single subcutaneous injection (10 mcg); Saxagliptin Single dose orally (5 mg); Placebo tablet and Placebo (normal saline) injection; Subcutaneous injection (2mg) weekly for 6 weeks
Interventions: intervention 1: Exenatide intervention 2: Saxagliptin intervention 3: Exenatide extended-release (ER) intervention 4: Placebo
Intervention descriptions: intervention 1: Single subcutaneous injection (10 mcg) intervention 2: Single dose orally (5 mg) intervention 3: Subcutaneous injection (2mg) weekly for 6 weeks intervention 4: Placebo tablets and Placebo (normal saline) injections

Protocol documents:
Prot_SAP_000.pdf: 
Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
 
 
 
 
 
 
 
 
Comparative Effects of Antidiabetic Medications on Postprandial Hyperlipidemia, Free Fatty 
Acid Signaling, and Endothelial Dysfunction in Individuals with Prediabetes 
 
NCT02104739 
 
Version Date: 02/18/2016 
 
 


Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
Protocol Title: 
Comparative Effects of Antidiabetic Medications on Postprandial 
Hyperlipidemia, Free Fatty Acid Signaling, and Endothelial Dysfunction in 
Individuals with Prediabetes 
Principal Investigator: 
Absalon D. Gutierrez, MD 
 
 
Co-Investigators: 
Heinrich Taegtmeyer, MD, DPhil 
Philip Orlander, MD 
 
 
Population: 
This study will require 40 obese prediabetic (otherwise generally healthy) 
subjects, males and female, aged 30-70 years old, from the Houston, TX area. 
Number of Sites: 
Single site 
 
 
Study Duration: 
3 years 
 
 
Subject Duration: 
4 months (not including optional extension study). Optional extension study will take 6 
additional weeks, and may be completed within one year of finishing required study procedures. 
 
 
General Information 
It is a paradox that medical efforts to control blood glucose in type 2 diabetes mellitus have not 
decreased the risk of cardiovascular disease. Postprandial lipid concentrations are a strong predictor of 
cardiovascular risk, independent of traditional cardiovascular risk factors. The new classes of 
antidiabetic medications - GLP-1 agonists and DPP-IV inhibitors - affect lipid as well as glucose 
metabolism. This study will investigate the efficacy of these medications in reducing postprandial 
hyperlipidemia, disrupting the concurrent proinflammatory free fatty acid signaling, and ameliorating 
endothelial dysfunction in individuals with prediabetes. This will consist of a single center, randomized, 
crossover, placebo-controlled double-blinded prospective trial involving three study arms representing 
the aforementioned medications: exenatide (GLP-1 agonist), saxagliptin (DPP-IV inhibitor), and placebo 
(control arm). For each study arm, subjects will eat a standardized atherogenic high-fat test lunch. 
Venous blood draws and measurements of forearm blood flow will be done prior to the meal and 
periodically during a 6-hour period after the meal. Forearm blood flow measurements will assess for 
changes in endothelial function. The blood will be analyzed for multiple markers of hyperlipidemia and 
free fatty acid signaling. The results will provide new insights into the anti-inflammatory effects of 
multiple antidiabetic medications via the mechanisms of postprandial hyperlipidemia, free fatty acid 
signaling, and endothelial function in prediabetic individuals. At the request of the sponsor (CCTS) and 
due to updates in the medical literature, pioglitazone is no longer being studied. The pioglitazone study 
arm has been removed.  Also at the request of the sponsor (CCTS), we have added an optional, 
nonrandomized extension study to address the issue of exenatide efficacy during longer treatment 
duration. 
 
Background Information 
Coronary heart disease accounts for more than two-thirds of all deaths in patients with type 2 diabetes 
1 
mellitus. In spite of aggressive efforts to improve blood glucose control, these measures generally yield 
2-4 
little to no positive impact on cardiovascular outcomes. 
Recent large epidemiological studies suggest that 
postprandial lipid concentrations are a strong predictor of cardiovascular risk, independent of traditional 
cardiovascular risk factors.5-8 As some of the newer antidiabetic medications affect 
lipid as well as glucose metabolism, this research will focus on the effects of these medications on 
the treatment of postprandial hyperlipidemia. 


Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
Exenatide is a glucagon-like receptor agonist (GLP-1 agonist) which lowers postprandial glucose and 
positively modifies several cardiovascular risk factors when given long-term. Recently, it was shown that 
a single dose of exenatide reduced postprandial elevations in lipids, lipoproteins, and free fatty acids in 
both impaired glucose tolerance and early type 2 diabetes mellitus.9 Moreover, exenatide improved 
postprandial endothelial function.10 Exenatide treatment also has a potent effect on free fatty acid 
signaling.11 
 
Saxagliptin is a dipeptidyl peptidase-IV (DPP-IV) inhibitor which prevents the inactivation of native GLP- 
1 and glucose-dependent insulinotropic peptide (GIP). Saxagliptin also has potent effects on free fatty 
12 
acid signaling. 
There are no studies showing whether a single dose of saxagliptin would reduce 
postprandial elevations in lipids, lipoproteins, free fatty acids, and endothelial dysfunction in a manner 
similar to exenatide. 
 
 
While these medications are traditionally used to lower blood glucose in diabetic individuals, their 
additional effects in altering postprandial hyperlipidemia will provide new insights in the mechanisms 
of atherogenesis. Though glycemic control might have little impact on cardiovascular outcomes,2-4 
these therapies potentially show new promise in the future treatment of coronary heart disease. 
 
 
The following Specific Aims will test the hypotheses that exenatide and saxagliptin have potent anti- 
inflammatory postprandial effects as evidenced by modulation of free fatty acid signaling, the reduction 
of hyperlipidemia, and amelioration of endothelial dysfunction in prediabetic subjects. At the request of 
sponsor and due to updates in the medical literature, pioglitazone is no longer being studied. The 
pioglitazone study arm and relevant specific aim have been removed. 
 
Objectives 
Specific Aim #1: Determine How Incretin-Based Therapies Modulate the Mechanisms of Postprandial 
Hyperlipidemia in the Prediabetic State 
 
 
Hypothesis: A single dose of exenatide or saxagliptin will reduce serum free fatty acid (FFA) levels 
and subsequently downregulate FFA-induced cellular proinflammatory signaling. 
Hypothesis: A single dose of exenatide or saxagliptin will attenuate postprandial excursions 
of proatherogenic lipids and lipoproteins. 
Hypothesis: Six weeks of treatment with long-acting exenatide will further reduce serum 
free fatty acid (FFA) levels, downregulate FFA-induced cellular proinflammatory signaling, and 
attenuate postprandial excursions of proatherogenic lipids and lipoproteins. 
 
Specific Aim #2: Identify the Effect of the Above Therapies on the Amelioration of Endothelial 
Dysfunction in Postprandial Hyperlipidemia 
Hypothesis: Changes in endothelial dysfunction (measured by forearm blood blow) will correlate 
with changes in triglycerides and free fatty acids in the postprandial state. 
 
Study Design 
Potential study subjects in UT clinics will be identified via All Scripts. A study coordinator or investigator 
will go out to clinics with high volumes of potential subjects and inform patients of the study, given the 
approval of the clinic’s attending physician. Furthermore, we will use CPHS-approved newspaper ads 
and flyers as means to recruit patients outside of the UT clinics. All interested patients (both in UT 
clinics and outside of UT clinics) will be given a phone number to call for the purpose of discussing 
study participation further. 


Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
Interested potential subjects will be prescreened for the above criteria via a telephone interview. If the 
subject meets criteria via telephone interview, he or she will be invited to participate in an hour-long 
outpatient screening visit. At this time, subjects will be consented for participation in the study. We will 
perform a complete history and physical exam. We will also draw the following baseline fasting labs 
(npo since midnight, except for water and chronic medications): complete metabolic panel, lipid panel, 
hemoglobin A1C, complete blood count, and urine pregnancy test (if applicable). Subjects will receive 
monetary compensation for this screening visit ($40) Results will be reviewed. If the subject meets the 
inclusion and exclusion criteria, then he or she will be invited to participate in the trial. 
 
 
This will be a single center, randomized, crossover, placebo-controlled double-blinded prospective 
trial. Each subject will participate in three separate, daylong outpatient studies at the Clinical Research 
Unit (CRU). Each study will represent one of the three arms of the trial: Exenatide 10 mcg 
subcutaneous injection, saxagliptin 5 mg oral tablet, or placebo. The order of the studies will be 
randomized in a crossover design, and each study will take place at least ≥ 10 days apart to ensure 
sufficient washout of each medication. The three studies, however, must all be completed in period of 
no longer than four months. Subjects will receive monetary compensation for each study visit ($95 
each). 
 
 
Each study will begin with the patient presenting to Clinical Research Unit (CRU) at approximately 0800 
after an overnight fast. Peripheral venous access will be obtained in a stable vein in an upper extremity. 
A blood pressure cuff and a strain gauge will be placed at the widest part of the opposite forearm (to 
measure forearm blood flow via venous occlusion plethysmography). Baseline blood draws (described 
below) and forearm venous occlusion plethysmography will be performed at 1045 (± 10 minutes). At 
this time, the study medication (exenatide, saxagliptin, or placebo) will be given. At 1100 (± 10 minutes), 
the participant will be fed an atherogenic high-fat test lunch equivalent to a McDonald’s® Big Mac meal. 
The standardized meal will be prepared by the Memorial Hermann TMC cafeteria. 
Peripheral venous blood will be drawn for analysis before the meal and every 2 hours (± 10 minutes 
for each blood draw) during the 6 hours after eating the meal (see below). Forearm venous occlusion 
plethysmography will be measured every 3 hours (± 10 minutes for each measurement) during the 6 
hours after eating the meal. 
 
After completing the three study visits, subjects will be invited to participate in an optional, 
nonrandomized extension study.   For the extension study, subjects will take exenatide ER (extended- 
release exenatide) weekly for total of six weeks. This will start with a brief CRU visit, where subjects 
will be provided with exenatide ER (brand name “Bydureon”) pens and necessary education on dosing 
and administration.  Vital signs will be taken. A urine pregnancy test will be done if applicable. 
Subjects with prior history of pancreatitis, medullary thyroid cancer, or multiple endocrine neoplasia 
type 2 (MEN 2) will be excluded from this extension study. Subjects will receive monetary 
compensation for this screening visit ($25) 


Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
Approximately one week after completing the sixth and final dose of exenatide ER, the patient will be 
brought back to CRU after an overnight fast at approximately 0900. Similar to prior visits, peripheral 
venous access will be obtained in a stable vein in an upper extremity. A blood pressure cuff and a strain 
gauge will be placed at the widest part of the opposite forearm (to measure forearm blood flow via 
venous occlusion plethysmography). Baseline blood draws (described below) and forearm venous 
occlusion plethysmography will be performed at 1045 (± 10 minutes). No study medication will be given, 
as the exenatide ER has a long half-life (2 weeks). At 1100 (± 10 minutes), the participant will be fed an 
atherogenic high-fat test lunch equivalent to a McDonald’s® Big Mac meal. The standardized meal will 
be prepared by the Memorial Hermann TMC cafeteria. Peripheral venous blood will be drawn for 
analysis before the meal and at the 2 hour timepoint (± 10 minutes for each blood draw).  Forearm 
venous occlusion plethysmography will be measured before the meal and at 3 hours (± 10 minutes for 
each measurement).  After all measurements are completed (at 3 hours after the meal), the extension 
study is completed.  Subjects will receive monetary compensation for this visit ($75). 
 
The research aims will be addressed as follows: 
 
Specific Aim #1A: The effect of a single dose of exenatide or saxagliptin on serum free fatty acid (FFA) 
levels and FFA-induced cellular proinflammatory signaling. On the exenatide and saxagliptin studies, 
plasma levels of free fatty acids, high-sensitivity C-reactive protein, adiponectin, insulin, and glucose 
will be drawn at baseline and at every two hours (± 10 minutes) for up to 6 hours after ingestion of the 
meal. 
 
Blood will also be drawn at baseline and every 2 hours (± 10 minutes) after ingestion of meal for 
monocyte isolation. This blood will be processed by the CRU and in my lab at UTHSC. The processed 
samples will be analyzed by Quest Laboratories, my laboratory at UTHSC, and Dr. Taegtmeyer’s 
laboratory at UTHSC. All samples not analyzed by Quest will be stored in a -80°C freezer for later 
analyses described in Study Procedures. Also, a drop of blood will be analyzed at baseline and 2 
hours for blood cells counts and oxygen levels via a co-oximeter. The results will be analyzed by my 
laboratory and Dr. Qingchun Tong’s laboratory. 
 
 
Specific Aim #1B: The effect of a single dose of exenatide or saxagliptin on postprandial excursions of 
proatherogenic lipids and lipoproteins. On the exenatide and saxagliptin studies, plasma levels of 
triglycerides (TG), total cholesterol, apolipoprotein B-48, apolipoprotein C-III, remnant lipoprotein TG, 
and remnant lipoprotein cholesterol will be drawn at baseline and then at every two hours after 
ingestion of the meal. This blood will be processed at the CRU. Some of the blood will be analyzed by 
Quest Laboratories. The rest of the blood will be stored in a -80°C freezer; it will later be analyzed by 
my laboratory at UTHSC and Dr. Taegtmeyer’s laboratory at UTHSC. 
 
 
Specific Aim #2: The Effect of the Above Therapies on the Amelioration of Endothelial Dysfunction in 
Postprandial Hyperlipidemia. On all studies, endothelial dysfunction will be assessed via non-invasive 
venous occlusion strain gauge plethysmography (for the measurement of forearm blood flow), per the 
13 
method described by Skilton et al. 
hours after the meal. 
These measurements will be done at baseline and every three 
 
All above procedures will be repeated in the placebo study. 


Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
The entire trial will be completed in about three years. 40 subjects will need to complete the study (see 
Data Analysis Plan). To accomplish this, about 50 subjects will be consented. A 20% drop out rate may 
be expected for personal reasons alone. 
 
Efficacy Assessment: 
The primary efficacy objective is to determine whether a single dose of exenatide or saxagliptin 
compared with placebo will reduce levels of serum free fatty acids and disrupt FFA-induced 
proinflammatory signaling in monocytes during the postprandial period in patient with 
prediabetes. 
 
 
The  secondary  efficacy  objective  is  to  determine  whether  a  single  dose  of  exenatide  or 
saxagliptin compared with placebo will reduce levels of serum triglycerides during the 
postprandial period in patient with prediabetes. 
 
 
Other efficacy objectives are (1) to determine whether a single dose of exenatide or saxagliptin 
compared with placebo will reduce lipoprotein levels, and improve endothelial function during the 
postprandial period in patient with prediabetes, and (2) to determine if six weeks of exenatide ER 
treatment reduce levels of serum free fatty acids, disrupt FFA-induced proinflammatory signaling 
in monocytes, and will reduce levels of serum triglycerides during the postprandial period in 
patient with prediabetes. 
 
Safety Assessment: 
Study drug toxicities will be assessed throughout the study. Adverse events will be evaluated from the 
first dose of study medication while the patient is in the study, until 30 days after the last dose of 
study medication. Patients will be followed until all treatment-related adverse events have recovered 
to baseline or are deemed irreversible by the principal investigator. Patients will be monitored for the 
following adverse reactions related to each study drug: 
 
 
Exenatide (single dose): nausea, vomiting, hypoglycemia, diarrhea, and hypersensitivity-related 
reactions including skin rash (rare). Other risks listed in package insert would relate only to long-term 
use of this medication and are not expected for this study. 
 
 
Saxagliptin (single dose): nausea, vomiting, hypoglycemia, headache, minor upper respiratory 
infections, and hypersensitivity-related reactions including skin rash (rare). Other risks listed in package 
insert would relate only to long-term use of this medication and are not expected for this study. 
 
Exenatide ER (Six doses): nausea, vomiting, hypoglycemia, diarrhea, hypersensitivity-related reactions 
including skin rash (rare). A rare adverse event related to prolonged use of exenatide is pancreatitis. 
 
Study Population 
 
Inclusion Criteria: 
1. 
Men and women, ages 30 to 70 years of age inclusive 
2.           Diagnosis of Prediabetes - defined as either impaired fasting glucose (fasting glucose of 100-125 
mg/dL), impaired glucose tolerance (2-hour postprandial blood glucose of 140-199 mg/dL after 75 gram 
oral glucose challenge), and/or a hemoglobin A1C ranging from 5.7% to 6.4% 
3. 
Subjects are allowed, but not required, to be on statins, ACE-inhibitors, beta-blockers, 
angiotensin-receptor blockers, thiazide diuretics, and/or loop diuretics at doses that have been 
stable for at least the last 3 months 


Dr. Gutierrez 
Version 9.0, 01/07/16 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
 
4. 
BMI between 30-35 kg/m2 (±1 kg/m2) 
5. 
Body weight has been stable (±4-5 pounds) over the prior three months. 
6. 
Women  of  childbearing  age  must  agree  to  use  an  acceptable  method  of  pregnancy 
prevention (barrier methods, abstinence, or surgical sterilization) for the duration of the study 
7. 
Patients must have the following laboratory values: Hematocrit ≥ 34 vol% S. creatinine < 1.5 
mg/dl in men and 1.4 mg/dl in women AST (SGOT) < 2.5 times ULN, ALT (SGPT) < 2.5 times ULN, 
alkaline phosphatase< 2.5 times ULN 
 
Exclusion Criteria: 
1. 
History of Type 1 or Type 2 diabetes mellitus 
2. 
History of diabetic ketoacidosis or hyperosmolar nonketotic coma 
3. 
Pregnant or breastfeeding women 
4. 
Patients must not be receiving lipid-lowering medications other than statins within the last 3 
months 
5. 
Patient must not be receiving metformin, DPP-IV inhibitors, GLP-1 agonists, thiazolidinediones, 
insulin, sulfonylureas, acarbose, SGLT-2 inhibitors, corticosteroids, or immunosuppressive therapy within 
the last 3 months and cannot take them for the duration of the study. Patient must not be 
 
 
receiving NSAIDS or antioxidant vitamins within the last 1 week, and cannot take them for the 
duration of the study. 
6. 
Patients must not be on hormone replacement therapy. 
7. 
Patients with diabetic gastroparesis 
8. 
Patients with current tobacco use 
9. 
Patients with active malignancy 
10. 
Patients with history of urinary bladder cancer 
11. 
Patients with dietary restrictions precluding a high-fat meal 
12. 
Patients with a history of clinically significant heart disease (NYHA III or IV; more than non- 
specific ST-T wave changes on the EKG), peripheral vascular disease (history of claudication), or 
pulmonary disease (dyspnea on exertion of one flight or less; abnormal breath sounds on 
auscultation) will not be studied 
13. 
Subjects with a history of any serious hypersensitivity reaction to the study medications 
14. 
Prisoners or subjects who are involuntarily incarcerated 
15. 
Subjects who are compulsorily detained for treatment of either a psychiatric or physical 
(e.g., infectious disease) illness 
16. 
Subjects with known allergic reactions to the study medications or test meal 
17. 
Subjects unwilling or unable to provide informed consent 
18. 
Subjects determined by the investigator(s) to not be appropriate candidates for the study 
19. 
Subjects with prior history of pancreatitis, medullary thyroid cancer, or multiple endocrine neoplasia type 2 
(MEN 2) will be excluded from the extension study only. 


Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
For Recruitment 
 
Allscripts will be scanned for subjects meeting entry criteria. These subjects will then be 
contacted during their next clinic visit, with the approval of their physicians. The encounter is 
 
strictly voluntary on the patient’s behalf. 
 
 
CPHS approved newspaper advertisements will be used 
 
CPHS approved flyers will be posted at UT Health Sciences Center 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dr. Gutierrez 
IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
 
 
Version 9.0, 01/07/16 
 
Study Procedures 
 
Table 1: Time and Event Schedule for Required Protocol Procedures 
 
Procedure 
Visit 1 
(Screening) 
Visit 2 
Visit 3 
Visit 4 
Obtain Informed Consent 
X 
Confirm Eligibility 
X 
Medical History 
X 
X 
X 
X 
Concomitant 
Medications 
X 
X 
X 
X 
Physical Examination 
X 
X 
X 
X 
Vital Signs 
X 
X 
X 
X 
EKG 
X 
Pregnancy Test (if 
applicable) 
X 
X 
X 
X 
CMP – including FPG, 
LFTs, serum creatinine 
X 
Lipid panel (including 
serum TG and total 
cholesterol) 
X 
X 
X 
X 
HbA1C 
X 
CBC 
X 
FFA 
X 
X 
X 
hsCRP 
X 
X 
X 
Adiponectin 
X 
X 
X 
Glucose, Insulin 
X 
X 
X 
Monocyte isolation (for 
NfKB, TLR2, TLR4) 
X 
X 
X 
Apolipoproteins B-48, C- 
III 
X 
X 
X 
Remnant lipoproteins 
(TG, cholesterol) 
X 
X 
X 
Blood cell counts, oxygen 
levels 
X 
X 
X 
Venous Occlusion 
Plethysmography 
X 
X 
X 
Assess for Adverse 
Events 
X 
X 
X 
Administration of study 
drug/placebo 
X 
X 
X 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
There are 4 total required visits which will involve the procedures listed above. There are two 
optional visits (5 and 6) which are discussed later.  Visit 1 (screening visit) will take one hour. Visits 2, 
3, and 4 are the study visits. Each study visit (Visits 2, 3, and 4) will begin at about 0800 and end at 
about 1700. Each study visit will take place ≥ 10 days apart to ensure sufficient washout of each study 
medication. The three visits, however, must all be completed in period of no longer than four months. 
Weight will be measured at each study visit. 
 
In visit 1, a total of 20 cc of blood will be drawn for screening labs. The blood drawn at these visits 
will be analyzed by Quest Laboratories. 
 
In visits 2 through 4, there will be four blood draws per visit. The first two blood draws require 40 cc of 
of blood each and the last two blood draws require 20 cc of blood. Hence, for each study visit (Visit 2-4) 
there will be 120 cc of blood will be drawn. About 20 cc of urine will be collected for urine pregnancy 
test in women of childbearing potential, at every visit (Visits 1-4). For these visits, the free fatty acids 
(FFA), hsCRP, insulin, glucose, and urine pregnancy will be analyzed by Quest Laboratories. The lipid 
panels after the approval of this protocol revision will also be analyzed by Quest Laboratories. The lipid 
panels (prior to the approval of this protocol revision), adiponectin, apolipoproteins B48 and C-III, 
remnant lipoproteins, and monocytes (NfKB), TLR2, and TLR4) will be analyzed by both Dr. Heinrich 
Taegtmeyer’s laboratory at UTHSC and my laboratory at UTHSC. Blood cell counts and oxygen levels 
will be analyzed by my laboratory and Dr. Qingchun Tong’s laboratory. These changes were made due 
to the heavy time burden and costs in analyzing these labs.\ 
We will gather the information listed in the above table. 
Visit 5 is the first optional visit for subjects who choose to participate in the extension study.  This 
consists of a brief CRU visit, where subjects will be provided with exenatide ER (brand name 
“Bydureon”) pens and necessary education on dosing and administration. Vital signs will be taken. 
About 20 cc of urine will be collected for urine pregnancy test in women of childbearing potential. 
Subjects with prior history of pancreatitis, medullary thyroid cancer, or multiple endocrine neoplasia 
type 2 (MEN 2) will not participate in this this extension study. 
 
 
Visit 6 is the second optional visit for subjects who choose to participate in the extension study.  This 
visit will begin at about 0900 and end at about 1300. There will be two blood draws, each requiring 40 
cc of blood.  About 20 cc of urine will be collected for urine pregnancy test in women of childbearing 
potential. For this visit, the free fatty acids (FFA), hsCRP, insulin, glucose, and urine pregnancy will be 
analyzed by Quest Laboratories. The lipid panels after the approval of this protocol revision will also be 
analyzed by Quest Laboratories. The lipid panels (prior to the approval of this protocol revision), 
adiponectin, apolipoproteins B48 and C-III, remnant lipoproteins, and monocytes (NfKB), TLR2, and 
TLR4) will be analyzed by both Dr. Heinrich Taegtmeyer’s laboratory at UTHSC and my laboratory at 
UTHSC. Blood cell counts and oxygen levels will be analyzed by my laboratory and Dr. Qingchun Tong’s 
laboratory. 
 
All data will be recorded in file folders and binders, which will be stored in the Clinical Research Unit 
in locked, secure cabinets which will only be accessible to the PI and his team. 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
al. 
 
Plasma free fatty acid (FFA) concentration will be determined by an enzymatic calorimetric 
quantification method. High-sensitivity CRP (hsCRP) will be determined by an immunoluminometric 
method. Plasma adiponectin concentration will be measured by ELISA. Plasma insulin is measured by 
radioimmunoassay. Plasma glucose is measured by an automated glucose analyzer. Plasma 
triglycerides and cholesterol are determined using a colorimetric method. Serum concentration of 
apolipoprotein B-48 (ApoB48) will be measured by ELISA. Plasma apolipoprotein C-III (ApoCIII) will be 
measured on an automated colorimetric immunoassay. Remnant –like particles of cholesterol and 
triglyceride will be isolated from plasma using an immunoaffinity assay, then measured using 
aforementioned methods for plasma cholesterol and triglycerides. Blood cell counts and oxygen levels 
will be analyzed via co-oximetry. 
 
For mononuclear cells (monocytes), there is a specific isolation technique. Blood samples will be 
collected in EDTA tubes and layered on a density gradient cell separation medium. Samples will 
centrifuged serially to yield a pellet of mononuclear cells. For Western blotting, mononuclear cell 
lysates will be prepared, electrophoresed, and immunoblotted. Mononuclear antibodies against NfKb 
(p65), TLR2, TLR4 and actin will be used and all values will be corrected for loading to actin. 
 
Venous occlusion plethysmography will be performed per the method described by Skilton et 
13 
 
Serum and plasma specimens will be stored in a -80 degrees C freezer for no more than 6 years. The 
samples will be stored while waiting processing. Any unused sample may be used for future studies if 
the subject consents to this. The freezer will be locked an accessible only to the PI and his team. 
 
Data and Safety 
Monitoring Adverse Event 
All adverse events, including those that are serious, will be graded by the investigator as follows: 
 
 
Mild (Grade 1): awareness of event but easily tolerated 
 
Moderate (Grade 2): discomfort enough to cause some interference with usual activity 
 
 
Severe (Grade 3): inability to carry out usual activity 
 
Very    Severe   (Grade    4):    debilitating;    significantly    incapacitates    subject   despite 
symptomatic therapy. 

The following categories and definitions of causal relationship to a study medication as determined by 
a physician should be used: 
 
Related: There is a reasonable causal relationship to study medication administration and 
 
the adverse event. 
 
Not   Related:   There   is   not   a   reasonable   causal   relationship   to   study   medication 
administration and the adverse event. 
 
The expression “reasonable causal relationship” is meant to convey in general that there are facts 
(e.g., evidence such as de challenge/re challenge) or other arguments to suggest a positive causal 
relationship. 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
Collection and Reporting 
Adverse events can be spontaneously reported or elicited during open-ended questioning, 
examination, or evaluation of a subject. To prevent reporting bias, subjects should not be questioned 
regarding the specific occurrence of one or more adverse events. 
 
 
If known, the diagnosis of the underlying illness or disorder should be recorded, rather than its individual 
symptoms. The following information should be captured for all AEs: onset, duration, intensity, 
seriousness, relationship to investigational product, action taken, and treatment required. If treatment 
for the event was administered, it should be recorded in the medical record. The investigator must 
supply the IRB with any additional information requested, notably for reported deaths of subjects. 
 
Serious Adverse Events 
Following the subject’s written consent to participate in the study, all SAEs, whether related or not 
related to study drug, must be collected, including those thought to be associated with protocol- 
specified procedures. All SAEs must be collected that occur during the screening period and within 30 
days of discontinuation of dosing. If applicable, SAEs must be collected that relate to any later 
protocol-specified procedure. The investigator should report any SAE occurring after these time 
periods that is believed to be related to study drug or protocol-specified procedure. 
An SAE report should be completed for any event where doubt exists regarding its status of 
seriousness. If the investigator believes that an SAE is not related to study drug, but is potentially 
related to the conditions of the study (such as withdrawal of previous therapy, or a complication of a 
study procedure), the relationship should be specified in the narrative section of the SAE Report Form. 
All SAEs, whether related or unrelated to study medications, and all pregnancies must be reported to 
the University of Texas (UT) Health Sciences Center at Houston IRB within 24 hours of study 
personnel becoming aware of the event. If only limited information is initially available, follow-up 
reports are required. The original SAE form must be kept on file at the study site. 
All SAEs should be reported to the UT Health Sciences Center at Houston IRB. 
Safety Monitoring 
 
 
The PI and his team will monitor the study at each visit. All treatment-emergent AEs will be recorded on 
source documents (i.e. original documents, data, and records). AEs include those reported 
spontaneously by the subject and those noted incidentally or as observed by the investigator or study 
personnel. All clinically significant abnormalities noted upon physical examination, or other diagnostic 
test results should be reported as an AE, except for baseline measurements that may be considered 
part of the medical history. In addition, all clinically significant AEs that continue at Study Termination 
will be followed up by the investigator and evaluated with additional tests if necessary, until the 
underlying cause is diagnosed or resolution occurs. All AEs will be evaluated for intensity and causal 
relationship with use of the study medication and/or study procedures by the investigator and reported 
to the UT Health Sciences Center at Houston IRB. All SAEs will be reported to the UT Health Sciences 
Center at Houston IRB and the sponsor within 24 hours. In addition, a safety report will be submitted to 
the IRB annually. Any new information regarding exenatide or saxagliptin will be submitted the IRB. 
 
Pregnancy 
Women of childbearing potential (WOCBP) must use an acceptable method of birth control (as described 
above) during the course of the study, in such a manner that the risk of failure is minimized. 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
All WOCBP MUST have a negative urine pregnancy test before receiving any study medications. A urine 
pregnancy test will be done at the beginning of each study day. If the urine pregnancy test is positive, 
the subject must not receive the study medication or any study procedures that day. The subject must 
see her primary care physician or OB/GYN physician for further evaluation. If pregnancy is confirmed by 
this medical provider, the subject will be discontinued from the study. If the medical provider 
determines that the subject is not pregnant, the subject is allowed to resume the study on a later date. 
 
 
In addition, all WOCBP must be instructed to contact the investigator and/or other study personnel 
immediately if they suspect they might be pregnant (e.g., missed or late menstrual period) at any 
time during study participation. 
 
 
If, following initiation of the study medication, it is subsequently discovered that a study subject is 
pregnant or may have been pregnant at the time of study medication exposure, including at least 6 half- 
lives after medication administration, the subject will be discontinued from the study. The subject must 
establish or continue care with a qualified primary care or OB/GYN physician. A single dose of any of the 
study medications is not expected to have a significant impact on a pregnancy, but the pregnancy should 
be monitored by the above medical provider. 
 
The investigator must immediately notify the UTHSC CPHS in accordance with CHPS 
reporting procedures. 
 
Statistics 
For univariate analysis, we will conduct Student’s t-tests/ANOVA, or their nonparametric equivalents, as 
appropriate for the comparison among the groups. Variables with highly skewed distribution will be 
transformed such as natural log scale before the analysis. The models will be developed to evaluate the 
effect of medications for each of three Specific Aims. The response of metabolic markers and 
endothelial function (as measured by forearm blood flow) to different medications (exenatide, 
sitagliptin, or placebo), over time, will be analyzed using mixed effects model or generalized estimating 
equation (GEE) model that accounts for correlation of repeated measures over time in crossover design 
(please see paragraph below for a description of primary analyses and main 
time points of interest). A secondary consideration will be interaction effects, which will be also 
examined during regression model construction. All analyses will perform using SAS 9.3 (SAS 
Institute, Cary, NC, USA) assuming statistical significance at P<0.05. 
 
 
For Specific Aim #1 – the primary outcome measure is free fatty acid (FFA) level, and the main time 
points of interest are baseline and 6 hours. A key secondary outcome measure for the same specific 
aims is triglyceride level, of which the main time points of interest are also baseline and 6 hours. 
Specific Aim #2 reflects largely exploratory work; all pertinent data (measurements of endothelial 
function) will be considered secondary outcomes. At this time, there is no reported effect size between 
venous occlusion plethysmography regarding placebo and exenatide, at baseline and 6 hours. The goal 
for Specific Aim #2 is to determine the effect size (between baseline and 6 hours) between groups – 
which will be ascertained after testing the first 20 subjects. Furthermore, we will have two nurses 
assessing identical measurements, in order to assess inter-rater reliability. 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
The sample size calculation is based on free fatty acid (FFA) levels being the primary outcome measure 
for this study, using the time points of baseline and 6 hours. Based on the reported effect sizes for fatty 
acids (in regard to both placebo and exenatide, prior to the meal and at the end of the post meal period) 
9 
from Schwartz, 40 subjects will provide >90% power to detect an effect size of 2.5 SDs. Regarding a key 
secondary outcome - triglyceride levels at baseline and 6 hours – Koska’s data (10; Supplemental Table 
2) shows that if we assume a 1.1 change for placebo and a 0.3 change for exenatide and assuming an 
SD=0.9 at each time point (prior to the meal and at the end of the post meal period), 40 subjects will 
provide 80% power to detect this difference (effect size=0.8/1.1=0.7). As stated above, measurements of 
endothelial function (at baseline and 6 hours) reflect secondary outcomes, and an effect size will be 
ascertained after testing the first 20 subjects. 
 
Ethics 
This study will be conducted in accordance with Good Clinical Practice (GCP), as defined by the 
International Conference on Harmonization (ICH) and in accordance with the ethical principles 
underlying European Union Directive 2001/20/EC and the United States Code of Federal 
Regulations, Title 21, Part 50 (21CFR50). 
 
 
The study will be conducted in compliance with the protocol. The protocol, any amendments, and the 
subject informed consent will receive University of Texas Health Science Center at Houston Committee for 
the Protection of Human Subjects (IRB) approval/favorable opinion before initiation of the study. 
 
 
All potential serious breaches must be reported to the IRB immediately. A serious breach is a breach 
of the conditions and principles of GCP in connection with the study or the protocol, which is likely to 
affect, to a significant degree, the safety or physical or mental integrity of the subjects of the study or 
the scientific value of the study. 
 
 
Study personnel involved in conducting this study will be qualified by education, training, and 
experience to perform their respective tasks. This study will not use the services of study personnel 
where sanctions have been invoked or where there has been scientific misconduct or fraud (e.g., 
loss of medical licensure; debarment). 
 
Institutional Review Board 
 
Before study initiation, the investigator will have written and dated approval/favorable opinion from 
the IRB for the protocol, consent form, subject recruitment materials/process (e.g., advertisements), 
and any other written information to be provided to subjects. 
 
Informed Consent 
The investigators will ensure that subjects are clearly and fully informed about the purpose, potential 
risks, and other critical issues regarding clinical studies in which they volunteer to participate. Freely 
given written informed consent must be obtained from every subject before clinical study 
participation, including informed consent for any screening procedures conducted to establish subject 
eligibility for the study. 
Investigators must: 
1)   Provide a copy of the consent form and written information about the study in the language in 
which the subject is most proficient prior to clinical study participation. The language must be 
non-technical and easily understood. 
2)   Allow time necessary for subject to inquire about the details of the study. 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
3)   Obtain an informed consent signed and personally dated by the subject and by the person 
who conducted the informed consent discussion. 
4)   Obtain the IRB’s written approval/favorable opinion of the written informed consent form and any 
other information to be provided to the subjects, prior to the beginning of the study, and after any 
revisions are completed for new information. 
5)   Revise the informed consent whenever important new information becomes available that is 
relevant to the subject's consent. The investigator, or a person designated by the investigator, 
should  fully  inform  the  subject  of  all  pertinent  aspects  of  the  study  and  of  any  new 
information relevant to the subject's willingness to continue participation in the study. This 
communication should be documented. 
 
 
The rights, safety, and well-being of the study subjects are the most important considerations 
and should prevail over interests of science and society. 
 
 
 
Data handling and record keeping 
The PI will retain, in a confidential manner, all data pertinent to the study for all subjects. All data will 
be recorded in file folders and binders, which will be stored in the Clinical Research Unit in locked, 
secure cabinets which will only be accessible to the PI and his team. The PI and his team will retain 
source documents and accurate case histories that record all observations and other data pertinent to 
the investigation (e.g., the medical record) for the maximum period required by applicable regulations 
and guidelines or following institutional procedures. The PI will have direct access to subjects’ identity; 
however, other team members will know the encoded identifying information. Data will be linked to 
subjects via a study identification code. 
 
 
A record of the disposition of study drugs is will be maintained at the Memorial Hermann Central 
Pharmacy, where the study drugs will be stored. This will also be the site of blinding of medications. 
 
Quality control and assurance 
An annual report will be delivered to the Center for Clinical and Translational Sciences to assure that this 
clinical trial is progressing appropriately. A statistician will work with us to assure that assure that the 
data collected are accurate, consistent, complete and reliable. There are no plans for third-party 
monitoring. 
 
Publication Plan 
This research will result in publication of two papers by the end of the third year of the study. Data at 
screening is available to research subjects immediately after screening. All other data will not be 
available to subjects until after completion of the study. This takes into account the blinded nature of 
the protocol. 


IRB NUMBER: HSC-MS-13-0791 
IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
References 
 
 
1. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart 
disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior 
myocardial infarction. N Engl J Med. 1998 Jul 23;339:229-34. 
 
 
2. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications 
in veterans with type 2 diabetes. N Engl J Med. 2009 Jan 8;360:129-39. 
 
 
3. ADVANCE Collaborative Group, Patel A, MacMahon S, et al. Intensive blood glucose control 
and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008 Jun 12;358:2560- 
72. 
 
4. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. 
Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008 Jun 12;358:2545- 
59. 
 
5. Nordestgaard BG, Benn M, Schnohr P, Tybjaerg-Hansen A. Nonfasting triglycerides and risk 
of myocardial infarction, ischemic heart disease, and death in men and women. JAMA. 2007 
Jul 18;298:299-308. 
 
 
6. Freiberg JJ, Tybjaerg-Hansen A, Jensen JS, Nordestgaard BG. Nonfasting triglycerides 
and risk of ischemic stroke in the general population. JAMA. 2008 Nov 12;300:2142-52. 
 
 
7. Eberly LE, Stamler J, Neaton JD, Multiple Risk Factor Intervention Trial Research 
Group. Relation of triglyceride levels, fasting and nonfasting, to fatal and nonfatal coronary 
heart disease. Arch Intern Med. 2003 May 12;163:1077-83. 
 
 
8. Bansal S, Buring JE, Rifai N, Mora S, Sacks FM, Ridker PM. Fasting compared 
with nonfasting triglycerides and risk of cardiovascular events in women. JAMA. 2007 
Jul 18;298:309-16. 
 
 
9. Schwartz EA, Koska J, Mullin MP, Syoufi I, Schwenke DC, Reaven PD. Exenatide suppresses 
postprandial elevations in lipids and lipoproteins in individuals with impaired glucose tolerance and 
recent onset type 2 diabetes mellitus. Atherosclerosis. 2010 Sep;212:217-22. 
 
 
10. Koska J, Schwartz EA, Mullin MP, Schwenke DC, Reaven PD. Improvement of 
postprandial endothelial function after a single dose of exenatide in individuals with impaired 
glucose tolerance and recent-onset type 2 diabetes. Diabetes Care. 2010 May;33:1028-30. 
 
 
 
11. Chaudhuri A, Ghanim H, Vora M, et al. Exenatide exerts a potent antiinflammatory effect. 
J Clin Endocrinol Metab. 2012 Jan;97:198-207. 
 
 
12. Makdissi A, Ghanim H, Vora M, et al. Sitagliptin exerts an antinflammatory action. J 
Clin Endocrinol Metab. 2012 Jun 28. 


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IRB APPROVAL DATE: 02/18/2016 
Dr. Gutierrez 
Version 9.0, 01/07/16 
 
 
 
13. Skilton MR, Sieveking DP, Harmer JA, et al. The effects of obesity and non- 
pharmacological weight loss on vascular and ventricular function and structure. Diabetes Obes 
Metab. 2008 Sep;10:874-84. 
 
 
14. Gutierrez AD, de Serna DG, Robinson I, Schade DS. The response of gamma vitamin E 
to varying dosages of alpha vitamin E plus vitamin C. Metabolism. 2009 Apr;58:469-78. 
 
 
15. Eliasson B, Moller-Goede D, Eeg-Olofsson K, et al. Lowering of postprandial lipids in 
individuals with type 2 diabetes treated with alogliptin and/or pioglitazone: A randomised 
double-blind placebo-controlled study. Diabetologia. 2012 Apr;55:915-25. 
 
 
16. Patel C, Ghanim H, Ravishankar S, et al. Prolonged reactive oxygen species generation 
and nuclear factor-kappaB activation after a high-fat, high-carbohydrate meal in the obese. J 
Clin Endocrinol Metab. 2007 Nov;92:4476-9. 
 
 
17. Shimabukuro M, Chinen I, Higa N, Takasu N, Yamakawa K, Ueda S. Effects of dietary 
composition  on  postprandial  endothelial  function  and  adiponectin  concentrations  in 
healthy humans: A crossover controlled study. Am J Clin Nutr. 2007 Oct;86:923-8. 
 
 
18. Anderson TJ, Uehata A, Gerhard MD, et al. Close relation of endothelial function in the 
human coronary and peripheral circulations. J Am Coll Cardiol. 1995 Nov 1;26:1235-41. 
 
 
19. Takase B, Uehata A, Akima T, et al. Endothelium-dependent flow-mediated vasodilation 
in coronary and brachial arteries in suspected coronary artery disease. Am J Cardiol. 1998 
Dec 15;82:1535,9, A7-8. 
 
 
20. Taegtmeyer H, McNulty P, Young ME. Adaptation and maladaptation of the heart 
in diabetes: Part I: General concepts. Circulation. 2002;105:1727-33. 
 
 
21. Harmancey R, Wilson CR, Taegtmeyer H. Adaptation and maladaptation of the heart 
in obesity. Hypertension. 2008;52:181-7. 
 
 
22. Jialal I, Bajaj 
M. 
DPP-4 inhibitors 
and atherosclerosis: 
The 
promise. 
Atherosclerosis. 2013;227:224-5. 
 
 
23. Barbieri M, Rizzo MR, Marfella R, et al. Decreased carotid atherosclerotic process by 
control of daily acute glucose fluctuations in diabetic patients treated by DPP-IV inhibitors. 
Atherosclerosis. 2013;227:349-54. 
 
 
24. Schwartz EA, Reaven PD. Lipolysis of triglyceride-rich lipoproteins, 
vascular 
inflammation, and atherosclerosis. Biochim Biophys Acta. 2012 May;1821:858-66.