Fatty Liver Study in Patients With Type II Diabetes

In patients with type 2 diabetes whose glycemic control is not accomplished with Metformin
alone, there are several options for additional hypoglycemic agent. As per recent National
guidelines at least three "second line" agents can be added to metformin: thiazolidinediones,
Lantus insulin, and DPP4 inhibitors. All three approaches have been proven to help
accomplishing goals of therapy for glycemic control (HbA1c<7%) in clinical trials. Whether
one approach is superior to the other in improving associated non-glycemic metabolic
abnormalities and risk for future morbidity and mortality in patients with type 2 diabetes
remains a matter of intense debate. Among these abnormalities, excessive triglyceride content
in the liver (fatty liver or liver steatosis) is a major predictor of risk for non-alcoholic
steato-hepatitis (NASH) and liver cirrhosis. Fatty liver is highly prevalent in patients with
type 2 diabetes. There are no clinical studies done to determine if any of these three
therapeutic options is superior at reducing the liver triglyceride content in patients with
type 2 diabetes and fatty Liver. Therefore, in this study we propose to measure and compare
the effects on liver triglyceride content when either pioglitazone, lantus insulin, or DPP4
inhibitors are added to metformin in patients with poorly controlled type 2 diabetes
(HbA1c>7.6%) and fatty liver (presence of "bright" liver in abdominal ultrasound). The
primary objective of this trial is to measure changes in hepatic lipid content using three
common alternative therapeutic strategies to improve glycemic control in patients with type 2
diabetes who are not controlled with metformin alone.

Inclusion Criteria:

1. Subject has provided informed consent in a manner approved by the Institutional Review
Board (IRB) and is willing and able to comply with the trial procedures.

2. Adults at least 18 years of age at the time of consent.

3. Have type 2 diabetes mellitus.

4. Be on a stable medication with metformin (2000 mg/day) for at least 3 months prior to
study enrollment.

5. Have blood A1c >7.6% and < 8.5% within 3 months prior to study enrollment.

6. Have fatty liver, which is diagnosed by ultrasonographic findings of "bright liver"
within 1 year of study enrollment.

7. Stable medication for lipid lowering, blood pressure control, dietary supplements,
including vitamins, for at least 3 months.

8. Women of Childbearing Potential must be willing and able to use acceptable forms of
birth control while on the study.

Exclusion Criteria:

1. Currently taking medication that can affect glucose metabolism other than Metformin.

2. History of Kidney diseases that, in the opinion of the investigator , would place the
subject at increased risk of participation or plasma levels of creatinine > 1.4 for
women and > 1.5 for men.

3. History of Cirrhosis of liver, hepatitis, or other liver diseases that, in the opinion
of the investigator, would place the subject at increased risk of participation.

4. Current alcohol consumption more than12 to 15 g of alcohol a day, or >12 oz of beer, 5
oz of wine, or 1.5 oz of distilled spirits.

5. History of heart failure.

6. Concurrent participation on another research study

7. Use of an investigational agent in the 30 days prior to signing informed consent.

8. History of prior non-compliance or the presence or history of psychiatric conditions
(including drug or alcohol addiction) that would, in the opinion of the investigator,
make it difficult for the subject to comply with the study procedures or follow the
investigators instructions.

9. Females who are pregnant or lactating

10. Current Diagnosis or History of Bladder Cancer