Reversing Type 1 Diabetes After it is Established

Study Overview
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Brief Summary
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The primary purpose of this study is to determine if giving the combination therapy consisting of Thymoglobulin® (ATG) and Neulasta® (GCSF) to patients with established Type 1 Diabetes (T1D) is safe and secondarily, if the ATG and GCSF will preserve insulin production.

Detailed Description
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This is a randomized, placebo controlled, phase I/II trial. Potential subjects will be screened via a 4 hour mixed meal tolerance test to assess residual beta cell (C-peptide) function. If the C-peptide level at any time is ≥ 0.1 pmol/ml, and the subject meets the additional inclusion and exclusion criteria, they will be eligible for randomization and enrollment. The study will be randomized 2:1 such that 17 subjects will receive active therapy and 8 will receive placebo. Subjects must receive Thymoglobulin®/ Neulasta® or placebo within 8 weeks of randomization. Thymoglobulin® (2.5mg/kg)/placebo will be given as 0.5 mg/kg IV on day 1 and 2 mg/kg on day 2. Six doses of Neulasta® (6mg/dose)/placebo will be given as standard of care every 2 weeks, with the first dose given prior to discharge after the Thymoglobulin® infusion. Complete metabolic panel (CMP) and complete blood count (CBC) will be done at the screening visit, just prior to study drug initiation, daily during the Thymoglobulin® infusion admission, and at follow up visits. Following discharge, daily phone calls will be made to the subjects during the first 5 days of therapy and weekly thereafter. In addition, weekly phone calls for the month following completion of therapy will be used to document adverse reactions. Thereafter calls will be made every two weeks.

Official Title
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Reversing Type 1 Diabetes After it is Established: A Pilot Safety and Feasibility Study of Anti-Thymocyte Globulin (Thymoglobulin®)and Pegylated GCSF (Neulasta®) in Established Type 1 Diabetes

Conditions
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Diabetes Mellitus, Type 1

Intervention / Treatment
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* Drug: Anti-Thymocyte Globin (ATG)
* Drug: Placebo
* Drug: Pegylated GCSF


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Must be > 12 years < 45 Must have a diagnosis of T1D of greater than 4 months duration, with an upper limit of 2 years, Now only recruiting for those diagnosed greater than 1 year but less than 2 years. Must have at least one diabetes-related autoantibody present (e.g., islet cell autoantigen (ICA), GAD, ZnT8, or islet antigen 2 (IA2) autoantibodies) Must have stimulated C-peptide levels ≥ 0.1 pmol/ml (0.3ng/mL) when measured during a mixed meal tolerance test (MMTT), conducted at least 4 months from diagnosis of diabetes, and within 8 weeks of randomization Must be EBV PCR negative within two weeks of randomization if EBV seronegative at screening Be at least 6 weeks from last live immunization Be willing to forgo live vaccines for 3 months following last dose of study drug Be willing to comply with intensive diabetes management Normal screening values for complete blood count (CBC), renal function and electrolytes (CMP). Exclusion Criteria: Be immunodeficient or have clinically significant chronic lymphopenia: (Leukopenia (< 3,000 leukocytes /μL), neutropenia (<1,500 neutrophils/μL), lymphopenia (<800 lymphocytes/μL), or thrombocytopenia (<125,000 platelets/μL). Have a chronic infection at time of randomization Have a positive PPD Be currently pregnant or lactating, or anticipate getting pregnant within the next two years Require use of other immunosuppressive agents Have serologic evidence of current or past HIV, Tuberculosis, Hepatitis B or Hepatitis C infection Have any complicating medical issues or abnormal clinical laboratory results that interfere with study conduct, or cause increased risk to include pre-existing cardiac disease, chronic obstructive pulmonary disease (COPD), sickle cell disease, neurological, or blood count abnormalities (e.g., lymphopenia, leukopenia, or thrombocytopenia) Have a history of malignancies Evidence of liver dysfunction with angiotensin sensitivity test (AST) or ALT greater than 3 times the upper limits of normal Evidence of renal dysfunction with creatinine greater than 1.5 times the upper limit of normal Vaccination with a live virus within the last 6 weeks Current use of non-insulin pharmaceuticals that affect glycemic control Active participation in another T1D treatment study in the previous 30 days Known allergy to G-CSF or ATG Prior treatment with ATG or known allergy to rabbit derived products Any condition that in the investigator's opinion, may adversely affect study participation or may compromise the study results

Ages Eligible for Study
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Minimum Age: 12 Years
Maximum Age: 45 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: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Anti-Thymocyte Globin plus pegylated GCSF<br>Subjects will receive an infusion of Anti-Thymocyte Globin (ATG) followed by 6 doses of pegylated GCSF every 2 weeks for 10 weeks. | Drug: Anti-Thymocyte Globin (ATG)<br>* Anti-Thymocyte Globin (ATG) will be given as 0.5/mg/kg on day 1 and 2mg/kg on day 2.<br>* Other names: Thymoglobulin;Drug: Pegylated GCSF<br>* 6 doses of pegylated GCSF (6mg/dose) will be given subcutaneously every 2 weeks beginning after the ATG infusion.<br>* Other names: Neulasta;|
| Placebo Comparator: Placebo<br>Saline infusion will be given on both Day 1 and Day 2 followed by placebo injection given in identical volumes in identical syringes in the identical subcutaneous manner | Drug: Placebo<br>* Saline infusions will be given on Day 1 and Day 2 followed by placebo injections given in identical volumes in identical syringes<br>* Other names: Saline infusion;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Metabolic Function Baseline to 12 Months. | Area Under Curve (AUC) C-peptide production. Subjects underwent a 2 hour mixed meal tolerance test (MMTT) using a 6ml/kg load of boost to stimulate insulin production. Samples were collected at baseline, 10 minutes, 20 minutes, 30 minutes, 60 minutes, 90 minutes, and 120 minutes. AUC was then calculated. Subjects repeated the MMTT at baseline, 3, 6, 9, and 12 months following ATG/GCSF or placebo. The primary outcome for the study was the change over 12 months in AUC C-peptide (1 year - baseline) for those who received ATG/GCSF versus the change in AUC C-peptide (1 year - baseline) for those who received placebo | Baseline and 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percent Change in Regulatory T Cells (Treg) Baseline to 12 Months | Change in regulatory T cells (Treg) baseline to 12 months | Change in Baseline to 12 months | 
| A1c | Change in A1c baseline to 12 months | Change in baseline to 12 months | 
| Change in Insulin Requirements, Baseline to 12 Months | Change in Insulin Requirements, baseline to 12 months | Change from baseline to 12 months | 
| Change in Glutamic Acid Decarboxylase Antibodies (GADA) From Baseline to 12 Months | Change in Glutamic Acid Decarboxylase Antibodies (GADA) over 12 months | Change from baseline to 12 months | 
| Change in Insulin Autoantibodies (IAA) From Baseline to 12 Months | Change in Insulin Autoantibodies (IAA) over 12 months | Change from baseline to 12 months | 
| Change in Insulinoma Associated 2 Autoantibodies (IA-2A) From Baseline to 12 Months | Change in Insulinoma Associated 2 Autoantibodies (IA-2A) | Change from baseline to 12 months | 
| Change in Zinc Transporter 8 Autoantibodies (ZnT8A) From Baseline to 12 Months | Change in Zinc Transporter 8 Autoantibodies (ZnT8A) over 12 months | Change from baseline to 12 months | 
| Percentage of Neutrophils | Change in Neutrophil Count over 12 months | Change from baseline to 12 months | 
| Change in White Blood Count (WBC) From Baseline to 12 Months | Change in WBC over 12 months | Change from baseline to 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Autoimmune, Diabetes Mellitus, Glucose Metabolism