Clinical trial NCT02324842
Conditions: Type 2 Diabetes Mellitus
Sponsor: The University of Texas Health Science Center at San Antonio
Start date: 2014-11-01; Completion date: 2019-03-31
Enrollment: 45 participants; Allocation: RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
Specific Aim 1.To examine whether the combination of liraglutide plus canagliflozin can prevent the increase in Hepatic Glucose Production (HGP) following institution of canagliflozin therapy and produce an additive or even synergistic effect to lower the plasma glucose concentration and A1c.

Specific Aim 2: To examine whether combination therapy with liraglutide plus canagliflozin can produce an additive, or even synergistic, effect to promote weight loss and reduction in hepatic and visceral fat content.

Specific Aim 3. To examine whether combination therapy with liraglutide plus canagliflozin can produce an additive or even synergistic effect to reduce systolic/diastolic blood pressure and 24-hour integrated blood pressure.

Detailed description:
Specific Aim 1.To examine whether the combination of liraglutide plus canagliflozin can prevent the increase in HGP following institution of canagliflozin therapy and produce an additive or even synergistic effect to lower the plasma glucose concentration and A1c. We will examine this hypothesis by comparing the effect of administration of liraglutide alone, canagliflozin alone, and the combination of liraglutide plus canagliflozin on:(i) the rate of HGP; (ii) decrease in fasting plasma glucose concentration; (iii) counter-regulatory hormone response and (iv) A1c. We anticipate that the addition of liraglutide to canagliflozin will prevent the increase in plasma glucagon concentration, augment insulin secretion, and blunt/block the increase in HGP in response to canagliflozin, resulting in a greater decrease in fasting plasma glucose concentration and A1c than observed with each therapy alone.

Specific Aim 2: To examine whether combination therapy with liraglutide plus canagliflozin can produce an additive, or even synergistic, effect to promote weight loss and reduction in hepatic and visceral fat content.

Specific Aim 3. To examine whether combination therapy with liraglutide plus canagliflozin can produce an additive or even synergistic effect to reduce systolic/diastolic blood pressure and 24-hour integrated blood pressure.

Arms: arm 1: canagliflozin (film-coated tablet), 100 mg/day, increased to 300 mg/day after week two if tolerated without side effects arm 2: liraglutide, 1.2 mg/day, increased to 1.8 mg/day after week two if tolerated without side effects arm 3: canagliflozin, 100 mg/day, plus liraglutide, 1.2 mg/day, increased to 300 mg/day and 1.8 mg/day, respectively at week two, if tolerated without side effects
Interventions: intervention 1: Canagliflozin intervention 2: Liraglutide
Intervention descriptions: intervention 1: Canagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (1) intervention 2: Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Protocol documents:
Prot_SAP_000.pdf: 
 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
1 
V3    08/11/16 
COVER PAGE FOR PROTOCOL AND STATISTICAL ANALYSIS PLAN 
 
 
 
Official Study Title: Effect of Combined Incretin-Based Therapy Plus 
Canagliflozin on Glycemic Control and the Compensatory Rise in 
Hepatic Glucose Production in Type 2 Diabetic Patients  
 
 
NCT number: NCT02324842 
 
IRB Approval Date: 03/19/2018 
 
Unique Protocol ID: 28431754DIA4009 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
2 
V3    08/11/16 
 
 
 
 
Collaborative Protocol supported by Janssen Scientific Affairs, LLC (funding and 
canagliflozin). 
Sponsor-Investigator:  Eugenio Cersosimo, MD, University of Texas Health Science Center 
Co-Investigator: Ralph DeFronzo, MD, University of Texas Health Science Center 
 
28431754DIA4009 
Effect of Combined Incretin-Based Therapy Plus Canagliflozin on Glycemic Control and 
the Compensatory Rise in Hepatic Glucose Production in Type 2 Diabetic Patients  
 
 
 
RATIONALE: Endogenous (primarily hepatic) glucose production (HGP) plays a central 
role in the maintenance of normal glucose homeostasis and impaired regulation of HGP plays a 
pivotal role in the development of fasting and postprandial hyperglycemia in type 2 diabetes (1-
9).Because the liver is responsible for the majority (>80%) of HGP, it has become an important 
target for antidiabetic therapy (10).  
 
HGP is under tight hormonal control (11-14). Insulin is the primary regulator of HGP and 
a small increase in plasma insulin concentration strongly suppresses HGP (13). Conversely, 
glucagon and other counter-regulatory hormones (catecholamines, cortisol and growth hormone) 
stimulate HGP (14). The plasma glucose concentration also is a strong regulator of HGP, and an 
increase in the plasma glucose concentration, independent of plasma insulin and glucagon 
concentrations, strongly inhibits HGP(14). Conversely, hypoglycemia is a powerful stimulator of 
HGP (15).  
 
SGLT2 inhibitors represent a novel class of drugs which inhibit the renal sodium-glucose 
cotransporter 2 (SGLT2), produce glucosuria and decrease the plasma glucose concentration (16). 
The urinary glucose loss also promotes weight loss (16). Despite the large glucosuria produced by 
SGLT2 inhibitors and the accompanying weight loss, the decrease in HbA1c brought about SGLT2 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
3 
V3    08/11/16 
inhibitors is less than expected. For example, canagliflozin an SGLT2 inhibitor approved as an 
adjunct to diet and exercise to improve glycemic control in adults with  T2DM, promotes a urinary 
glucose loss of ~70-90 grams per day, but it only decreases HbA1c by ~0.6-0.8% (17). Therefore, 
we hypothesized that the glucosuria produced by SGLT2 inhibition stimulates compensatory 
mechanisms that act to raise the plasma glucose concentration and compensate for (oppose) the 
urinary glucose loss. To test this hypothesis, we examined the effect of glucosuria produced by 
dapagliflozin administration on the rate of HGP in T2DM individuals. Administration of 
dapagliflozin (10 mg/day) produced glucosuria (~3 gram/hour) and reduced the fasting plasma 
glucose (FPG) concentration by 37 mg/dl (see preliminary results). Because of the close 
relationship between the FPG and HGP, we anticipated that the decrease in FPG produced by the 
induction of glucosuria would be accompanied by a parallel decrease in HGP. However, to our 
surprise, following an initial decline in HGP, the decrease in FPG concentration was associated 
with a paradoxical increase in HGP. This suggests the presence of a “compensatory” mechanism 
in which loss of glucose in the urine and the accompanying decrease in plasma glucose 
concentration following dapagliflozin administration triggers an increase in HGP in an attempt to 
maintain the plasma glucose concentration at its fasting hyperglycemic level(18). The increase in 
HGP following dapagliflozin administration was associated with an increase in plasma glucagon 
concentration which was closely related to the increase in HGP. Because glucosuria results in 
decreased return of glucose from the glomerular filtrate to the renal vein, it results in widening the 
glucose A-V difference across the kidney and this could provide a signal to the CNS to stimulate 
(directly or indirectly via glucagon secretion) HGP to compensate for urinary glucose loss. 
Alternatively, the increase in glucagon secretion could represent the response to the acute decline 
in FPG concentration induced by dapagliflozin. Whatever the mechanism(s), our findings indicate 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
4 
V3    08/11/16 
the presence of a “reno-hepatic” interaction that participates in the regulation of plasma glucose 
concentration. The primary aim of the present study is to examine whether the combination of 
incretin-based therapy, liraglutide, plus canagliflozin can block the compensatory increase in HGP, 
augment the decrease in plasma glucose concentration produced by canagliflozin, and enhance the 
decline in A1c.   
 
Canagliflozin, like other SGLT2 inhibitors, is associated with weight loss and a reduction 
in systolic blood pressure (17,19).  The weight loss amounts to ~2.5 kg during the first year and 
plateaus thereafter, without any attenuation of the drug’s glucosuric effect.  This suggests a 
resetting of the appetite regulation center in the hypothalamus, leading to an increase in caloric 
intake that negates the loss of glucose calories in the urine.  GLP-1 receptor agonists bind to the 
GLP-1 receptor in the hypothalamus, causing appetite suppression and weight loss.  We 
hypothesize that combined liraglutide-canagliflozin treatment will result in additive, even 
synergistic, decreases in body weight, hepatic fat content, and visceral fat content in type 2 diabetic 
patients. 
 
Canagliflozin also reduces systolic (by 4-5 mmHg), and to a lesser extent diastolic (by 1-2 
mmHg), blood pressure (17).  The decline in blood pressure is evident within the initial 2-4 weeks 
of treatment and most likely is related to the mild intravascular volume depletion associated with 
the natriuretic action of canagliflozin.  GLP-1receptor agonists also possess natriuretic properties 
(20), improve endothelial dysfunction by augmenting release of the potent vasodilator nitric oxide 
(21), and cause a modest reduction in blood pressure (21).  Therefore, one might expect 
combination therapy with liraglutide plus canagliflozin to have an additive, even synergitic, effect 
to reduce systolic/diastolic blood pressure and in the present study we will examine the 
hypotensive action of combined therapy with canagliflozin plus liraglutide. 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
5 
V3    08/11/16 
 
The SPECIFIC AIMS of the study are: 
 
Specific Aim 1.To examine whether the combination of liraglutide plus canagliflozin 
can prevent the  increase in HGP following institution of canagliflozin therapy and produce 
an additive or even synergistic effect to lower the plasma glucose concentration and A1c. We 
will examine this hypothesis by comparing the effect of administration of liraglutide alone, 
canagliflozin alone, and the combination of liraglutide plus canagliflozin on:(i) the rate of HGP; 
(ii) decrease in fasting plasma glucose concentration; (iii) counter-regulatory hormone response 
and (iv) A1c. We anticipate that the addition of liraglutide to canagliflozin will prevent the increase 
in plasma glucagon concentration, augment insulin secretion, and blunt/block the increase in HGP 
in response to canagliflozin, resulting in a greater decrease in fasting plasma glucose concentration 
and A1c than observed with each therapy alone.     
 
Specific Aim 2:  To examine whether combination therapy with liraglutide plus 
canagliflozin can produce an additive, or even synergistic, effect to promote weight loss and 
reduction in hepatic and visceral fat content. 
 
Specific Aim 3. To examine whether combination therapy with liraglutide plus 
canagliflozin can produce an additive or even synergistic effect to reduce systolic/diastolic blood 
pressure and 24-hour integrated blood pressure.  
Background:  
 
Endogenous (primarily hepatic) glucose production (HGP) plays a central role in the 
maintenance of glucose homeostasis and impaired regulation of HGP plays a pivotal role in the 
development of both fasting and postprandial hyperglycemia in patients with type 2 diabetes 
mellitus (T2DM) (1-9). 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
6 
V3    08/11/16 
 
The tissues/mechanisms responsible for the regulation of glucose metabolism during the 
fasting state, e.g. after an overnight fast, are very different than those responsible for the regulation 
of the plasma glucose concentration following glucose ingestion, e.g. after a mixed meal (1). After 
an overnight fast, tissue glucose uptake (~2 mg/kg.min) is closely matched by the rate of HGP 
(3,9). The rate of HGP is under tight hormonal control (11-14). Insulin is the primary determinant 
of basal HGP, and a small increase in the portal plasma insulin concentration markedly suppresses 
HGP (13).Conversely, glucagon is a strong stimulator of HGP and an increase in the portal 
glucagon concentration augments HGP (11,12,14,22).  
 
The plasma glucose concentration also is an important regulator of HGP (23-27). Studies 
with the pancreatic clamp technique have demonstrated that hyperglycemia strongly inhibits HGP 
in the absence of changes in plasma insulin and glucagon concentrations (26). Conversely, 
hypoglycemia strongly activates HGP (15). Thus, changes in the plasma glucose concentration can 
affect HGP both directly and indirectly via alterations in both insulin and glucagon secretion.  
 
Suppression of HGP by hyperinsulinemia and hyperglycemia following glucose ingestion 
is a critical determinant of postprandial hyperglycemia (26,29,30. Thus, glucose balance across 
the liver (uptake versus production) is an important factor which determines the rise in postprandial 
plasma glucose concentration.  
Subjects with T2DM manifest severe hepatic insulin resistance and an increased rate of basal HGP, 
leading to fasting hyperglycemia (1). Excessive glucagon secretion also contributes to accelerated 
rate of HGP in T2DM patients (1,11). Numerous clinical studies have demonstrated that the rise 
in basal HGP is the principal factor responsible for the increase in FPG concentration in T2DM 
subjects (1-3,5,6,).  


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
7 
V3    08/11/16 
 
Canagliflozin is a member of a new class of antidiabetic drugs and recently has been 
approved by the FDA for the treatment of T2DM. Canagliflozin lowers the plasma glucose 
concentration by inhibiting the SGLT2 transporter and producing glucosuria (17). Because SGLT2 
inhibitors produce urinary glucose loss, they also promote weight loss (17). Clinical studies have 
demonstrated that canagliflozin promotes the excretion of ~70-90 grams of glucose per day and 
results in a weight loss of 2.5-3 kg during the first 6-12 months of therapy (31,32). Despite the 
significant weight loss and large glucosuria produced by canagliflozin, the decrease in HbA1c 
caused by the drug is modest. Clinical studies have reported that a maximal dose of canagliflozin 
and other SGLT2 inhibitors cause only a 0.6-0.8% decrease in HbA1c in drug naïve T2DM 
diabetic subjects and in diabetic patients treated with metformin, sulfonylureas or pioglitazone 
(31-42)(reviewed in ref #43). Thus, we hypothesize that the glucosuria produced by canagliflozin 
stimulates a compensatory response in glucose homeostasis that offsets the urinary glucose loss in 
an attempt to maintain the plasma glucose concentration constant at its fasting level.   
 
Results from our lab(see below) demonstrate that the SGLT2 inhibitor dapagliflozin (10 
mg) produces significant glucosuria and decreases the fasting plasma glucose concentration. 
Because of the strong correlation between the basal rate of HGP and the fasting plasma glucose 
concentration (4),we anticipated that the decrease in FPG concentration brought about 
dapagliflozin in T2DM patients would be accompanied by a decline in HGP. In contrast, the 
decrease in FPG produced by dapagliflozin was accompanied by a paradoxical increase in the 
rate of HGP. The increase in HGP in response to glucosuria suggests the presence of a “reno-
hepatic” interaction in the regulation of glucose metabolism. In normal glucose tolerant (NGT) 
individuals, a “reno-hepatic axis” that leads to a compensatory increase in HGP in response to 
urinary glucose loss and maintains the plasma glucose concentration can be viewed as beneficial 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
8 
V3    08/11/16 
because it prevents the development of hypoglycemia. However, this “compensatory” increase in 
HGP in T2DM individuals is paradoxical because it occurs while the plasma glucose concentration 
is well within the hyperglycemic range, and quantitatively offsets the reduction in plasma glucose 
concentration in response to the glucosuric effect of the SGLT2 inhibitor. Delineation of the 
mechanisms responsible for the “paradoxical” increase in HGP produced by glucosuria (i) will 
improve our understanding of the regulation of glucose homeostasis, and (ii) has important clinical 
implications. Thus, if the rise in HGP in response to glucosuria can be blocked, the decrease in 
plasma glucose concentration produced by SGLT2 inhibitors can be enhanced. We hypothesize 
that the combination of an SGLT2 inhibitor with incretin-based therapy, which stimulates insulin 
and inhibits glucagon secretion (43,44), will block the paradoxical rise in HGP and augment the 
ability of the  SGLT2 inhibitor to lower the plasma glucose concentration and HbA1c.Although 
the DPP4 inhibitors augment insulin and inhibit glucose secretion, their effect on the beta cell is 
weak and it is likely that they will not inhibit the paradoxical increase in HGP observed following 
the initiation of canagliflozin therapy (44).   In contrast, the GLP-1 receptor agonists have a potent 
effect on the beta cell to augment insulin secretion and inhibit glucagon (45),thus causing a greater 
more durable reduction in A1c (46).  Further, the DPP4 inhibitors are weight neutral and do not 
reduce the blood pressure, whereas the GLP-1 receptor agonists promote weight loss and decrease 
the blood pressure.  Although canagliflozin is approved for use with the GP-1 receptor agonists, it 
is unclear whether they produce an additive, or even synergistic, effect to reduce body weight and 
blood pressure.  Therefore, in the present study we have chosen to examine combination therapy 
with canagliflozin and liraglutide. 
 
Preliminary Results: To examine the effect of lowering the plasma glucose concentration 
with a SGLT2 inhibitor on the rate of endogenous (primarily reflects hepatic) glucose production, 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
9 
V3    08/11/16 
we treated T2DM individuals with dapagliflozin, which lowers the plasma glucose concentration 
by inhibiting renal glucose reabsorption and producing glucosuria. 15 T2DM subjects (age=54+4, 
BMI=32.7+2.7 kg/m2, HbA1c= 8.3+0.2%) treated with metformin alone or in combination with a 
sulfonylurea participated in the study. Subjects received dapagliflozin (10 mg/day, n=12) or 
placebo (n=6) for 2 days and HGP was measured before and after dapagliflozin administration. 
Subjects were admitted to the Clinical Research Center (CRC) for 3 days. On day 1, basal HGP 
was measured with 3-3H-glucose. Measurement of HGP was performed at 6 AM following a 
10hour overnight fast. At 6 AM, subjects received a prime (25 µCi X FPG/100) -continuous (0.25 
µCi/min) infusion of 3-3H-glucose. Arterialized blood (heated hand technique) was drawn from a 
catheter placed retrogradely in a vein in the dorsum of the hand. After a 3 hour tracer equilibration 
period, 4 blood samples (-20, -10, -5, and 0 minutes) were obtained and plasma insulin, glucagon, 
and glucose concentrations and 3-3H-glucose specific activity were measured. On day 2, subjects 
received a 3-3H-glucose infusion as on day 1 and the tritiated glucose infusion was continued until 
1 PM. After a 3 hour tracer equilibration period, subjects received dapagliflozin or placebo (at 9 
AM) and blood samples were drawn every 20 minutes for 4 hours after drug administration. Plasma 
glucose, insulin, and glucagon concentrations and 3-3H-glucose specific activity were measured. 
On day 3, subjects received a second dose of dapagliflozin or placebo and HGP was measured as 
described for day 1. 24-hour urinary collections, to quantitate urinary glucose excretion, were 
obtained on days 1, 2 and 3. Dapagliflozin caused a significant increase in urinary glucose 
excretion (78+18 and 91+23 grams/day on days 2 and 3after dapagliflozin, respectively)compared 
to 2+1 grams/day on day 1 (before dapagliflozin) (p<0.0001). Figure 1 depicts the fasting plasma 
glucose, insulin and glucagon concentrations and the rate of HGP measured on day 2 (before and 
immediately after the start of dapagliflozin). 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
10 
V3    08/11/16 
Figure 1: Plasma glucose (A), insulin (C), and glucagon (D) concentration and the rate of HGP 
(B) before and immediately after dapagliflozin and placebo administration at time zero. 
 
The plasma glucose concentration decreased similarly in subjects receiving dapagliflozin 
and placebo (by 37+18 and 38 + 13 mg/dl, respectively, at 240 minutes). The decrease in the 
plasma glucose concentration in subjects receiving placebo can be explained by the prolonged 
fasting period (~20 hours). Consistent with this, the rate of HGP decreased significantly in subjects 
receiving placebo from 2.10+0.24 at baseline to 1.40+0.16 mg/kg.min at the end of the study 
(p<0.001).In marked contrast, during the first 30 minutes following dapagliflozin administration, 
HGP initially decreased slightly and then increased progressively (Figure 1B) such that the rate of 
HGP during the last 40 minutes of the study was above baseline (2.32 + 0.42 versus 2.20 +0.28 
mg/kg.min, P=0.12). The mean difference in HGP between dapagliflozin-treated and placebo-
treated subjects (0.70+0.34 mg/kg.min, p<0.001) virtually is identical to the amount of glucose 
excreted in the urine in dapagliflozin-treated subjects (~15 grams). Thus, the decrease in FPG in 
placebo-treated subjects was entirely accounted for by a decline in HGP, while the decline in FPG 
in dapagliflozin-treated subjects was entirely accounted for by renal glucose excretion. On day 3, 
the fasting plasma glucose concentration was reduced by 23 mg/dl in dapagliflozin-treated 
subjects, while the FPG increased by 5 mg/dl in placebo-treated subjects. The blunted decline in 
FPG concentration in dapagliflozin-treated subjects was explained by a 16% increase in HGP 
Time (min)
0
60
120
180
240
Plasma Glucose (mg/dl)
120
135
150
165
180
Placebo
Dapagliflozin
Drug Ingestion
Time (min)
0
60
120
180
240
Plasma Insulin (uU/ml)
4
6
8
10
Placebo
Dapagliflozin
Drug Ingestion
Time (min)
0
60
120
180
240
EGP (mg/kg.min) 
1.0
1.5
2.0
2.5
Drug Ingestion
Dapagliflozin
Placebo
0
Plasma Glucagon 
55
60
65
70
75
Drug
Ingesti
A. 
C. 
D. 
B. 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
11 
V3    08/11/16 
(from 2.20 +0.25 to 2.56 + 0.52, P<0.05). There was no significant change in HGP in subjects who 
received placebo. On day 3, HGP remained elevated in dapagliflozin-treated subjects (0.36 
mg/kg.min) and resulted in the addition of ~47 grams glucose per day to the circulation. This 
amount of glucose (~47 grams), produced as a result of the increase in HGP, was equal to 
approximately one half (52%) of the amount of glucose excreted in the urine secondary to SGLT2 
inhibition by dapagliflozin. Thus, the increase in HGP in response to glucosuria offsets, by at least 
half, the amount of glucosuria produced by inhibiting SGLT2. If the increase in HGP had been 
prevented, the decrease in the FPG caused by dapagliflozin would have been at least double that 
achieved with the drug.   
 
The plasma insulin concentration decreased progressively in both placebo-treated and 
dapagliflozin-treated groups on day 2. On day 3, the plasma insulin concentration in both groups 
was unchanged compared to day 1, while the plasma glucagon concentration progressively 
increased in subjects receiving dapagliflozin on day 2 (Figure 1D) and did not change in placebo-
treated subjects. On day 3, the plasma glucagon concentration was 32% higher compared to day 1 
(p<0.05) in dapagliflozin-treated subjects, while there was no significant change in plasma 
glucagon concentration in placebo-treated subjects.  The progressive decline in plasma insulin 
concentration (despite the rebound increase in HGP and plasma glucose concentration) and the 
paradoxical rise in plasma glucagon concentration facilitate the increase in HGP and plasma 
glucose concentration following dapagliflozin administration. 
 
RESEARCH HYPOTHESIS: 
 
We hypothesize that the glucosuria produced by the inhibition of SGLT2 triggers an 
increase in the rate of HGP to compensate for the urinary glucose loss in an attempt to maintain 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
12 
V3    08/11/16 
the plasma glucose concentration constant at the fasting level. Based upon our preliminary data, 
we hypothesize that the rise in plasma glucagon concentration, in concert with the decline in 
plasma insulin concentration, is the critical trigger that mediates the compensatory rise in HGP. 
The compensatory increase in HGP offsets by ~50% the amount of glucose lost in the urine. This 
“paradoxical” increase in HGP attenuates the decrease in plasma glucose concentration and 
A1cand reduces the clinical efficacy of the SGLT2 inhibitor.  Further, we hypothesize that 
combination therapy with an incretin-based agent, e.g. liraglutide, plus an SGLT2 inhibitor will, 
by inhibiting glucagon and stimulating insulin secretion, prevent the compensatory rise in HGP 
and amplify the decrease in plasma glucose concentration and A1c caused by the SGLT2 inhibitor.  
We also hypothesize that combination therapy with canagliflozin/liraglutide will cause an additive, 
or even synergistic, decrease in body weight/hepatic fat content/visceral fat content and 
systolic/diastolic blood pressure. 
 
Significance: Increased basal rate of HGP and impaired suppression of HGP following a 
meal are major causes of fasting and postprandial hyperglycemia, respectively, in T2DM 
individuals (1-9). Based on our preliminary data, we hypothesize that the increase in HGP in 
response to glucosuria indicates the presence of an interaction between the kidney and liver, i.e. 
“a reno-hepatic axis” that plays a pivotal role in the regulation of glucose homeostasis. The present 
study will provide novel insights about the regulation of glucose homeostasis, and has important 
clinical implications. Although SGLT2 inhibitors produce large glucosuria and promote 2-3 kg 
weight loss, the decline inA1c (0.6-0.8%) is less than expected (11). In NGT individuals, the 
presence of a “reno-hepatic axis” that leads to a compensatory increase in HGP in response to 
glucosuria and maintains the FPG within the normal range represents a protective response against 
the development of hypoglycemia. On the other hand, the “compensatory” increase in HGP in 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
13 
V3    08/11/16 
T2DM individuals is paradoxical in that it occurs while the plasma glucose concentration is well 
within the hyperglycemic range and opposes by ~50% the urinary glucose loss produced by 
SGLT2 inhibitors. This markedly attenuates the glucose lowering effect of the SGLT2 inhibitors. 
The present study will help to elucidate the mechanisms that mediate the rise in HGP in response 
to glucosuria and allow the development of strategies to prevent this compensatory rise in HGP 
and increase the efficacy of SGLT2 inhibitors. Our preliminary data suggest an important role for 
increased glucagon secretion in mediating the “reno-haptic” interaction. In this study, we will 
examine the ability of liraglutide to block the increase in plasma glucagon concentration and 
subsequent stimulation of HGP in response to canagliflozin -induced glucosuria. Liraglutide 
stimulates insulin and inhibits glucagon secretion. Therefore, it has the potential to prevent the 
compensatory rise in HGP following canagliflozin administration and provide an additive, even 
synergistic, decrease in the plasma glucose concentration and HbA1c. Further, we anticipate that 
combination therapy with canagliflozin plus liraglutide will produce an additive, even synergistic, 
effect to reduce body fat content and blood pressure. 
EXPERIMENTAL DESIGN AND METHODS 
 
Subjects: 45subjects with T2DM according to the ADA criteria will participate in the 
study. Subjects must be between 18-70 years of age, drug naïve or on a stable dose (more than 3 
months) of metformin or on metformin and a sulfonylurea and have HbA1c >7.0% and <10.0%. 
Subjects taking drugs known to affect glucose metabolism (other than metformin) will be 
excluded. Other than diabetes, subjects must be in good general health as determined by physical 
exam, medical history, blood chemistries, CBC, TSH, T4, and urinalysis. Only subjects whose 
body weight has been stable (± 3 lbs) over the preceding three months and who do not participate 
in an excessively heavy exercise program will be included.  Individuals with evidence of 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
14 
V3    08/11/16 
proliferative diabetic retinopathy or plasma creatinine >1.4 females or >1.5 males or eGFR< 60 
ml/min.172m2 will be excluded.   
 
 
Study design: Each subject will receive the following: (i) quantitation of basal hepatic 
glucose production with 3-3H-glucose; (ii) OGTT with measurement of plasma glucose, insulin, 
C-peptide, and glucagon; (iii) determination of total body fat content with DEXA; (iv) 
measurement of hepatic, visceral, and abdominal subcutaneous fat content with MRS/MRI; (v) 24-
hour continuous blood pressure monitoring; (vi) A1c x 2 and then started on one of the following 
therapies for 4 months:  (1) canagliflozin (film-coated tablet), 100 mg/day, increased to 300 
mg/day after week two  if tolerated without side effects; (2) liraglutide, 1.2 mg/day, increased to 
1.8 mg/day after week two if tolerated without side effects; (3) canagliflozin, 100 mg/day, plus 
liraglutide, 1.2 mg/day, increased to 300 mg/day and 1.8 mg/day, respectively at week two, if 
tolerated without side effects.  
 
Visit 1: Screening. After a 10 hour overnight fast, medical history will be obtained and 
physical exam is performed. Blood will be drawn for FPG, routine blood chemistries (including 
renal function tests), lipid profile, A1c, and thyroid function. An ECG, urinalysis and pregnancy 
test will be performed.  DEXA and OGTT will be performed and 24-hour blood pressure 
monitoring will be initiated. Preventative foot exam will be performed (see description in follow-
up section). 
 
Visit 2:  Hepatic, visceral, and subcutaneous abdominal fat content will be measured by 
MRI/MRS after an overnight fast. 
 
Visit 3: The rates of endogenous (primarily hepatic) glucose production and whole body 
glucose disposal will be measured with 3-3H-glucose. Subjects will report to the CRC at 6 AM 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
15 
V3    08/11/16 
after a 10 hour overnight fast. At 6 AM a catheter will be placed into an antecubital vein and a 
prime (40 uCi x FPG/100)-continuous (0.4uCi) infusion of [3-3H]-glucose will be started and 
continued until 3 PM. At 8 AM, a second catheter will be placed retrogradely in a vein on the 
dorsum of the hand, which is placed in a heated box (70°C)for sampling of arterialized blood. 
After 3 hours of tracer equilibration, blood samples will be drawn from the catheter on the dorsum 
of the hand at -30,-20,-15,-10,-5 and 0 (time zero is drug ingestion time) minutes. At 9 AM, blood 
samples will be obtained from the retrograde catheter on the dorsum of the hand every 20 minutes 
from 9 AM to 3 PM. Plasma glucose, insulin, C-peptide, glucagon, cortisol, growth hormone, and 
catecholamine concentrations, and [3-3H]-glucose specific activity will be measured. Urine will 
be collected from 6 to 9 AM and from 9 AM to 3 PM. Urinary volume and urinary glucose 
concentration will be measured to obtain urinary glucose excretion. The study will end at 3 PM 
and subjects will be allowed to return home. 
 
Visit 4:After completing visit 3, subjects will return to the CRC within 7-14 days for a 
repeat measurement of HGP with tritiated glucose as per visit 3, with the following exception:  at 
time zero (at 9 AM), using a table of random numbers, subjects will be randomized to receive one 
of the following:(i) canagliflozin (100 mg orally) n=15; (ii) liraglutide (1.2 mg sc); n=15; or (iii) 
canagliflozin 100 mg, plus liraglutide, 1.2 sc; n=15. We will also draw blood to monitor kidney 
function.  Prior to initiation of therapy, subjects have a one hour session with a dietician who will 
discuss a nutritionally balanced, weight maintaining diet. 
 
After completion of the above studies, subjects will continue to take canagliflozin, 
liraglutide, or canagliflozin plus liraglutide for 4 months.  Subjects will return for follow up visits 
at weeks 2, 4, 6, 8, 12, 15 and 16. During each follow-up visit we will draw blood to monitor 
kidney function. We will also draw some blood to measure A1c, lipid profile and FPG (fasting 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
16 
V3    08/11/16 
plasma glucose) and weight and blood pressure will be measured. Measurements for A1c and lipid 
profile will be taken during visits 15 or 16, not on both. In addition, preventative foot exams will 
be done on a monthly basis (see description in follow-up section).   During weeks 15-16 
measurement of total body fat (DEXA), hepatic/visceral/abdominal subcutaneous fat content 
(MRS/MRI), OGTT, 24-hour blood pressure monitoring, and HGP (as described in visits 4) will 
be repeated. 
Schedule of events for Visits 1-4 
Visit 1:  
- 
Screening procedures (including tests to monitor renal function and preventative foot 
exam)– about 60-90 minutes  
- 
Test 1: Oral Glucose Tolerance Test (OGTT) – about 2 hours 
- 
Test 2: DEXA scan – about 10 minutes 
- 
Test 3: 24-hour blood pressure monitoring – carried out over a 24 hour period during 
normal daily life 
 
Visit 2:  
- 
MRI or an MRS – about 2 hours 
 
Visit 3:  
- 
HGP (hepatic glucose production) measurement  
- 
Catheter placed at 6AM (elbow); small amount of radioactive glucose given 
o Infusion continued until 3PM 
- 
2nd catheter placed at 8AM (hand); hand placed in heated box 
- 
From 8:30AM to 9AM blood samples will be drawn from hand at 6 time points 
within 30 minutes (-30, -20, -15, -10, -5 and 0) 
- 
At 9AM blood samples will be drawn from the hand every 20 minutes from 9AM 
to 3PM.  
- 
6AM – 9AM there will be one urine collection 
- 
9AM -3PM there will be one urine collection  
- 
Procedure ends at 3PM 
 
Visit 4: within 7-14 days of visit 3 
- 
Repeat HGP as in Visit 3 
- 
Difference: at 9AM (time 0) the subject will be randomly assigned one of the 
following: (i) canagliflozin (100 mg orally) alone, (ii) liraglutide (1.2 mg 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
17 
V3    08/11/16 
subcutaneously) alone, or (iii) both canagliflozin 100 mg and lirgaglutide 1.2 mg 
sc 
- 
Renal function tests 
 
** Return home with instructions on taking medication assigned during visit 4 for 4 months.  
 
Follow-up visits 
- 
At weeks 2, 4, 6, 8, 12, 15 and 16 blood will be drawn for A1c, lipid profile, renal 
function tests (BMP on visits 4-16) and, FPG (fasting plasma glucose), and weight 
and blood pressure will be measured. 
- 
3 visits during weeks 15 and 16 for repeat testing 
- 
1: DEXA scan (as in visit 1, test 2) ~ 10 min 
- 
1: OGTT (as in visit 1, test 1) ~ 3 hours 
- 
1: 24-hour blood pressure monitoring (as in visit 1, test 3)  
- 
2: MRI/MRS (as in visit 2)- ~2 hours 
- 
3: HGP (as in visit 3) ~ 9 hours 
 
- 
Preventative foot exams will be done on a monthly bases during the study. These 
exams include the following: 
 
o Visual inspection of both feet 
o Monofilament sensory tests for both feet 
o Pulse exams for both legs and feet 
 
 
Data Analysis and Statistical Methods: 
 
The primary end point of the study is the change in the rate of HGP during the last hour 
of the study (i.e. from 300-360 minutes) following drug administration compared to the basal rate 
of HGP (before drug administration). This change in HGP will be compared among the 3 different 
treatments (canagliflozin, liraglutide, canagliflozin plus liraglutide) with ANOVA. Post hoc 
analysis will be performed with paired t-test.  
 
The rate of HGP will be calculated as previously described (18). Under steady-state post 
absorptive conditions, the basal rate of endogenous (primarily reflects hepatic) glucose appearance 
(Ra) equals the 3-3H-glucose infusion rate divided by the steady state plasma tritiated glucose 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
18 
V3    08/11/16 
specific activity. After drug administration, non-steady conditions for 3-3H-glucose specific 
activity prevail and the total rate of glucose appearance (Ra) is calculated from Steele’s equation. 
Ra will be calculated for each time point after the drug administration and compared to Ra in the 
placebo study.  
 
Secondary end points will be: (i) the decrease in the fasting plasma glucose concentration 
and A1c at the end of the study compared to baseline, (ii) improvement in oral glucose tolerance 
and insulin secretion during OGTT; (iii) improvement in Matsuda index of insulin sensitivity 
during OGTT; (iv) change in plasma glucagon concentration at the end of the study compared to 
baseline; (v) change in plasma insulin concentration at the end of the study compared to baseline; 
(vi) change in total body, hepatic/visceral/abdominal subcutaneous fat content at study end  
compared to baseline; (vii) change in 24-hour blood pressure at study end compared to baseline.  
 
Values will be presented as the mean + SD. The difference in HGP and all secondary 
endpoints at study end versus baseline will be calculated and compared between each active 
treatment group with ANOVA.    
We plan to perform additional analysis on plasma samples that were obtained during the study. 
We plan to carry out both lipidomic and metabolomic analyses on samples previously collected at 
baseline, week 2 and 16 for all 45 completers.  These analyses utilize GCMS to identify specific 
lipids and metabolites in plasma that are increased or decreased.  Using pathway analysis, this can 
provide insight into specific intracellular defects that are present in individuals with type 2 
diabetes. 
Anticipated Results and Data Interpretation 
 
Consistent with our preliminary data with dapagliflozin we anticipate that, after an initial 
decline, HGP progressively will increase following canagliflozin administration compared to the 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
19 
V3    08/11/16 
baseline study. We anticipate that plasma glucagon concentration will increase following 
canagliflozin administration and plasma insulin concentration will decline. Based upon previous 
studies (42), we anticipate that a single administration of liraglutide will cause an increase in 
plasma insulin concentration and a decrease in plasma glucagon concentration compared to the 
baseline study. The increase in plasma insulin and decrease in plasma glucagon concentration will 
result in greater decline in both HGP and fasting plasma glucose concentration compared to the 
baseline study. We also anticipate that the increase in plasma glucagon concentration and rise in 
HGP following canagliflozin administration will be prevented when canagliflozin is co-
administered with liraglutide. Therefore, we anticipate an additive, and even synergistic, decrease 
in the plasma glucose concentration following the co-administration of canagliflozin plus 
liraglutide compared to either drug alone.   
 
After 4 months of treatment, we anticipate that T2DM patients treated with canagliflozin 
plus liraglutide will have a greater decline in A1c, FPG, 24-hour blood pressure, total body fat, 
hepatic fat, and visceral and abdominal subcutaneous fat content when compared to either 
canagliflozin alone or liraglutide alone.  We also expect to observe a greater improvement in beta 
cell function (insulin secretion/insulin resistance index) and insulin sensitivity (Matsuda index) 
during the OGTT in the canagliflozin/liraglutide group compared to the other two groups. 
 
Sample Size Calculation: In preliminary results, the difference in the rate of basal HGP 
during the last hour between dapagliflozin-treated and placebo-treated individuals was 0.70+0.34 
mg/kg.min (mean+SD). From this, we computed that 15 individuals per group would provide 95% 
power to detect a similar difference in HGP between (i)canagliflozin-treated versus canagliflozin 
plus liraglutide-treated individuals and (ii) between liraglutide-treated versus canagliflozin plus 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
20 
V3    08/11/16 
liraglutide-treated individuals at alpha =0.05. To ensure 15 completers per group, we have set the 
sample size at 90.  
 
SAFETY 
All drugs can cause unwanted effects called side effects.  As of 28 September 2015, approximately     
13173 subjects have received canagliflozin in completed or ongoing studies of 12 weeks or longer.    
Side effects found in  these studies that are more likely to occur with canagliflozin include those 
below.  The subject should speak with the doctor about any changes to his or her diet or other 
medications they are taking:  
 
• Dizziness or lightheadedness upon standing - These adverse events, from a decrease in 
blood pressure, occur soon after starting canagliflozin and are more likely to occur in 
people on medicines to lower blood pressure including diuretics (water pills such as 
Lasix/furosemide),  on a low salt diet, older patients  or those who have reduced kidney 
function. While subject is  taking canagliflozin, the subject should try to avoid becoming 
dehydrated and should speak to the doctor about any changes in his or her diet or other 
medications.  This side effect may occur in up to 1 in 20 people on canagliflozin, or slightly 
more frequently in those at risk as described above. 
 
• Hypoglycemia in patients taking other medications associated with hypoglycemia    
. If subject takes canagliflozin with another medicine that can cause low blood sugar, such 
as a sulfonylurea or insulin, the subject’s risk of getting low blood sugar is higher. The 
dose of the subject’s sulfonylurea medicine or insulin may need to be lowered while the 
subject takes canagliflozin and the subject should speak to the doctor about any changes in 
other medications. This side effect is very common and may occur in more than 1 in 10 
people on canagliflozin. 
Signs and symptoms of low blood sugar may include: 
o headache 
o drowsiness 
o weakness 
o dizziness 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
21 
V3    08/11/16 
o confusion 
o irritability 
o hunger 
o fast heart-beat 
o sweating 
o shaking or feeling jitter 
 
• Increased urination and thirst – Symptoms might include feeling thirsty , having a dry 
tongue, urinating more frequently or in larger amounts, an urgent need to urinate or more 
frequent urination  at night. These side effects may occur in up to 1 in 20 people taking 
canagliflozin. 
• Urinary tract infections – Symptoms of urinary tract infections may include burning with 
urination, discomfort in passing urine, or fever.  This side effect may occur  in up to 1 in 
20 people on canagliflozin. 
• Allergic reaction including rash or hives – These events can occur shortly after starting 
canagliflozin, are generally not serious or associated with other serious symptoms, such as 
breathing problems. This side effect may occur in up to 1 in 20 people on canagliflozin. 
• Constipation – The side effect of constipation may occur in slightly more than 1 in 50 
people on canagliflozin. 
• Nausea - There is a slightly higher rate of nausea (stomach sickness or queasy sensation) 
with canagliflozin.  . The side effect of nausea may occur in slightly more than 1 in 50 
people on canagliflozin. 
 
• Laboratory changes that have been observed in clinical studies with canagliflozin 
o Blood test might show an increase in the LDL, or “bad”, cholesterol.  


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
22 
V3    08/11/16 
o Blood test might show an increase in serum potassium, phosphate and/or 
hemoglobin; decreases in serum urate can also occur.  These changes are generally 
not serious and not associated with serious symptoms.   
o A change in lab tests associated with kidney function might occur. These changes 
have generally been temporary and may relate to hydration status.   During the 
study, the doctor regularly monitors kidney function, and may discuss with subject 
any necessary changes in subject’s diet or other medications. 
o  
• Bone fractures may occur in up to 1 in 50 people per year on canagliflozin. 
 
• Amputation of the toes (and to a lesser extent the foot or leg) could occur in up to 1 in 
150 people per year on canagliflozin.  This risk is greater in those with a prior history of 
amputation, disease of the circulation involving the legs or in those with nerve damage 
due to diabetes. 
Side effects in patients not involved in clinical studies who have been prescribed canagliflozin to 
treat their diabetes include those below. It is difficult to know specifically how often these side 
effects occur or always be certain if they are more likely to occur as a result of canagliflozin 
because these were not reported in the manner similar to data collection in a clinical study.  
• Serious allergic reactions, including those with the symptoms of swelling of the face, 
throat, and/or tongue or breathing problems.    
 
• Related to changes in lab tests associated with kidney function, severe cases of decreases 
in kidney function have been reported more commonly in patients who were dehydrated. 
Acute Kidney Injury: Sudden kidney injury (acute kidney injury) has happened to 
people taking canagliflozin. Talk to your doctor right away if you: 
o reduce the amount of food or liquid you drink for example, if you are sick or 
cannot eat or 
o you start to lose liquids from your body for example, from vomiting, diarrhea or 
being in the sun too long.  Seek medical attention immediately if you experience 
signs and symptoms while taking these medicines such as: 
▪ Decreased urine 
▪ Swelling in your legs or feet 
 
• 
Infections of the urinary tract that can spread to the kidneys or into the bloodstream. Symptoms 
may include high fever, increased heart rate and breathing, low blood pressure, low urine output 
and lower back pain. Call your doctor if you experience these symptoms. 
 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
23 
V3    08/11/16 
• 
Diabetic ketoacidosis - your blood may show increased levels of blood acids called 
ketones. Sometimes this can occur even if your blood sugar levels are not very high (e.g., less 
than 250 mg/dL [13.9 mmol/L]). The risk of developing diabetic ketoacidosis may be increased 
with prolonged fasting, excessive alcohol consumption, dehydration, sudden reductions in 
insulin dose, or a higher need of insulin due to major surgery or serious illness. Symptoms may 
include difficulty breathing, nausea, vomiting, excessive thirst, rapid weight loss, abdominal 
pain, confusion, fruity-smelling breath, a sweet or metallic taste in your mouth, a different odor 
to your urine or sweat, and unusual fatigue or sleepiness. This side effect may occur in up 1 in 
1000 people with Type 2 diabetes. Call your doctor if you experience these symptoms. Do not 
stop or change study drug or diabetes medicines without first discussing with your doctor.There 
may be side effects with the use of canagliflozin that are not yet known.  Sometimes the 
University of Texas Health Science Center at San Antonio may learn new facts about the study 
drugs/treatments. It is possible that this information might make the subject change their mind 
about being in the study. If new information is discovered, the study doctor will inform the 
subject of such new information in a timely manner. 
o  
For Women: 
• Vaginal yeast infections and vaginal itching - Symptoms such as vaginal itching, 
burning, irritation, odor or discharge. This side effect may occur in slightly more than 1 in 
10 women on canagliflozin. 
For Men:  
Yeast infection at the head of the penis - Symptoms such as penile itching, irritation, burning, 
swelling, 
foul 
smelling 
discharge 
or 
pain. 
In 
0.3% 
(1 
in 
300 
) of men who are not circumcised, this could lead to swelling of the foreskin, and require 
circumcision.  The side effect of yeast infection may occur in up to 1 in 20 men on canagliflozin. 
PREGNANCY AND BIRTH CONTROL DURING THE STUDY 
Canagliflozin has been tested for its ability to cause harm to the fetus during pregnancy or cause 
birth defects. These studies have been done in animals.  The studies that have been completed do 
not indicate that canagliflozin is associated with birth defects.   


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
24 
V3    08/11/16 
Nonetheless, women who are pregnant, lactating or intend to become pregnant during the study 
will  not be allowed to participate in the study.  Women who could possibly become pregnant must 
have a negative pregnancy test prior to starting on the study drug and report immediately to the 
study site if they suspect they are pregnant during the study. 
Women who are able to have children and are heterosexually active, must use birth control 
(contraception) during the study.  Birth control methods that can be used while in this study 
include: avoiding sex, birth control pills, birth control injections or patch, intrauterine device, 
barrier method (for example, condoms or diaphragm) combined with spermicide (foam, cream, or 
gel), or the male partner is sterile (e.g. sperm tubes are cut or blocked).  The type of birth control 
used must be discussed with the study doctor before the start of the study. The study doctor must 
approve the method the subject uses before the subject can enter the study. 
If the subject becomes pregnant during the study, he or she must tell the doctor immediately. The 
subject will have to stop taking the study drug.  The doctor will advise the subject about medical 
care and will ask the subject to allow him/her to collect information about the pregnancy and the 
health of the subject’s baby. 
For male subjects, if his partner becomes pregnant, the subject must tell the study doctor 
immediately. 
The following are the risks associated with Liraglutide: 
Likely, not serious 
In 100 people, approximately 20 or more may have: 
• 
Nausea 
Less likely, not serious 
In 100 people, approximately 20 or less may have: 
• 
Back pain  
• 
Nasopharyngitis 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
25 
V3    08/11/16 
• 
Sinusitis 
• 
Dizziness  
• 
UTI 
• 
Influenza 
• 
Headache 
• 
Upper respiratory tract infection 
• 
Constipation 
• 
Vomiting 
• 
Diarrhea 
Rare and Serious 
In 100 people, approximately 5 or less may have: 
• 
Thyroid C-cell Tumors – There have been 4 reported cases of thyroid C-cell hyperplasia 
among Victoza-treated patients and 1 case in a comparator-treated patient (1.3 vs 0.6 cases per 
1000 patient-years). 
• 
Pancreatitis – There were 7 cases of pancreatitis among Victoza-treated patients and 1 case 
among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with 
Victoza were reported as acute pancreatitis and two cases with Victoza were reported as chronic 
pancreatitis.  
• 
Hypoglycemia may occur in patients taking other antidiabetic medications such as a 
sulfonylurea or insulin but is uncommon in patients taking only metformin. Liraglutide taken with 
another medicine that can cause low blood sugar, such as a sulfonylurea, the risk of getting low 
blood sugar is increased. The dose of sulfonylurea medicine may need to be lowered while taking 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
26 
V3    08/11/16 
liraglutide and a physician should be contacted about any changes in other medications. This side 
effect may occur in more than 1 in 10 people on liraglutide. 
 
Adverse Events and Serious Adverse Events 
I. 
Management of Safety Data 
This Study has been designated as an interventional study.  Janssen requirements for IIS 
interventional studies are all adverse events regardless of causality and special situations 
excluding those from subjects not exposed to a Janssen Medicinal Product and product 
quality complaints with or without an adverse event will be reported, once the subject has 
signed and dated an Informed Consent Form is obtained until the subject has completed 
participation in the study and for 30 days after the last dose of study drug. 
 
II. 
Definitions 
a. Adverse Event (AE) 
An adverse event is any untoward medical occurrence in a clinical study subject administered 
a medicinal (investigational or non-investigational) product. An adverse event does not 
necessarily have a causal relationship with the treatment. An adverse event can therefore be 
any unfavorable and unintended sign (including an abnormal finding), symptom, or disease 
temporally associated with the use of a medicinal (investigational or non- investigational) 
product, whether or not related to that medicinal (investigational or non-investigational) 
product. (Definition per International Conference on Harmonisation [ICH]). 
This includes any occurrence that is new in onset or aggravated in severity or frequency from 
the baseline condition, or abnormal results of diagnostic procedures, including laboratory test 
abnormalities. 
 
b. Adverse Events of Special Interest  
Events that Janssen Scientific Affairs is actively monitoring as a result of a previously 
identified signal (even if non-serious).  These adverse events are:   
Diabetic ketoacidosis (DKA), Amputation  
 
The INSTITUTION and the PRINCIPAL INVESTIGATOR) will transmit all AEs related to 
Diabetic ketoacidosis following exposure to a Janssen product under study in a DKA form 
provided by the COMPANY in accordance with Section 10,Transmission Methods, in English. 
If also an SAE, please submit Janssen within 24-hours of becoming aware of the event(s). 
 
 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
27 
V3    08/11/16 
c. Individual Case Safety Report (ICSR) 
A valid ICSR must contain the four minimum criteria required to meet regulatory 
reporting requirements. 
• an identifiable subject (not disclosing the subject’s name and address) 
• an identifiable reporter (investigational site) 
• a Janssen medicinal product 
• an adverse event, outcome, or certain special situation 
 
The minimum information required is: 
• suspected Janssen product (doses, indication) 
• date of therapy (start and end date, if available) 
• batch or lot number, if available 
• subject details (subject ID and country) 
• gender 
• age at AE onset 
• reporter ID 
• adverse event detail (AE verbatim in English), onset date, relatedness, causality, action 
taken, outcome, (if available) 
• Janssen protocol ID 
 
d. Product Quality Complaint (PQC) 
A product quality compliant is related to a potential quality issue during manufacturing, 
packaging, release testing, stability monitoring, dose preparation, storage or distribution 
of the product, or delivery system.  Not all PQCs involve a subject.  Lot and batch 
numbers are of high significance and need to be collected whenever available. 
 
Examples of PQC include but not limited to: 
• Functional Problem: e.g., altered delivery rate in a controlled release product 
• Physical Defect:  e.g. abnormal odor, broken or crushed tablets/capsules 
• Potential Dosing Device Malfunction: e.g.,  autoinjector button not working, needle 
detaching from syringe 
• Suspected Contamination 
• Suspected Counterfeit. 
 
e. Serious Adverse Event (SAE) 
A serious adverse event based on ICH and EU Guidelines on Pharmacovigilance for 
Medicinal Products for Human Use is any untoward medical occurrence that at any dose: 
 
• 
Results in death 
• 
Is life-threatening 
(The subject was at risk of death at the time of the event. It does not refer to an 
event that hypothetically might have caused death if it were more severe.) 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
28 
V3    08/11/16 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity 
• 
Is a congenital anomaly/birth defect 
• 
Is a suspected transmission of any infectious agent via a medicinal product 
• 
Is medically important* 
 
*Medical and scientific judgment should be exercised in deciding whether expedited 
reporting is also appropriate in other situations, such as important medical events that may 
not be immediately life threatening or result in death or hospitalization but may jeopardize 
the subject or may require intervention to prevent one of the other outcomes listed in the 
definition above. These should usually be considered serious. 
 
NOTE: DEATH FOR ANY REASON SHOULD BE REPORTED AS A SERIOUS 
ADVERSE EVENT. 
 
For reports of hospitalization, it is the sign, symptom or diagnosis which led to the 
hospitalization that is the serious event for which details must be provided. 
 
Any event requiring in-patient hospital admission (or the prolongation of hospitalization) 
must be reported as an SAE. Events that do not meet the criteria for SAE reporting are: 
• Reasons described in the Protocol, e.g. drug administration, Protocol-required 
testing 
• Social reasons, e.g. overnight stay because of distance between home and hospital 
• Surgery or procedure planned and documented prior to entry into the Study. 
 
Any event requiring hospitalization or prolongation of hospitalization that occurs during 
the study must be reported as a serious adverse event, except hospitalizations for the 
following: 
• Hospitalizations not intended to treat an acute illness or adverse event (e.g., social 
reasons such as pending placement in long-term care facility) 
• Surgery or procedure planned before entry into the study. [Note: Hospitalizations 
that were planned before the start of data collection and where the underlying 
condition for which the hospitalization was planned has not worsened will not be 
considered serious adverse events. Any adverse event that results in a 
prolongation of the originally planned hospitalization is to be reported as a new 
serious adverse event.] 
 
The cause of death of a subject in a study within 30 days of the last dose of study drug, 
whether or not the event is expected or associated with the study drug, is considered a 
serious adverse event. 
 
f. Unlisted (Unexpected) Adverse Event/Reference Safety Information 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
29 
V3    08/11/16 
An adverse event is considered unlisted if the nature or severity is not consistent with the 
applicable product reference safety information. For a medicinal product(s) with a 
marketing authorization, the expectedness of an adverse event will be determined by 
whether or not it is listed in the applicable product information. 
 
III. 
Special Situations  
Safety events of interest for a Janssen medicinal product that require expediting reporting 
and/or safety evaluation include, but are not limited to: 
• Drug exposure during pregnancy (maternal and paternal) 
• Overdose of a Janssen medicinal product  
• Exposure to a Janssen medicinal product from breastfeeding  
• Suspected abuse/misuse of a Janssen medicinal product 
• Inadvertent or accidental exposure to a Janssen medicinal product  
• Any failure of expected pharmacological action (i.e., lack of effect) of a Janssen 
medicinal product 
• Medication error involving a Janssen medicinal product (with or without patient 
exposure to the Janssen medicinal product, e.g., name confusion) 
• Suspected transmission of any infectious agent via a medicinal  
• Unexpected therapeutic or clinical benefit from use of a Janssen medicinal product 
 
These safety events may not meet the definition of an adverse event; however, they are 
treated in the same manner as adverse events. Special situations should be recorded on 
the Adverse Event page of the CRF. 
 
Any special situation that meets the criteria of a serious adverse event should be recorded 
on a Serious Adverse Event Report Form and be reported to Janssen Scientific Affairs 
within 24 hours of becoming aware of the event. 
 
IV. 
Pregnancy  
All initial reports of pregnancy must be reported to Janssen Scientific Affairs by the Sponsor 
Investigator within 24 hours of their awareness of the event using the Serious Adverse 
Event Form. Abnormal pregnancy outcomes (e.g. spontaneous abortion, stillbirth, and 
congenital anomaly) are considered serious adverse events and must be reported using the 
Serious Adverse Event Form.  
 
Any subject who becomes pregnant during the study must be promptly withdrawn from the 
study and discontinue further study treatment. 
 
Because the effect of the Janssen medicinal product on sperm is unknown, pregnancies in 
partners of male subjects exposed to a Janssen medicinal product will be reported by the 
Sponsor Investigator within 24 hours of their awareness of the event using the Serious 
Adverse Event Form.  Depending on local legislation this may require prior consent of the 
partner. 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
30 
V3    08/11/16 
 
Follow-up information regarding the outcome of the pregnancy and any postnatal sequelae 
in the infant will be required. 
 
V. 
Reporting Procedures for Adverse Events and Pregnancies [and/or Pregnancies in 
Partners] 
All adverse events, whether serious or non-serious, related or not related, special situations, 
pregnancy exposures and/or pregnancies in partners following exposure to a Janssen medicinal 
product are to be documented by the investigator and recorded in the CRF and in the subject’s 
source records. Investigators must record in the CRF their opinion concerning the relationship 
of the adverse event to a Janssen medicinal product.  
All (serious and non-serious) adverse events reported for a Janssen medicinal product should 
be followed-up in accordance with clinical practice. 
 
All serious adverse events that have not resolved by the end of the study, or that have not 
resolved upon discontinuation of the subject's participation in the study, must be followed until 
any of the following occurs: 
• The event resolves 
• The event stabilizes 
• The event returns to baseline, if a baseline value/status is available 
• The event can be attributed to agents other than the study drug or to factors unrelated to 
study conduct 
• It becomes unlikely that any additional information can be obtained (subject or health care 
practitioner refusal to provide additional information, lost to follow-up after demonstration 
of due diligence with follow-up efforts) 
 
All serious adverse events, pregnancy exposures and/or pregnancies in partners for Janssen 
medicinal products under study should be reported directly by the Sponsor Investigator, 
within 24 hours of becoming aware, to Janssen Scientific Affairs using the Janssen 
Scientific Affairs Serious Adverse Event Report Form. In the event the study is blinded, the 
Sponsor Investigator will submit an unblinded SAE or pregnancy exposure report to Janssen 
Scientific Affairs. 
 
All follow-up information for serious adverse events that are not resolved at the end of the 
study or by the time of patient withdrawal must be reported directly by the Sponsor 
Investigator, within 24 hours becoming aware, to Janssen Scientific Affairs using the 
Janssen Scientific Affair’s Serious Adverse Event Report Form. 
 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
31 
V3    08/11/16 
VI. 
Product Quality Complaints for Janssen Medicinal Products 
 
A PQC may have an impact on the safety and efficacy of the product. Timely, accurate, and 
complete reporting and analysis of PQC information from studies are crucial for the 
protection of patients, investigators, and Janssen Scientific Affairs, and are mandated by 
regulatory agencies worldwide. Janssen Scientific Affairs has established procedures in 
conformity with regulatory requirements worldwide to ensure appropriate reporting of PQC 
information.  Lot and/or Batch #s shall be collected or any reports of failure of expected 
pharmacological action (i.e., lack of effect). 
 
All initial PQCs involving a Janssen product under study must be reported to Janssen 
Scientific Affairs by the Sponsor Investigator within 24 hours after being made aware of 
the event. 
 
If the defect for a Janssen product under study is combined with either a serious adverse 
event or non-serious adverse event, the Sponsor Investigator must report the PQC to Janssen 
Scientific Affairs according to the serious adverse event reporting timelines.  A sample of the 
suspected product should be maintained for further investigation if requested by Janssen 
Scientific Affairs. 
 
VII. 
Maintenance of Safety Information 
All safety data should be maintained in a clinical database in a retrievable format. The 
Institution and Sponsor Investigator shall provide all adverse events, both serious and non-
serious, in report format. However, in certain circumstances more frequent provision of 
safety data may be necessary, e.g. to fulfill a regulatory request, and as such the data shall be 
made available within a reasonable timeframe at Janssen Scientific Affair’s request. 
 
VIII. 
Transmission Methods: 
The following methods are acceptable for transmission of safety information to Janssen 
Scientific Affairs: 
• Electronically via Janssen SECURE Email service (preferred) 
• For business continuity purposes, if SECURE Email is non-functional: 
o Facsimile (fax), receipt of which is evidenced in a successful fax transmission 
report 
• Telephone (if fax is non-functional). 
 
Please use the contact information and process information provided by Janssen Scientific 
Affairs. 
 
IX. 
Procedures for Reporting Adverse Events (AE), Serious Adverse Events (SAE), 
Pregnancy, and Product Quality Complaints (PQC) to Janssen Scientific Affairs 
 
A. AEs, SAEs, Special Situations and Pregnancy Reporting. 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
32 
V3    08/11/16 
The Institution and the Sponsor Investigator will transmit SAEs and Special Situations in a 
form provided by Janssen Scientific Affairs in accordance with Section VIII Transmission 
methods, in English within 24-hours of becoming aware of the event(s). 
 
All available clinical information relevant to the evaluation of a related SAE or Special 
Situation is required. 
 
• The Institution and/or Sponsor Investigator are responsible for ensuring that these cases 
are complete and if not are promptly followed-up. A safety report is not considered 
complete until all clinical details needed to interpret the case are received. Reporting of 
follow-up information should follow the same timeline as initial reports. 
 
• Copies of any and all relevant correspondences with regulatory authorities and ethics 
committees regarding any and all serious adverse events, irrespective of association with 
the Janssen Product under study, are to be provided to Janssen Scientific Affairs using a 
transmission method in Section VIII within 24 hours of such report or correspondence 
being sent to applicable health authorities. 
 
 
B. PQC Reporting 
The Institution and the Sponsor Investigator will report any suspected PQC to the Janssen 
contact within 24 hours of becoming aware of the complaint.  The product should be 
quarantined immediately and if possible, take a picture. 
 
X. 
Reconciliation of SAEs 
At a minimum, on a quarterly basis and at the end of the Study, Janssen Scientific Affairs 
will provide to the Institution and/or Sponsor Investigator, a listing of all SAEs reported to 
Janssen Scientific Affairs.  The Sponsor Investigator will review this listing and provide any 
discrepancies to Janssen Scientific Affairs. 
 
Upon request, Institution and/or Sponsor Investigator shall provide Janssen Scientific Affairs 
with a summary list of all SAEs, and AEs of Special Interest and Special Reporting Situation 
reports to date, for reconciliation purposes. 
 
XI. 
Dissemination 
of 
Safety 
Information 
from 
Janssen 
Scientific 
Affairs 
to 
Institution/Sponsor Investigator Sponsor Investigator will be responsible for submitting IND 
safety reports for the Study Product to Institution’s IRB in accordance with Federal regulations 
21 CFR 312.66.   
 
Janssen Scientific Affairs agrees to provide to the Sponsor Investigator IND safety reports for 
the Study Product as they become available until all subjects in the Protocol have completed 
their last Study visit according to the Protocol (i.e. Last Subject Last Visit has occurred).  


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
33 
V3    08/11/16 
 
All observed or volunteered AEs or suspected causal relationship to the study drugs or procedures 
will be reported.  For all AEs, the investigator must pursue and obtain information adequate both 
to determine the outcome of the AE and to assess whether it meets the criteria for classification as 
an SAE requiring immediate notification to Janssen Scientific Affairs, LLC and to UTHSCSA IRB 
(per UPIRSO policy).  For all AEs, sufficient information should be obtained by the investigator 
to determine causality of the AE.  For AEs with a causal relationship to the investigational product, 
follow-up by the investigator is required until the event is resolved or stabilized at a level 
acceptable to the investigator, and IRB. 
As part of ongoing safety reviews, any non-serious adverse event that is determined by the 
investigator to be serious will be reported as an SAE.  To assist in the determination of case 
seriousness, further information may be requested from the investigator to provide clarity and 
understanding of the event in the context of the clinical study. 
All AEs related to protocol procedures will be reported to the IRB, Janssen Scientific Affairs, LLC 
and to FDA (by the study sponsor). Subjects will self-report AEs occurring at all other times. (iii) 
Any clinically significant findings from ECGs, labs, vital sign measurements, other procedures, 
etc. that result in a diagnosis will be reported to the IRB and subjects physician for a follow up 
outside of the research study.  Any conditions that may put subjects to risk will be grounds for 
withdrawing the subject from the study. Investigators will report to the IRB their assessment of 
the potential relatedness of each AE to study procedure, disease, or study drug via Unanticipated 
Problems Involving Risk to Subjects or Others (UPIRSO) or AE Report. 
The Collection of UPIRSO begins after the subject has signed informed consent and has started 
the study procedures. If a subject experiences an UPIRSO after signing informed consent, the 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
34 
V3    08/11/16 
event will NOT be collected unless the investigator feels that the event may have been caused by 
a protocol procedure/study medication.  UPIRSOs will be reported to the IRB in according to the 
IRB policy. Study site personnel will alert the IRB (within 24 hours) of becoming aware of any 
life threatening or fatal events via approved method.  Alerts issued via telephone are to be 
immediately followed with official notification. An SAE is any AE from this study that results in 
1 of the following outcomes: 
• death 
• initial or prolonged in subject hospitalization 
• a life-threatening experience (that is, immediate risk of dying) 
• persistent or significant disability/incapacity 
• considered significant by the investigator for any other reason. 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious adverse drug events when, based upon appropriate 
medical judgment, they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. All other AEs will be 
reported to the IRB once a year in the Continuing Review Report. As the PI/Sub-PI evaluates 
SAEs/AEs, actions will be taken to eliminate any hazards and/or changes that should be 
submitted to the IRB, if necessary, will be considered. 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
35 
V3    08/11/16 
Risks will be minimized by a careful screening process including medical history, physical 
exam, and review of complete blood count, coagulation tests, chemistry and electrocardiogram.  
Experienced study research personnel during the visits and procedures and of at least one 
physician at all times (or on call during the 4-day in-patient visit) further minimizes any potential 
risks. 
Severity Assessment 
If required, when documenting the AE, the investigator will use the adjectives MILD, 
MODERATE or SEVERE to describe the maximum intensity of the AE.    These intensity 
grades are defined as follows: 
MILD Does not interfere with subject’s usual function 
MODERATE Interferes to some extent with subject’s usual function 
SEVERE 
Interferes significantly with subject’s usual function 
The terms “serious” and “severe” are not synonymous.  The term “severe” is often used to 
describe the intensity (severity) of a specific event.  The event itself, however, may be of 
relatively minor medical significance.  This is not the same as “serious,” which is based on 
subject/event outcome or action criteria.  Accordingly, a severe event is not necessarily a serious 
event. 
Causality Assessment 
The investigator’s assessment of causality must be provided for all AEs.  The investigator must 
record the causal relationship in the CRF, as appropriate, and report such an assessment in 
accordance with the serious adverse event reporting requirements, if applicable.  An 
investigator’s causality assessment is the determination of whether there exists a reasonable 
possibility that the investigational product caused or contributed to an AE.  If the investigator 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
36 
V3    08/11/16 
does not know whether or not the investigational product caused the event, then the event will be 
handled as “related to investigational product” for reporting purposes.  If the investigator’s 
causality assessment is “unknown but not related to investigational product”, this should be 
clearly documented on study records.  In addition, if the investigator determines an SAE to be 
associated with study procedures, the investigator must record this causal relationship in the 
source documents and CRF, as appropriate, and report such an assessment in accordance with 
SAE reporting requirements. 
Withdrawal Due to Adverse Events 
Withdrawal due to AE should be distinguished from withdrawal due to insufficient response, and 
recorded on the appropriate AE CRF.  When a subject withdraws due to an SAE, the SAE must 
be reported in accordance with the reporting requirements. 
Eliciting Adverse Event Information and Reporting 
The investigator is to report all directly observed AEs and all AEs spontaneously reported by the 
study subject.  Each study subject will be questioned about AEs.  Each AE is to be assessed to 
determine if it meets the criteria for SAEs.  If an SAE occurs, expedited reporting will follow 
appropriate regulations. 
Serious Adverse Event Reporting Requirements 
If an SAE is determined as UPISRO, it will be reported to IRB in accordance with UPIRSO 
policy. 
In the rare event that the investigator does not become aware of the occurrence of an SAE 
immediately (e.g., an outpatient study subject initially seeks treatment elsewhere), the 
investigator is to report the event within 24 hr after learning such event and document the time of 
first awareness of the AE.   


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
37 
V3    08/11/16 
Non-Serious Adverse Event Reporting Requirements 
All AEs will be reported on the AE page(s) log.  AEs should be reported using concise medical 
terminology on the CRFs as well as on the form for collection of the SAE information. 
Sponsor Reporting Requirements to Regulatory Authorities 
AE reporting, including suspected serious unexpected adverse reactions, will be carried out in 
accordance with applicable regulations. Expected AEs or AEs that are not related to the study 
will be reported on the annual progress report to the IRB. 
 
The investigator also must notify the IRB of the occurrence of the SAE, in writing, as 
soon as is practicable and in accordance with local law 
 
Subject Monitoring 
Subjects will be monitored for AEs throughout the study by the study unit staff.  Safety 
parameters, including laboratory results and ECGs, will be assessed by the principal investigator 
or his delegate using the site’s criteria for clinical laboratory and ECG acceptance ranges as 
suggested guidelines in making the medical assessment. 
Scheduled safety measurements will be repeated according to appropriate SOPs or upon request 
from a physician.  Any abnormal repeated measurement will be evaluated by a physician and 
repeated if judged necessary.  Further action may be taken on the physician’s request. 
Subjects will be advised to notify their health care professionals (e.g., physician, dentist, and/or 
pharmacist) that they are participating in a clinical research study of a drug called synthetic 
glucagon for injection before taking any medicines or undergoing any medical procedure. 
Data Integrity  


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
38 
V3    08/11/16 
The data collected during the study will be reviewed in a timely fashion by the PI or Sub-
Investigator to ensure that the studies are performed as approved by the IRB and the study 
medication is well tolerated, and that plasma glucose concentration during the study meets the 
targets of the study. In the case that the levels of plasma glucose concentrations do not meet the 
targets, the PI will decide which measures are required to achieve that.  The PI will convert the 
data in the sheet to electronic file and will be responsible for the data analysis. The PI will 
review the patient records with the nurse coordinator every month to ensure the safety of all 
study participants and that any encountered AE are within the expected frequency and severity. 
The Research Compliance Manager and/or UTHSCSA Compliance monitors may conduct 
periodic monitoring of the research protocol/procedure and participant records for compliance 
and adherence to the study protocol.  The monitoring tool used by the Research Compliance 
Manager will indicate the date of the review.   
Data will be discussed at the monthly Clinical Management Team with the PI or Sub-
Investigator. Safety data will also be assed at the submission of annual progress reports to the 
IRB. 
 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
39 
V3    08/11/16 
References: 
 
1) 
DeFronzo RA.  Banting Lecture. From the triumvirate to the ominous octet:  a new 
paradigm for the treatment of type 2 diabetes.  Diabetes 58:773-795, 2009 
2) 
DeFronzo RA. Lilly Lecture: The triumvirate: β-cell, muscle, liver: a collusion responsible 
for NIDDM. Diabetes37: 667– 687, 1988 
3) 
DeFronzo RA, Ferrannini E, Simonson DC. Fasting hyperglycemia in non-insulin 
dependent diabetes mellitus: contributions of excessive hepatic glucose production and 
impaired tissue glucose uptake. Metabolism38: 387– 395, 1989 
4) 
Ferrannini E, Simonson DC, Katz LD, Reichard G, Bevilacqua S, Barrett EJ, Olsson M, 
DeFronzo RA. The disposal of an oral glucose load in patients with non-insulin dependent 
diabetes. Metabolism37: 79– 85, 1988 
5) 
Chen YD, Jeng CY, Hollenbeck CB, Wu MS, Reaven GM. Relationship between plasma 
glucose and insulin concentration, glucose production, and glucose disposal in normal 
subjects and patients with non-insulin-dependent diabetes. J Clin Invest82: 21– 25, 1988 
6) 
Jeng CY, Sheu WH, Fuh MM, Chen YD, Reaven GM. Relationship between hepatic 
glucose production and fasting plasma glucose concentration in patients with NIDDM. 
Diabetes43: 1440– 1444, 1994 
7) 
Magnusson I, Rothman DL, Katz LD, Shulman RG, Shulman GI. Increased rate of 
gluconeogenesis in type II diabetes mellitus: a 13C nuclear magnetic resonance study. J 
Clin Invest90: 1323– 1327, 1992 
8) 
Consoli A, Nurjhan N, Reilly JJ, Jr, Bier DM, Gerich JE. Mechanism of increased 
gluconeogenesis in noninsulin-dependent diabetes mellitus: role of alterations in systemic, 
hepatic, and muscle lactate and alanine metabolism. J Clin Invest86: 2038– 2045, 1990 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
40 
V3    08/11/16 
9) 
DeFronzo RA, Ferrannini E. Regulation of hepatic glucose metabolism in humans. 
Diabetes Metab Rev3: 415– 460, 1987 
10) 
Edgerton DS, Johnson KM, Cherrington AD. Current strategies for the inhibition of hepatic 
glucose production in type 2 diabetes.Front Biosci. 14:1169-81, 2009. 
11) 
Cherrington AD. Banting Lecture 1997. Control of glucose uptake and release by the liver 
in vivo. Diabetes 48:1198-214, 1999 
12) 
Lin HV, Accili D. Hormonal regulation of hepatic glucose production in health and 
disease.Cell Metab. 14:9-19, 2011 
13) 
Sindelar DK, Chu CA, Venson P, Donahue EP, Neal DW, Cherrington AD. Basal hepatic 
glucose production is regulated by the portal vein insulin concentration. Diabetes 47: 523-
9, 1998 
14) 
Gustavson SM, Chu CA, Nishizawa M, Neal D, Farmer B, Yang Y, Donahue EP, Flakoll 
P, Cherrington AD. Effects of hyperglycemia, glucagon, and epinephrine on renal glucose 
release in the conscious dog. Metabolism. 53:933-41, 2004 
15) 
Cersosimo E, Zaitseva IN, Ajmal M Effects of beta-adrenergic blockade on hepatic and 
renal glucose production during hypoglycemia in conscious dogs.Am J Physiol. 275(5 Pt 
1):E792-7, 1998 
16) 
Abdul-Ghani MA, Norton L, Defronzo RA. Role of sodium-glucose cotransporter 2 (SGLT 
2) inhibitors in the treatment of type 2 diabetes.Endocr Rev. 32:515-31, 2011.  
17) 
Cefalu WT, Leiter LA, Yoon K-H, Arias P, Niskanen L, Xie J, Balis DA, Canovatchel W, 
Meininger G.  Efficacy and safety of canagliflozin versus glimeperide in patients with type 
2 diabetes inadequately controlled with metformin (CANTATA-SU):  52 week results from 
a randomised, double-blind, phase 3 non-inferiority trial.  Lancet 382:941-950, 2013. 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
41 
V3    08/11/16 
18) 
Merovci A, Solis, C, Daniele G, Eldor R, Fiorentino TV, Perez Z,Tripathy D, Xiong  J, 
Norton L, Abdul-Ghani MA, DeFronzo RA. Dapagliflozin  improves muscle insulin 
sensitivity but t enhances endogenous glucose production. s. J. Clin. Invest. 124:509-
14,2014. 
19). 
Stenlof K, Cefalu WT, Kim K-A, Alba M, Usiskin K, Tong C, Canovatchel W, 
Meininger G.  Efficacy and safety of canagliflozin monotherapy in subjects with type 2 
diabetes mellitus inadequately controlled with diet and exercise.  DiabObesMetab 
15:372-382, 2013. 
20). 
Gutzwiller JP, Tschopp S, Bock A, Zehnder CE, Huber AR, Kreyenbuehl M, Gutmann 
H, Drewe J, Henzen C, Goeke B, Beglinger C.  Glucagon-like peptide 1 induces 
natriuresis in healthy subjects and in insulin-resistant obese men.  J ClinEndocrinolMetab 
89:3055-3061, 2004. 
21). 
Chilton R, Wyatt J, Nandish S, Oliveros R, Lujan M.  Cardiovascular comorbidities of 
type 2 diabetes mellitus:  defining the potential of glucagonlike peptide-1-based 
therapies.  Am J Med 124(suppl 1):S35-S53, 2011. 
22) Stumvoll M, MeyerC, Kreider M, Perriello G, Gerich J. Effects of glucagon on renal and 
hepatic glutamine gluconeogenesis in normal postabsorptive humans.Metabolism. 
47:1227-32, 1998. 
23) 
Basu A, Caumo A, Bettini F, Gelisio A, Alzaid A, Cobelli C: Impaired basal glucose 
effectiveness in NIDDM: contribution of defects in glucose disappearance and production, 
measured using an optimized minimal model independent protocol. Diabetes 46:421-432, 
1997 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
42 
V3    08/11/16 
24) 
Nielsen MF, Basu R, Wise S, Caumo A, Cobelli C, Rizza RA: Normal glucose-induced 
suppression of glucose production but impaired stimulation of glucose disposal in type 2 
diabetes: evidence for a concentration-dependent defect in uptake. Diabetes 47:1735-1747, 
1998 
25) 
Kelley DE, Mandarino LJ: Hyperglycemia normalizes insulin-stimulated skeletal muscle 
glucose oxidation and storage in noninsulin-dependent diabetes mellitus. J Clin Invest 
86:1999-2007, 1990 
26) 
DeFronzo RA, Ferrannini E, Hendler R, Felig P, Wahren J: Regulation of splanchnic and 
peripheral glucose uptake by insulin and hyperglycemia in man. Diabetes 32:35-45, 1983 
27) 
Connolly CC, Myers SR, Neal DW, Hastings JR, Cherrington AD. In the absence of 
counterregulatory hormones, the increase in hepatic glucose production during insulin-
induced hypoglycemia in the dog is initiated in the liver rather than the brain. 45:1805-13, 
1996. 
28) 
DeFronzo RA, Ferrannini E, Hendler R, Felig P, Wahren J: Regulation of splanchnic and 
peripheral glucose uptake by insulin and hyperglycemia in man. Diabetes 32:35-45, 1983 
29) 
 Katz LD, Glickman MG, Rapoport S, Ferrannini E, DeFronzo RA.  Splanchnic and 
peripheral disposal of oral glucose in man. Diabetes 32:675–679, 1983. 
30) 
Mari A, Wahren J, DeFronzo RA, Ferrannini E. Glucose absorption and production 
following oral glucose: comparison of compartmental and arteriovenous-difference 
methods. Metabolism 43:1419-25, 1994.  
31) 
Schernthaner G, Gross JL, Rosenstock J, Guarisco M, Fu M, Yee J, Kawaguchi M, 
Canovatchel W, Meininger G.  Canagliflozin compared with sitagliptin for patients with 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
43 
V3    08/11/16 
type 2 diabetes who do not have adequate glycemic control with metformin plus 
sulfonylurea.  Diabetes Care 36:2505-2515, 2013. 
32) 
Rosenstock J, Aggarwal N, .Polidori D, Zhao Y, Usiskin K, Capuano G, Canovatchel W.  
Dose-ranging effects of canagliflozin, a sodium-glucose cotransporter 2 inhibitor, as add-
on to metformin in subjects with type 2 diabetes.  Diabetes Care 35:1232-1238, 2012. 
33) 
Haring H-U, Merket L, Seewaldt-Becker E, Weimer M, Meinicke T, Woerle HJ, Broedl 
U.  Empagliflozin as add-on to metformin plus sulfonylurea (SU) for 24 weeks improves 
glycemic control in patients with type 2 diabetes (T2DM).  Diabetes 62(suppl 1):A279, 
2013. 
34) 
Kovacs C, Seshiah V, Swallow R, Jones R, Rattunde H, Woerle HJ, Broedl UC.  
Empagliflozin as add-on to pioglitazone with or without metformin improves glycemic 
control in patients with type 2 diabetes (T2DM).  Diabetes 62(suppl 1):A290, 2013. 
35) 
Haring H-U, Merker L, Seewaldt-Becker E, Weiner M, Meinicke T, Broedl UC.  
Emphagliflozin as add-on to metformin for 24 weeks improves glycemic control in patients 
with type 2 diabetes (T2DM).  Diabetes 62(suppl 1):A282, 2013. 
36) 
Stenlof K, Cefalu WT, Kim K-A, Alba M, Usiskin K, Tong C, Canovatchel W, 
Meininger G.  Efficacy and safety of canagliflozin monotherapy in subjectswithtype 2 
diabetes mellitus inadequatelycontrolledwithdiet and exercise.  DiabObesMetab 15:372-
382, 2013. 
37) 
Bailey CJ, Iqbal N, T'joen C, et.al. Dapagliflozinmonotherapy in drug-naïve patients with 
diabetes: a randomized-controlled trial of low-dose range. Diabetes ObesMetab. 14:951-
9, 2012 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
44 
V3    08/11/16 
38) 
Henry RR, Murray AV, Marmolejo MH, et.al. Dapagliflozin, metformin XR, or both: 
initial pharmacotherapy for type 2 diabetes, a randomised controlled trial. Int J ClinPract. 
66:446-56, 2012 
39) 
Bailey CJ, Gross JL, Pieters A, et.al. Effect of dapagliflozin in patients with type 2 
diabetes who have inadequate glycaemic control with metformin: a randomised, double-
blind, placebo-controlled trial. Lancet375:2223–33, 2010. 
40) 
Nauck MA, Del Prato S, Meier JJ, et.al. Dapagliflozin versus glipizide as add-on therapy 
in patients with type 2 diabetes who have inadequate glycemic control with metformin: a 
randomized, 52-week, double-blind, active-controlled noninferiority trial. Diabetes Care. 
34:2015-22, 2011 
41) 
Devineni D, Morrow L, Hompesch M, Skee D, Vandebosch A, Murphy J, Ways K, 
Schwartz S.  Canagliflozin improves glycaemic control over 28 days in subjects with type 
2 diabetes not optimally controlled on insulin.  Diabetes ObesMetab 14:539-545, 2012. 
42) 
Sha S, Devineni D, Ghosh A, Polidori D, Chien S, Wexler D, Shalayda K, Demarest K, 
Rothenberg P.  Canagliflozin, a novel inhibitor of sodium glucose co-transporter 2, dose 
dependently reduces calculated renal threshold for glucose excretion and increases 
urinary glucose excretion in healthy subjects.  Diabetes ObesMetab 13:669-672, 2011. 
43) 
Cervera A, Wajcberg E, Sriwijitkamol A, Fernandez M, Zuo P, Triplitt C, Musi N, 
DeFronzo RA, Cersosimo E.  Mechanism of action of exenatide to reduce postprandial 
hyperglycemia in type 2 diabetes.  Am J PhysiolEndocrinolMetab 294:E846-E852, 2008. 
44) 
Balas B, Baig MR, Watson C, Dunning BE, Ligueros-Saylan M, Wang Y, He YL, Darland 
C, Holst JJ, Deacon CF, Cusi K, Mari A, Foley JE, DeFronzo RA. The dipeptidyl peptidase 
IV inhibitor vildagliptin suppresses endogenous glucose production and enhances islet 


 
14-322H, Cersosimo, Form BB, 03-19-18, AMD 
45 
V3    08/11/16 
function 
after 
single-dose 
administration 
in 
type 
2 
diabetic 
patients.J 
ClinEndocrinolMetab. 92:1249-55, 2007. 
45) 
Bunck MC, Comer A, Eliasson B, Heine RJ, Shaginian RM, Taskinen MR, Smith U, Yki-
Jarvinen H, Diamant M.  Effects of exenatide on measure of -cell function after 3 years 
in metformin-treated patients with type 2 diabetes.  Diabetes Care 34:2041-2047, 2011. 
46) 
Pratley RE, Nauck M, Bailey T, Montanya E, Cuddihy R, Filetti S, Thomsen AB, 
Sondergaard RE, Davies M.  Liraglutide versus sitagliptin for patients with type 2 diabetes 
who did not have adequate glycaemic control with metformin: a 26-week,randomised, 
parallel-group, open-label trial.  Lancet 375:147-1456, 2010.