The Effects of Liraglutide on Sudomotor Function and Inflammation in Type 2 Diabetes

The investigators propose to examine the effects of GLP-1 receptor agonist Liraglutide on
autonomic sudomotor function and endothelial and neurovascular functions as well as markers
of inflammation in patients with type 2 diabetes mellitus (T2DM). The primary objective will
be changes in peripheral autonomic function using sudorimetry (Sudoscan) after 1 year of
treatment.

The secondary objectives include changes on markers of inflammation and oxidative/nitrosative
stress including C-reactive protein (CRP), interleukin 1 beta (IL-1β), Interleukin 6 (IL6),
interleukin 12 (IL12), interleukin 10 (IL10), tumor necrosis factor α (TNF α), plasminogen
activator Inhibitor 1 (PAI-1), superoxide dismutase (SOD), nitrotyrosine,
carboxymethyl-lysine (CML), thiobarbituric acid reactive substances (TBARS), and asymmetric
dimethylarginine (ADMA). Additional objectives include changes in neurovascular and
endothelial function, measured by continuous Laser Doppler assessment of skin blood flow in
response to different stimuli; and changes in sensory-motor peripheral nerve function,
measured by clinical neuropathy scores (NSS & NIS), quantitative sensory testing and nerve
conduction testing.

The aim of this study is to capture patients early in the disease process, when autonomic
dysfunction is still potentially reversible. Several studies have shown the presence of
autonomic imbalance in the early stages of diabetes and even in the pre-diabetic state
(impaired glucose tolerance, impaired fasting glucose, and metabolic syndrome). We
hypothesize that by treating type 2 diabetic patients with Liraglutide early in the disease
process (<10 years of diagnosis), we will be able to improve peripheral autonomic imbalance,
endothelial and neurovascular function, and reduce inflammation and oxidative/nitrosative
stress. This will shed further insight into the mechanisms by which glucagon-like peptide-1
(GLP-1) exerts a neuroprotective role and improves the inflammatory process. The possibility
of improving autonomic imbalance, endothelial function and inflammation may have important
impact in the development of new potential therapeutic strategies to abrogate the
microvascular complications of diabetes

Inclusion Criteria:

1. established type 2 diabetes (diabetes duration of >6 months and <10 years).

2. Age 18-80 years

3. HbA1c at screening ≤ 10%

4. Subjects on stable (≥3 months prior to Screening) Standard of Care background diabetic
therapy. Diabetic treatment regimens include diet and exercise alone or in association
with oral anti-diabetic drugs (monotherapy or combinations) and/or long-acting
insulin.

Exclusion Criteria:

1. Presence of type 1 diabetes mellitus (defined as C-peptide <1 ng /ml, <35y and prone
to ketoacidosis)

2. Treatment with rapid-acting or short-acting insulin within the last 3 months

3. Proliferative retinopathy or maculopathy requiring acute treatment

4. Impaired renal function , defined as serum creatinine ≥ 125 µmol/L (≥1.4 mg/dL) for
males and ≥ 110 µmol/L (≥1.24 mg/dL) for females

5. Impaired liver function, defined as aspartate transaminase (AST) or alanine
transaminase (ALT), ≥ 2.5 times the upper limit of normal

6. Presence of clinically significant peripheral or autonomic neuropathy that is clearly
of non-diabetic origin

7. Uncontrolled treated/untreated hypertension (systolic blood pressure (BP) ≥180 or
diastolic blood pressure (BP) ≥100 at screening)

8. Clinically significant active macrovascular disease including myocardial infarction or
cerebrovascular event within the past 6 months. Other exclusions include coronary
artery bypass graft or coronary angioplasty in the previous 3 months, unstable angina
pectoris (chest pain at rest, worsening chest pain, or admission to the emergency room
(ER) or hospital for chest pain) within the previous 3 months, and/or congestive heart
failure (NYHA Class III-IV)

9. Subjects known to be Hepatitis B surface antigen or Hepatitis C antibody positive with
active hepatitis.

10. Active infection (e.g., human immunodeficiency virus (HIV), hepatitis), or a history
of severe infection during the 30 days prior to screening

11. Evidence of immunocompromised status, including but not limited to individuals who
have undergone organ transplantation, who are known to be HIV positive, or who are
taking immunosuppressive drugs or chronic systemic corticosteroid treatment.

12. Major surgical procedure during the 30 days prior to screening

13. Diagnosis and/or treatment of malignancy (except for basal cell or squamous cell skin
cancer, in-situ carcinoma of the cervix, or in-situ prostate cancer) within the past 5
years

14. Known clinically significant gastric emptying abnormality (e.g. severe gastroparesis),
or history of gastric bypass (bariatric) surgery

15. Thyroid stimulating hormone (TSH) outside of normal limits at screening, or presence
of a thyroid nodule detected on physical examination that has not been fully evaluated

16. Thyroid hormone therapy that has not been stable for ≥6 weeks prior to Screening

17. Personal or family history of medullary thyroid carcinoma or multiple endocrine
neoplasia type 2 (MEN-2)

18. History of acute or chronic pancreatitis

19. Subjects taking medications that are known to affect autonomic function need to be at
a stable dose of those medications ≥ 3 months prior to inclusion in the study

20. Other clinically significant, active (over the past 12 months) disease of the
gastrointestinal, pulmonary, neurological, genitourinary or hematological system that,
in the opinion of the investigator, would compromise the subject's participation in
the study, might confound the results of the study or pose additional risk in
administering the study drug

21. Recurrent severe hypoglycemia and/or hypoglycemia unawareness.

22. Concurrent participation in another clinical trial with use of an experimental drug or
device within 30 days of study entry.

23. Known or suspected history of alcohol or substance abuse

24. Mental incapacity, unwillingness or language barrier precluding adequate understanding
of or cooperation with the study.

25. Women of childbearing potential (WOCBP*) who are pregnant, breast-feeding or intend to
become pregnant

26. WOCBP* must have a negative pregnancy test at Screening and must agree to use adequate
contraceptive methods** during the study and for one additional menstrual cycle
following the end-of-treatment visit

27. Known or suspected hypersensitivity to study product(s) or related products

28. Patients with low vitamin B12 levels will be excluded

29. Current use or use 6 months prior to study participation of dipeptidyl peptidase-4
(DPP-4) inhibitors or glucagon like peptide-1 (GLP-1) agonists will be excluded

30. Liraglutide has not been studied in combination with prandial insulin. Patients who
use prandial insulin may be excluded