The Effect of Intravenous Lactate on Brain Lactate Concentrations During Hypoglycemia

Study Overview
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Brief Summary
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Patients with type 1 diabetes (T1DM) who are unable to perceive symptoms of hypoglycemia, referred to as impaired awareness of hypoglycemia (IAH), are at very high risk of severe hypoglycemia. IAH affects approximately 25% of patients with T1DM. Brain lactate may be involved in the development of IAH. A recent study indicated increased brain lactate utilization during hypoglycemia in T1DM patients with IAH, which did not occur in patients with normal awareness of hypoglycemia (NAH). Conversely, administration of lactate to patients with NAH has been shown to attenuate counterregulatory hormone responses to and symptomatic awareness of hypoglycemia, thus causing a situation that resembles IAH. It has, however, not been demonstrated whether the excess of lactate is actually taken up or metabolized by the brain, and if so whether this occurs under euglycemic or hypoglycemic conditions or both. This project consists of two related studies. The objective of part 1 is to investigate the effect of elevated plasma lactate levels that are sufficient to impair awareness of hypoglycemia on brain lactate concentrations during euglycemia and hypoglycemia in T1DM patients with NAH. The objective of part 2 is to compare the effect of exogenous lactate on brain lactate concentrations between T1DM patients with NAH and T1DM patients with IAH. Furthermore, this study aims to determine the effect of acute hypoglycemia on the inflammatory function and composition of peripheral blood mononuclear cells.

Official Title
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The Effect of Intravenous Lactate Administration on Brain Lactate Concentrations and pH During Euglycemia and Hypoglycemia in Patients With Type 1 Diabetes With and Without Impaired Awareness of Hypoglycemia

Conditions
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Type 1 Diabetes Mellitus With Hypoglycemia

Intervention / Treatment
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* Drug: SodiumChloride
* Drug: Sodium Lactate


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diabetes duration ≥ 1 year Age: 18-50 years Body-Mass Index: 18-30 kg/m2 HbA1c: 42-75 mmol/mol (6-9%) Outcome Clarke questionnaire: 0-1 or >=3 Blood pressure: <160/90 mmHg Exclusion Criteria: Inability to provide informed consent Use medication other than insulin, except for oral contraceptives or stable thyroxin supplementation therapy Presence of any other medical condition that might interfere with the study protocol, such as brain injuries, epilepsy, a major cardiovascular disease event, known liver disease, anxiety disorders or a history of panic attacks. Microvascular complications of T1DM: Proliferative retinopathy, Symptomatic diabetic neuropathy (including autonomic neuropathy), Nephropathy; clinical/overt albuminuria or an estimated glomerular filtration rate <60ml/min/1.73m2 MR(I) contraindications (pregnancy, severe claustrophobia, metal parts in body)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 50 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Lactate infusion<br>Subjects will receive an intravenous lactate infusion to elevate plasma lactate levels | Drug: Sodium Lactate<br> <br> |
| Placebo Comparator: NaCl infusion<br>As a control condition, subjects will receive intravenous NaCl infusion | Drug: SodiumChloride<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| the effect of intravenous lactate administration, compared to placebo, on brain lactate concentrations during euglycemia and hypoglycemia in patients with T1DM and normal awareness of hypoglycemia |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 
| the effect of exogenous lactate on brain lactate concentrations during euglycemia and hypoglycemia between T1DM patients with normal awareness of hypoglycemia and T1DM patients with impaired awareness of hypoglycemia |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The changes in counterregulatory hormone and to hypoglycemia in response to lactate infusion, compared to placebo, in patients with normal awareness of hypoglycemia |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 
| The changes in and symptoms to hypoglycemia in response to lactate infusion, compared to placebo, in patients with normal awareness of hypoglycemia |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 
| The changes in brain pH in response to intravenous lactate administration, compared to placebo |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 
| Changes in immune cell composition capacity in response to hypoglycemia compared to euglycemia and in response to lactate infusion compared to placebo |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 
| Changes in immune cell cytokine production capacity in response to hypoglycemia compared to euglycemia and in response to lactate infusion compared to placebo |  | during stable euglycemia (40 min) and hypoglycemia (45 min) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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type 1 diabetes mellitus, impaired awareness of hypoglycemia, lactate, MR spectroscopy