Deep Phenotyping of Bone Disease in Type 2 Diabetes and Relations to Diabetic Neuropathy

Study Overview
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Brief Summary
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Objectives: The goal of this cross sectional clinical trial is to examine the phenotype of bone disease in type 2 diabetes.The main aims are to: Compare bone microarchitecture, bone biomechanical competence, and bone turnover markers as well as postural control in T2D patients with and without fractures. Examine how autonomic and peripheral neuropathy affects bone microarchitecture, bone material strength and bone turnover markers as well as postural control in T2D. Methods: The trial is of cross-sectional design and consists of examinations including Blood samples to analyze bone markers, glycemic state i.e. Bone scans including dual energy x-ray absorptiometry (DXA) and high resolution peripheral quantitative computed tomography (HRpQCT) to evaluate Bone Mineral Density, t-score and bone structure. Microindentation to evaluate bone material strength Skin autofluorescence to measure levels of advanced glycation endproducts (AGEs) in the skin Assesment of nerve function (peripheral and autonomic) Assesment of postural control, muscle strength and gait Participants: A total of 300 type 2 diabetes patients divided to three groups: 160 with no history of fractures or diabetic neuropathy 100 with a history of fracture(s) 40 with autonomic neuropathy or severe peripheral neuropathy

Official Title
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Deep Phenotyping of Bone Disease in Type 2 Diabetes and Relations to Diabetic Neuropathy

Conditions
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Type 2 Diabetes, Bone Disease, Osteoporosis, Diabetic Neuropathy Peripheral, Autonomic Neuropathy, Diabetic

Intervention / Treatment
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* Diagnostic Test: Dual Energy X-ray Absorbtiometry scan
* Diagnostic Test: High-resolution peripheral quantitative computed tomography
* Diagnostic Test: Microindentation
* Diagnostic Test: Thermal perception thresholds
* Diagnostic Test: Nerve conduction studies
* Diagnostic Test: Composite Autonomic Symptom Score 31
* Diagnostic Test: Skin biopsies with quantification of intra-epidermal nerve fibre density
* Diagnostic Test: Perception Threshold Tracking
* Diagnostic Test: Assessment of cardiovascular autonomic neuropathy
* Diagnostic Test: Handgrip strength
* Diagnostic Test: Force plate platform
* Diagnostic Test: Biospecimen collection
* Diagnostic Test: Isometric leg extension strength
* Diagnostic Test: Michigan Neuropathy Screening Instrument


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Men and women with minimum 40 years of age. Diagnosis of T2D. At least one of the following criteria must be met at diagnosis: HbA1c ≥ 48 mmol/mol (6,5 %) Plasma glucose ≥ 11,1 mmol/l Fasting plasma glucose ≥7,0 mmol/l Clinical effect of oral antidiabetic medication strengthens the diagnosis. Diagnosis of diabetes at least one year prior to inclusion of the study to avoid honeymoon diabetes. A history of fracture(s) (confirmed by radiographs analyzed by radiologist) following the diabetes diagnosis (T2D F+ group) Diagnosed with severe peripheral (VPT ≥ 50) or autonomic neuropathy defined by cardiac autonomic reflex tests or severe abnormalities in orthostatic blood pressure (T2D N+ group) Signed the informed consent. Not defined by the exclusion criteria. Exclusion Criteria: Severe decreased liver function (Alanin amino-transaminase (ALAT) >250 U/l, Gamma-Glutamyltransferase (GGT) >150 U/l). Moderate to severe kidney dysfunction, estimated Glomerular Filtration Rate (eGFR) <15 mmol/L/1,73m2. Pregnancy or breast feeding. Active malignancy or terminal ill. Previous chemotherapy or immunomodulating treatment Known severe vitamin deficiency Current or previous alcohol- or drug abuse. Not being able to understand Danish written and/or verbally. Terms according to investigators judgement that makes subjects unsuitable to participate including lack of ability to understand and comply with instructions and/or reduced physical ability, limiting the ability to participate in the examinations. Participating in other clinical studies utilizing experimental treatment or medication. Subjects with pathologic fractures (defined as fractures due to local tumors, tumor-like lesions, or focal demineralization as visualized on radiographs). Primary hyperparathyroidism, Paget's disease and other metabolic bone diseases, uncontrolled thyrotoxicosis, celiac disease not controlled by diet, known hypogonadism, severe COPD, hypopituitarism, Cushing's disease. Fracture < 6 month ago Initiation of antiresorptive or bone anabolic drugs <12 months ago to ensure stable bone turnover markers. History of fractures following the diagnosis of diabetes (T2D F-/N- and T2D N+ groups). History of peripheral or autonomic neuropathy defined by cardiac autonomic reflex tests or severe abnormalities in orthostatic blood pressure (T2D F-/N- group).

Ages Eligible for Study
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Minimum Age: 40 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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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| T2D F-/N-<br>Subjects with T2D and no previous history of any fractures or diabetic neuropathy (n=160) | Diagnostic Test: Dual Energy X-ray Absorbtiometry scan<br>* Evaluation of body composition and bone mass density<br>* Other names: DXA;Diagnostic Test: High-resolution peripheral quantitative computed tomography<br>* High-resolution peripheral quantitative computed tomography (HR-pQCT) assesses both volumetric bone mineral density (vBMD) and trabecular and cortical microarchitecture.<br>* Other names: HR-pQCT;Diagnostic Test: Microindentation<br>* Measures Bone Material Strength Index (BMSi) of cortical bone.<br>* Other names: Osteoprobe, ActiveLife, Santa Barbara, CA;Diagnostic Test: Thermal perception thresholds<br>* Heat and cold perception thresholds<br>* Other names: Quantitative Sensory Testing;Diagnostic Test: Nerve conduction studies<br>* Nerve conduction and amplitude of sural nerve<br>* Other names: NCStat-DPN-Check;Diagnostic Test: Composite Autonomic Symptom Score 31<br>* A validated self-assessment questionnaire quantifying the severity and distribution of autonomic symptoms across six domains (orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder and pupillomotor functions) by scoring 31 clinically selected questions<br>* Other names: COMPASS 31;Diagnostic Test: Skin biopsies with quantification of intra-epidermal nerve fibre density<br>* Skin biopsy<br>* Other names: PGP9.5, antibodies for subsets of ion-channels ect;Diagnostic Test: Perception Threshold Tracking<br>* Transcutaneous stimulation of large and small nerve fibres using weak electrical currents<br>* Other names: PTT;Diagnostic Test: Assessment of cardiovascular autonomic neuropathy<br>* Electrocardiographic recordings at rest and during cardiovascular autonomic reflex tests.<br>* Other names: Vagus device, Medicus Engineering ApS, Aarhus, Denmark;Diagnostic Test: Handgrip strength<br>* Evaluation of muscle strength<br>* Other names: Hydraulic dynamometer, Saehan Corporation, Gyungnam, South Korea;Diagnostic Test: Force plate platform<br>* Evaluation of balance while standing still<br>* Other names: Plux Biosignals, S.A, Arruda dos Vinhos, Portugal;Diagnostic Test: Biospecimen collection<br>* Biochemistry including bone turnover markers, glycemic status, inflammation markers i.e<br>* Other names: Urine samples;Diagnostic Test: Isometric leg extension strength<br>* Evaluation of muscle strength<br>* Other names: EasyForce Digital Dynamometer;Diagnostic Test: Michigan Neuropathy Screening Instrument<br>* MNSI is used to assess status of peripheral neuropathy. It includes two separate assessments: a 15-item self-administered questionnaire and a lower extremity examination that includes inspection and assessment of vibratory sensation and ankle reflexes.<br>* Other names: MNSI;|
| T2D F+<br>Subjects with T2D with a previous history of a fracture(s) (any fracture, major osteoporotic fracture (MOF) and peripheral) (n=100) | Diagnostic Test: Dual Energy X-ray Absorbtiometry scan<br>* Evaluation of body composition and bone mass density<br>* Other names: DXA;Diagnostic Test: High-resolution peripheral quantitative computed tomography<br>* High-resolution peripheral quantitative computed tomography (HR-pQCT) assesses both volumetric bone mineral density (vBMD) and trabecular and cortical microarchitecture.<br>* Other names: HR-pQCT;Diagnostic Test: Microindentation<br>* Measures Bone Material Strength Index (BMSi) of cortical bone.<br>* Other names: Osteoprobe, ActiveLife, Santa Barbara, CA;Diagnostic Test: Thermal perception thresholds<br>* Heat and cold perception thresholds<br>* Other names: Quantitative Sensory Testing;Diagnostic Test: Nerve conduction studies<br>* Nerve conduction and amplitude of sural nerve<br>* Other names: NCStat-DPN-Check;Diagnostic Test: Composite Autonomic Symptom Score 31<br>* A validated self-assessment questionnaire quantifying the severity and distribution of autonomic symptoms across six domains (orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder and pupillomotor functions) by scoring 31 clinically selected questions<br>* Other names: COMPASS 31;Diagnostic Test: Perception Threshold Tracking<br>* Transcutaneous stimulation of large and small nerve fibres using weak electrical currents<br>* Other names: PTT;Diagnostic Test: Assessment of cardiovascular autonomic neuropathy<br>* Electrocardiographic recordings at rest and during cardiovascular autonomic reflex tests.<br>* Other names: Vagus device, Medicus Engineering ApS, Aarhus, Denmark;Diagnostic Test: Handgrip strength<br>* Evaluation of muscle strength<br>* Other names: Hydraulic dynamometer, Saehan Corporation, Gyungnam, South Korea;Diagnostic Test: Force plate platform<br>* Evaluation of balance while standing still<br>* Other names: Plux Biosignals, S.A, Arruda dos Vinhos, Portugal;Diagnostic Test: Biospecimen collection<br>* Biochemistry including bone turnover markers, glycemic status, inflammation markers i.e<br>* Other names: Urine samples;Diagnostic Test: Isometric leg extension strength<br>* Evaluation of muscle strength<br>* Other names: EasyForce Digital Dynamometer;Diagnostic Test: Michigan Neuropathy Screening Instrument<br>* MNSI is used to assess status of peripheral neuropathy. It includes two separate assessments: a 15-item self-administered questionnaire and a lower extremity examination that includes inspection and assessment of vibratory sensation and ankle reflexes.<br>* Other names: MNSI;|
| T2D N+<br>Subjects with T2D matched by age and sex with severe peripheral (vibration perception threshold (VPT) > 50) or a history of autonomic neuropathy (n=40) | Diagnostic Test: Dual Energy X-ray Absorbtiometry scan<br>* Evaluation of body composition and bone mass density<br>* Other names: DXA;Diagnostic Test: High-resolution peripheral quantitative computed tomography<br>* High-resolution peripheral quantitative computed tomography (HR-pQCT) assesses both volumetric bone mineral density (vBMD) and trabecular and cortical microarchitecture.<br>* Other names: HR-pQCT;Diagnostic Test: Microindentation<br>* Measures Bone Material Strength Index (BMSi) of cortical bone.<br>* Other names: Osteoprobe, ActiveLife, Santa Barbara, CA;Diagnostic Test: Thermal perception thresholds<br>* Heat and cold perception thresholds<br>* Other names: Quantitative Sensory Testing;Diagnostic Test: Nerve conduction studies<br>* Nerve conduction and amplitude of sural nerve<br>* Other names: NCStat-DPN-Check;Diagnostic Test: Composite Autonomic Symptom Score 31<br>* A validated self-assessment questionnaire quantifying the severity and distribution of autonomic symptoms across six domains (orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder and pupillomotor functions) by scoring 31 clinically selected questions<br>* Other names: COMPASS 31;Diagnostic Test: Skin biopsies with quantification of intra-epidermal nerve fibre density<br>* Skin biopsy<br>* Other names: PGP9.5, antibodies for subsets of ion-channels ect;Diagnostic Test: Perception Threshold Tracking<br>* Transcutaneous stimulation of large and small nerve fibres using weak electrical currents<br>* Other names: PTT;Diagnostic Test: Assessment of cardiovascular autonomic neuropathy<br>* Electrocardiographic recordings at rest and during cardiovascular autonomic reflex tests.<br>* Other names: Vagus device, Medicus Engineering ApS, Aarhus, Denmark;Diagnostic Test: Handgrip strength<br>* Evaluation of muscle strength<br>* Other names: Hydraulic dynamometer, Saehan Corporation, Gyungnam, South Korea;Diagnostic Test: Force plate platform<br>* Evaluation of balance while standing still<br>* Other names: Plux Biosignals, S.A, Arruda dos Vinhos, Portugal;Diagnostic Test: Biospecimen collection<br>* Biochemistry including bone turnover markers, glycemic status, inflammation markers i.e<br>* Other names: Urine samples;Diagnostic Test: Isometric leg extension strength<br>* Evaluation of muscle strength<br>* Other names: EasyForce Digital Dynamometer;Diagnostic Test: Michigan Neuropathy Screening Instrument<br>* MNSI is used to assess status of peripheral neuropathy. It includes two separate assessments: a 15-item self-administered questionnaire and a lower extremity examination that includes inspection and assessment of vibratory sensation and ankle reflexes.<br>* Other names: MNSI;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluation of differences in bone microarchitecture between T2D patients with and without previous fractures assessed by HRpQCT. | Bone microarchitecture is a composite outcome assessed by HRpQCT at radius and tibia: Total volumetric mineral density, Trabecular volumetric mineral density, Cortical volumetric mineral density, Trabecular number, Trabecular thickness, Cortical thickness, Trabecular separation, Cortical porosity, bone stiffness and failure load. | Through study completion, estimated 3.5 years | 
| Differences in Bone material strength index (BMSi) between T2D patients with and without previous fractures measured by microindentation. |  | Through study completion, estimated 3.5 years | 
| Evaluation of differences in bone turnover markers between T2D patients with and without previous fractures by biochemical analysis of different bone markers (CTX, P1NP, osteocalcin (OC), ucOC, sclerostin, osteoglycin and osteopontin). |  | Through study completion, estimated 3.5 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The impact of autonomic neuropathy on bone microarchitecture in T2D assessed by HR-pQCT. | Compare bone microarchitectural parameters (assessed by HR-pQCT) in T2D patients with and without autonomic neuropathy (assessed by CAN-score from Vagus™ device, COMPASS31-score, intraepidermal nerve fiber density, orthostatic BP and ECG). | Through study completion, estimated 3.5 years | 
| The impact of autonomic neuropathy on bone material strength in T2D assessed by microindentation. | Compare bone material strength (assessed by microindentation) in T2D patients with and without autonomic neuropathy (assessed by CAN-score from Vagus™ device, COMPASS31-score, intraepidermal nerve fiber density, orthostatic BP and ECG). | Through study completion, estimated 3.5 years | 
| The impact of autonomic neuropathy on bone turnover markers in T2D. | Compare bone turnover markers in T2D patients with and without autonomic neuropathy (assessed by CAN-score from Vagus™ device, COMPASS31-score, intraepidermal nerve fiber density, orthostatic BP and ECG) | Through study completion, estimated 3.5 years | 
| The impact of peripheral neuropathy on bone microarchitecture in T2D assessed by HR-pQCT. | Compare bone microarchitectural parameters (assessed by HR-pQCT) in T2D patients with and without peripheral neuropathy (assessed by MNSI, PTT, QST, sural nerve conduction study and intraepidermal nerve fiber density) | Through study completion, estimated 3.5 years | 
| The impact of peripheral neuropathy on bone material strength in T2D assessed by microindentation. | Compare bone material strength (assessed by microindentation) in T2D patients with and without peripheral neuropathy (assessed by MNSI, PTT, QST, sural nerve conduction study and intraepidermal nerve fiber density) | Through study completion, estimated 3.5 years | 
| The impact of peripheral neuropathy on bone turnover markers in T2D. | Compare bone turnover markers in T2D patients with and without peripheral neuropathy (assessed by MNSI, PTT, QST, sural nerve conduction study and intraepidermal nerve fiber density). | Through study completion, estimated 3.5 years | 
| Compare postural control between T2D patients with and without fractures assessed by force platform. |  | Through study completion, estimated 3.5 years | 
| Compare postural control between T2D patients with and without peripheral/autonomic neuropathy. | Neuropathy assessed by PTT, QST, sural nerve conduction study, skin biopsies, COMPASS-31, MNSI and Vagus device. Postural control assessed by force platform. | Through study completion, estimated 3.5 years | 
| Compare muscle mass and strength in T2D patients with and without fractures | Compare muscle mass (assessed by DXA scan) and muscle strength (assessed by hand grip, leg extension strength and functional tests) in T2D patients with and without fractures. | Through study completion, estimated 3.5 years | 
| Compare muscle mass and strength in T2D patients with and without neuropathy | Compare muscle mass (assessed by DXA scan) and muscle strength (assessed by hand grip, leg extension strength and functional tests) in T2D patients with and without neuropathy (assessed by PTT, QST, sural nerve conduction study, skin biopsies, COMPASS-31, MNSI and Vagus device). | Through study completion, estimated 3.5 years |