## Protocol Section
### Identification Module
**NCT ID:** NCT06422494

**Acronym:** RAID-II

**Brief Title:** The Role of the Adrenergic System in Hypoglycaemia Induced Inflammatory Response in People With Type 1 Diabetes and People Without Type 1 Diabetes-RAID-II

**Official Title:** The Role of the Adrenergic System in Hypoglycaemia Induced Inflammatory Response in People With Type 1 Diabetes and People Without Type 1 Diabetes-RAID-II

#### Organization Study ID Info
**ID:** 115142
#### Organization
**Class:** OTHER
**Full Name:** Radboud University Medical Center
### Status Module
#### Completion Date
**Date:** 2025-10

**Type:** ESTIMATED

#### Expanded Access Info
#### Last Update Post Date
**Date:** 2024-05-22

**Type:** ACTUAL

**Last Update Submit Date:** 2024-05-21

**Overall Status:** NOT_YET_RECRUITING

#### Primary Completion Date
**Date:** 2025-09

**Type:** ESTIMATED

#### Start Date
**Date:** 2024-09

**Type:** ESTIMATED

**Status Verified Date:** 2024-05

#### Study First Post Date
**Date:** 2024-05-21
**Type:** ACTUAL
**Study First Submit Date:** 2024-05-08
**Study First Submit QC Date:** 2024-05-14
### Sponsor Collaborators Module

#### Lead Sponsor

**Class:** OTHER

**Name:** Radboud University Medical Center

#### Responsible Party

**Type:** SPONSOR

### Oversight Module

**Is FDA Regulated Device:** False

**Is FDA Regulated Drug:** False

**Oversight Has DMC:** False

### Description Module

**Brief Summary:** The goal of this trial is to study the effect that adrenaline has on the immune reaction seen during a low blood sugar. People with type 1 diabetes do not produce their own insulin. The cells in the pancreas that produce insulin are destroyed. People with type 1 diabetes require daily insulin administration. As a consequence of this insulin therapy the blood sugar can dip too low, causing symptoms such as confusion, irritation and tiredness. This is called hypoglycaemia. Hypoglycaemia has been associated with an increased risk for cardiovascular disease such as heart attacks. During hypoglycaemia the immune system is activated. The immune system consists of white blood cells which produce cytokines, these are proteins used to kill pathogens such as bacteria. During hypoglycaemia there are no pathogens but the cytokines are still produced, leading to unwanted damage. A previous study performed by our research group showed that the immune system activation caused by hypoglycaemia is associated with the stress hormone adrenaline. Adrenaline is released by the body in moments of stress such as during running or bungee jumping. Adrenaline is also released by the body during hypoglycaemia to increase the sugar level. Our hypothesis is that adrenaline activates the immune system during hypoglycaemia. Adrenaline acts in the body through two receivers, these are called alpha and beta receptors. These are present on almost all cells in the body especially on the immune cells. With the study we want to study the situation where there is a hypoglycaemia without the adrenaline. We will achieve this by lowering the blood sugar in participants. During the low blood sugar we will administer two drugs, which will attach themselves to the adrenaline receivers, the alpha and beta receptor. With this method we hope to block the adrenaline effects and with that block the immune response caused by adrenaline.

**Detailed Description:** Rationale: Hypoglycaemia has shown to cause a sustained pro-inflammatory response which could promote a pro-atherogenic state and explain the association between hypoglycaemia and cardiovascular events. This pro-inflammatory response has been linked to the adrenaline response to hypoglycaemia. Adrenergic blockade with α and β adrenergic receptor antagonists (ARA) has shown to blunt the leukocyte response after hypoglycaemia induction and adrenaline administration. Whether and to what degree a combined blockade blunts the hypoglycaemia induced pro-inflammatory response is unknown.

Objective: to examine the effect of adrenergic inhibition on the hypoglycaemia induced inflammatory response (e.g. leukocyte phenotype, cytokines, inflammatory proteins) by performing a hyperinsulinaemic hypoglycaemic glucose clamp alongside infusion of α-ARA and β-ARA. Secondary objectives consist of the effect of adrenergic blockade during hypoglycaemia on atherogenic parameters and glucose metrics ( e.g. time in range).

Study design: Intervention study with a cross-over design

Study population: Potentially eligible adult ( 16 - 75 years) participants will be recruited through social media, the Radboudumc outpatient clinic and other advertisements. We will recruit a total of 24 individuals, i.e. 12 healthy participants and 12 participants with type 1 diabetes. Participants with type 1 diabetes will be twice ( as there are two investigational days) equipped with a blinded continuous glucose monitoring device (CGM) during the test, which will measure interstitial glucose levels for a total of 10 days.

Intervention: All participants will undergo a hyperinsulinaemic hypoglycaemic glucose clamp ( nadir 2.8 mmol/L). During the clamp the participants will be randomized to receive an infusion of saline or an infusion of phentolamine and propranolol. This will be done using a cross-over design. The participants will undergo both the saline and adrenergic blockade.

Main study parameters/endpoints: The main study parameter will be the monocyte count after 60 minutes hyperinsulinaemic hypoglycaemic clamp and adrenergic blockade during the clamp.

### Conditions Module

**Conditions:**

- Diabetes Mellitus, Type 1

- Inflammation

### Design Module

#### Design Info

**Allocation:** RANDOMIZED

**Intervention Model:** CROSSOVER

**Intervention Model Description:** Potentially eligible adult ( 16 - 75 years) participants will be recruited through social media, the Radboudumc outpatient clinic and other advertisements. We will recruit a total of 24 individuals, i.e. 12 healthy participants and 12 participants with type 1 diabetes. Participants with type 1 diabetes will be twice ( as there are two investigational days) equipped with a blinded continuous glucose monitoring device (CGM) during the test, which will measure interstitial glucose levels for a total of 10 days.

##### Masking Info

**Masking:** SINGLE

**Masking Description:** Participants will be blinded tot the co-infusion during hypoglycaemia. This will be achieved by similar labelling, with phentolamine having the label infusion A and the propranolol infusion having the label infusion B. When administering saline the 50 milliliter syringes will be filled with saline instead of the solution containing either phentolamine or propranolol. Both saline syringes will still have the labels infusion A and infusion B. The investigators will not be blinded as they will be preparing the adrenergic solutions and the saline solutions. The participants will receive the same amount of millilitres during both infusions, determined by the amount infused during adrenergic blockade. Participants will be block-randomized with blocks of 2 using a randomisation list allocated to receive either the adrenergic blockade or the saline first. The coordinating investigator will have access to this list.

**Who Masked:**

- PARTICIPANT

**Primary Purpose:** BASIC_SCIENCE

#### Enrollment Info

**Count:** 24

**Type:** ESTIMATED

**Phases:**

- NA

**Study Type:** INTERVENTIONAL

### Arms Interventions Module

#### Arm Group 1

**Description:** The participants without type 1 diabetes

**Intervention Names:**

- Drug: hyperinsulinaemic hypoglycaemic clamp

- Drug: Propranolol Hydrochloride 1 MG/ML

- Drug: Phentolamine

**Label:** Participants without type 1 diabetes

**Type:** ACTIVE_COMPARATOR

#### Arm Group 2

**Description:** Participants with type 1 diabetes

**Intervention Names:**

- Drug: hyperinsulinaemic hypoglycaemic clamp

- Drug: Propranolol Hydrochloride 1 MG/ML

- Drug: Phentolamine

**Label:** Participants with type 1 diabetes

**Type:** ACTIVE_COMPARATOR

### Interventions

#### Intervention 1

**Arm Group Labels:**

- Participants with type 1 diabetes

- Participants without type 1 diabetes

**Description:** Insulin will be infused at a continuous rate of 60 mU∙m-2 ∙min-1 and glucose 20% will be infused at a variable rate, aiming for stable plasma glucose levels of 5.0 mmol/L. The infusion rate of glucose will be adjusted by plasma glucose levels, measured at 5-minute intervals. After 30 minutes of stable euglycaemia, plasma glucose levels will be allowed to drop gradually to 2.8 mmol/L and will be maintained at this level for 60 minutes. Then, insulin infusion and adrenergic blockade infusions will be stopped. Glucose infusion will be increased and then tapered until stable euglycaemia plasma levels are reached.

**Name:** hyperinsulinaemic hypoglycaemic clamp

**Type:** DRUG

#### Intervention 2

**Arm Group Labels:**

- Participants with type 1 diabetes

- Participants without type 1 diabetes

**Description:** When euglycaemic level of 5.0mmol/L is achieved we will start the adrenergic blockade which will continue throughout euglycaemia and hypoglycaemia. The participants will be administered a bolus of phentolamine of 70µg/kg followed by a dose of 7.0µg/kg/min continuous infusion and a bolus of propranolol of 14µg/kg followed by a dose of 1.4µg/kg/min.

**Name:** Propranolol Hydrochloride 1 MG/ML

**Type:** DRUG

#### Intervention 3

**Arm Group Labels:**

- Participants with type 1 diabetes

- Participants without type 1 diabetes

**Description:** When euglycaemic level of 5.0mmol/L is achieved we will start the adrenergic blockade which will continue throughout euglycaemia and hypoglycaemia. The participants will be administered a bolus of phentolamine of 70µg/kg followed by a dose of 7.0µg/kg/min continuous infusion and a bolus of propranolol of 14µg/kg followed by a dose of 1.4µg/kg/min.

**Name:** Phentolamine

**Type:** DRUG

### Outcomes Module

#### Other Outcomes

**Measure:** HbA1c expressed in mmol/L

**Time Frame:** At screening

**Measure:** Serum creatinine for kidney function expressed in umol/L

**Time Frame:** Once at the screening at least 1 week before the hypoglycaemia

**Description:** Measured by automatic sphygmomanometer

**Measure:** Vitals ( blood pressure and heart rate)

**Time Frame:** At both investigational days, every 15 minutes during each investigational day for a total of 8 hours.

**Description:** Using length and weight expressed in kg/m\^2

**Measure:** Body mass index

**Time Frame:** Once at the screening at least 1 week before the hypoglycaemia

**Measure:** Age

**Time Frame:** Once at the screening at least 1 week before the hypoglycaemia

**Description:** Male or female

**Measure:** Sex

**Time Frame:** Once at the screening at least 1 week before the hypoglycaemia

**Measure:** Duration of diabetes ( years)

**Time Frame:** Once at the screening at least 1 week before the hypoglycaemia

#### Primary Outcomes

**Description:** The number of monocytes following 60 minutes hypoglycaemia and adrenergic blockade compared to baseline. Adrenergic blockade using Phentolamine and Propranolol intravenously. Expressed in 10\^3/µl measured using a sysmex machine.

**Measure:** Monocyte count after 60 minutes of hypoglycaemia and adrenergic blockade

**Time Frame:** After 60 minutes of hypoglycaemia and adrenergic blockade

#### Secondary Outcomes

**Description:** Leukocyte count at the time points 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia, +1 day, +3 days and 1 week after of hypoglycaemia (e.g. Monocytes, granulocytes, lymphocytes).

**Measure:** Leukocyte count at the time points

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia, +1 day, +3 days and 1 week after of hypoglycaemia

**Description:** Ex vivo production of pro- and anti-inflammatory cytokines and chemokines after ex vivo stimulation of isolated leukocytes, including Tumor necrosis factor-α, Interleukin-6, Interleukin-10 and Interleukin-1β, 1β

**Measure:** Ex vivo production of pro- and anti-inflammatory cytokines and chemokines

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia, +1 day, +3 days and 1 week after of hypoglycaemia

**Description:** 92 circulating inflammatory proteins using Olink Proteomics inflammation panel

**Measure:** 92 circulating inflammatory proteins

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Inflammatory plasma protein using ELISA,(e.g high sensitive-crp)

**Measure:** Inflammatory plasma protein ( e.g. high-sensitive crp)

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Atherogenic parameters using ELISA including but not limited to, vascular endothelial cell adhesion molecule-1, vascular endothelial cell adhesion molecule-1, E-Selectin, P-selectin, Plasminogen activator inhibitor-1, Plasma Endothelin

**Measure:** Atherogenic parameters

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Plasma levels of hormones ( Cortisol, insulin, glucagon, growth-hormone, adrenaline, noradrenaline)

**Measure:** Plasma levels of hormones

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Amount of events

**Measure:** Amount of hypoglycaemic events measured by the blinded continuous glucose monitor

**Time Frame:** During the full study, 3 days before and 7 days after each investigational day

**Description:** Variability of glucose expressed as a standard deviation of the mean glucose

**Measure:** Variability measured by the blinded continuous glucose monitor

**Time Frame:** During the full study, 3 days before and 7 days after each investigational day

**Description:** Average glucose during the 10 days of measuring expressed as mmol/L

**Measure:** Average glucose measured by the blinded continuous glucose monitor

**Time Frame:** During the full study, 3 days before and 7 days after each investigational day

**Description:** Amount of time that glucose is between 3.8 and 10 mmol/L expressed as a percentage

**Measure:** Time in range measured by the blinded continuous glucose monitor

**Time Frame:** During the full study, 3 days before and 7 days after each investigational day

**Description:** Amount of plasma glycerol during and after hypoglycaemia

**Measure:** Amount of plasma glycerol

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Amount of Non-esterified fatty acids (NEFAs) during and after hypoglycaemia

**Measure:** Amount of Non-esterified fatty acids

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Measuring a panel of amino acids

**Measure:** Untargeted metabolomics profiling

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Gene expression changes in leukocytes (e.g. using RNA sequencing, quantitative PCR)

**Measure:** Gene expression changes in leukocytes

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Epigenetic changes in leukocytes (e.g. using Assay for Transposase- Accessible Chromatin using sequencing (ATACseq), DNA methylation analysis)

**Measure:** Epigenetic changes in leukocytes

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Description:** Functional changes in monocytes (e.g. using adhesion assays, differentiation experiments)

**Measure:** Functional changes in monocytes

**Time Frame:** 0, 30 minutes after euglycaemia, 60 minutes during hypoglycaemia

**Measure:** Adrenergic symptoms assessed using the validated Edinburgh Hypoglycaemia Score

**Time Frame:** 0, 30 minutes after euglycaemia, 30 minutes and 60 minutes during hypoglycaemia

**Measure:** Hypoglycaemia awareness using the modified Clarke score

**Time Frame:** At screening

### Eligibility Module

**Eligibility Criteria:** Inclusion Criteria:

* Overall inclusion criteria:

  * Ability to provide written informed consent
  * Body-Mass Index: 18,5-35 kg/m2
  * Age ≥16 years, ≤ 75 years
  * Blood pressure: \<140/90 mmHg
  * Non-smoking
  * Electrocardiogram not showing any serious arrythmias (premature ventricular complexes and premature atrial complexes accepted)

Diabetes group specific criteria:

* Insulin treatment according to basal-bolus insulin regimen (injections or insulin pump)
* Duration of diabetes \> 1 year
* HbA1c \< 100 mmol/mol,

Exclusion Criteria:

* Any event of cardiovascular disease in the past 5 years (e.g. myocardial infarction, stroke, symptomatic peripheral arterial disease)
* Pregnancy or breastfeeding or unwillingness to undertake measures for birth control
* Active epilepsy ( with the need for treatment)
* Allergy for sulphite
* Active asthma with use of β2-bronchodilators or obstructive lung disease
* Current treatment with Alpha- or beta-blockers (e.g. doxazosin, propranolol)
* History of clinical significant Arrhythmias
* Use of immune-modifying drugs or antibiotics
* Use of antidepressants ( Including monoamine oxidase inhibitors, tricyclic antidepressants and serotonin-reuptake inhibitors)
* Use of antipsychotics
* Use of statins with the inability to stop statins \>2 weeks before the investigational day.
* Proliferative retinopathy
* Nephropathy with an estimated glomerular filtration rate (by Chronic Kidney Disease Epidemiology Collaboration equation, CKD-EPI) ˂60ml/min/1.73m2

**Gender Based:** True

**Gender Description:** We aim to match our participants with each other to have comparable groups. So we aim to have the same amount of males and females.

**Healthy Volunteers:** True

**Maximum Age:** 75 Years

**Minimum Age:** 16 Years

**Sex:** ALL

**Standard Ages:**

- CHILD

- ADULT

- OLDER_ADULT

### Contacts Locations Module

#### Central Contacts

**Contact 1:**

**Email:** ilyas.mustafajev@radboudumc.nl

**Name:** Ilyas Mustafajev, M.D.

**Phone:** 0629669369

**Role:** CONTACT

**Contact 2:**

**Email:** rick.meijer@radboudumc.nl

**Name:** Rick Meijer, MD, PhD

**Role:** CONTACT

#### Overall Officials

**Official 1:**

**Affiliation:** Radboud University Medical Center (Radboudumc)

**Name:** Cees Tack, MD, PhD

**Role:** PRINCIPAL_INVESTIGATOR

### IPD Sharing Statement Module

**Access Criteria:** The coordinating researcher will review access requests. Seeing as the data are all anonymized access will be granted for additional research in the field of inflammation or diabetes.

**Description:** We will share the study protocol using a data repository accessible through the research team on demand. Starting around 6 months after publication.

**Info Types:**

- STUDY_PROTOCOL

**IPD Sharing:** YES

**Time Frame:** 6 months after publication

## Derived Section

### Condition Browse Module - Ancestors

- ID: D000044882

- Term: Glucose Metabolism Disorders

- ID: D000008659

- Term: Metabolic Diseases

- ID: D000004700

- Term: Endocrine System Diseases

- ID: D000010335

- Term: Pathologic Processes

- ID: D000001327

- Term: Autoimmune Diseases

- ID: D000007154

- Term: Immune System Diseases

### Condition Browse Module - Browse Branches

- Abbrev: BC18

- Name: Nutritional and Metabolic Diseases

- Abbrev: BC19

- Name: Gland and Hormone Related Diseases

- Abbrev: All

- Name: All Conditions

- Abbrev: BC20

- Name: Immune System Diseases

- Abbrev: BC23

- Name: Symptoms and General Pathology

### Condition Browse Module - Browse Leaves

- ID: M7115

- Name: Diabetes Mellitus

- Relevance: HIGH

- As Found: Diabetes

- ID: M7117

- Name: Diabetes Mellitus, Type 1

- Relevance: HIGH

- As Found: Diabetes Mellitus, Type 1

- ID: M10293

- Name: Inflammation

- Relevance: HIGH

- As Found: Inflammation

- ID: M10053

- Name: Hypoglycemia

- Relevance: HIGH

- As Found: Hypoglycemia

- ID: M11639

- Name: Metabolic Diseases

- Relevance: LOW

- As Found: Unknown

- ID: M25403

- Name: Glucose Metabolism Disorders

- Relevance: LOW

- As Found: Unknown

- ID: M7862

- Name: Endocrine System Diseases

- Relevance: LOW

- As Found: Unknown

- ID: M4629

- Name: Autoimmune Diseases

- Relevance: LOW

- As Found: Unknown

- ID: M10200

- Name: Immune System Diseases

- Relevance: LOW

- As Found: Unknown

### Condition Browse Module - Meshes

- ID: D000003920

- Term: Diabetes Mellitus

- ID: D000003922

- Term: Diabetes Mellitus, Type 1

- ID: D000007003

- Term: Hypoglycemia

- ID: D000007249

- Term: Inflammation

### Intervention Browse Module - Ancestors

- ID: D000000319

- Term: Adrenergic beta-Antagonists

- ID: D000018674

- Term: Adrenergic Antagonists

- ID: D000018663

- Term: Adrenergic Agents

- ID: D000018377

- Term: Neurotransmitter Agents

- ID: D000045504

- Term: Molecular Mechanisms of Pharmacological Action

- ID: D000045505

- Term: Physiological Effects of Drugs

- ID: D000000889

- Term: Anti-Arrhythmia Agents

- ID: D000000959

- Term: Antihypertensive Agents

- ID: D000014665

- Term: Vasodilator Agents

- ID: D000000317

- Term: Adrenergic alpha-Antagonists

### Intervention Browse Module - Browse Branches

- Abbrev: Hypo

- Name: Hypoglycemic Agents

- Abbrev: All

- Name: All Drugs and Chemicals

- Abbrev: AnArAg

- Name: Anti-Arrhythmia Agents

- Abbrev: AnAg

- Name: Antihypertensive Agents

- Abbrev: VaDiAg

- Name: Vasodilator Agents

### Intervention Browse Module - Browse Leaves

- ID: M10365

- Name: Insulin

- Relevance: LOW

- As Found: Unknown

- ID: M173166

- Name: Insulin, Globin Zinc

- Relevance: LOW

- As Found: Unknown

- ID: M10054

- Name: Hypoglycemic Agents

- Relevance: HIGH

- As Found: Ketoconazole

- ID: M14298

- Name: Propranolol

- Relevance: HIGH

- As Found: Sprain

- ID: M13551

- Name: Phentolamine

- Relevance: HIGH

- As Found: Orthopedic Surgery

- ID: M20746

- Name: Adrenergic Agents

- Relevance: LOW

- As Found: Unknown

- ID: M3671

- Name: Adrenergic beta-Antagonists

- Relevance: LOW

- As Found: Unknown

- ID: M20755

- Name: Adrenergic Antagonists

- Relevance: LOW

- As Found: Unknown

- ID: M20504

- Name: Neurotransmitter Agents

- Relevance: LOW

- As Found: Unknown

- ID: M4213

- Name: Anti-Arrhythmia Agents

- Relevance: LOW

- As Found: Unknown

- ID: M4277

- Name: Antihypertensive Agents

- Relevance: LOW

- As Found: Unknown

- ID: M17412

- Name: Vasodilator Agents

- Relevance: LOW

- As Found: Unknown

- ID: M3669

- Name: Adrenergic alpha-Antagonists

- Relevance: LOW

- As Found: Unknown

### Intervention Browse Module - Meshes

- ID: D000007004

- Term: Hypoglycemic Agents

- ID: D000011433

- Term: Propranolol

- ID: D000010646

- Term: Phentolamine

### Misc Info Module

- Version Holder: 2024-05-31
