Effect of Dulaglutide on Liver Fat in Patients With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease
Effect of Dulaglutide on Liver Fat in Patients With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease
This D-LIFT (Effect of dulaglutide on Liver Fat) trial is an investigator initiated,
 prospective, open label, randomized clinical study to examine the effect of dulaglutide 0.75
 mg subcutaneously weekly for 4 weeks, followed by 1.5 mg weekly for 20 weeks when included in
 the standard treatment for type 2 diabetes vs. standard treatment for type 2 diabetes (minus
 dulaglutide) in patients with type 2 diabetes and NAFLD. Hepatic steatosis (intracellular fat
 accumulation in hepatocytes) will be measured by MRI-PDFF, a validated quantitative biomarker
 for liver fat. The study will be conducted according to the CONSORT guidelines. The patient
 population for the trial will be derived from Medanta-The Medicity Hospital endocrine
 out-patient clinic, who would primarily visit for management of type 2 diabetes and other
 co-morbidities. The study will be conducted in Medanta-The Medicity Hospital, Gurugram,
 Haryana, which is a tertiary care center in North India. Patients deemed eligible will be
 screened for the trial. The clinical trial protocol will be presented for approval to the
 institutional ethics review board. Informed written consent will be obtained from all the
 participants before enrolment into the study.
OBJECTIVE Nonalcoholic fatty liver disease (NAFLD) is a public health problem in patients
 with type 2 diabetes mellitus (T2DM). The presence of type 2 diabetes in patients with NAFLD
 is a risk factor for its progression to a more severe liver disease known as nonalcoholic
 steatohepatitis (NASH). NASH, in turn, can progress to liver fibrosis, cirrhosis and
 hepatocellular cancer in some patients. GLP-1 receptor agonists are a class of anti-diabetic
 agents that reduce hyperglycemia and body weight. Liraglutide is a daily injectable GLP-1
 receptor agonist that has been shown to reduce liver fat in patients with type 2 diabetes and
 NAFLD. Dulaglutide is a weekly injectable GLP-1 receptor agonist that is approved for type 2
 diabetes. Data regarding the effect of dulaglutide on liver fat are scarce. Therefore, the
 present study is planned to evaluate the effect of dulaglutide on liver fat in patients with
 type 2 diabetes and nonalcoholic fatty liver disease.

 Materials and methods Study design This D-LIFT (Effect of dulaglutide on Liver Fat) trial is
 an investigator initiated, prospective, open label, randomized clinical study to examine the
 effect of dulaglutide 0.75 mg subcutaneously weekly for 4 weeks, followed by 1.5 mg weekly
 for 20 weeks when included in the standard treatment for type 2 diabetes vs. standard
 treatment for type 2 diabetes (minus dulaglutide) in patients with type 2 diabetes and NAFLD.
 Hepatic steatosis (intracellular fat accumulation in hepatocytes) will be measured by
 MRI-PDFF, a validated quantitative biomarker for liver fat. The study will be conducted
 according to the CONSORT guidelines. The patient population for the trial will be derived
 from Medanta-The Medicity Hospital endocrine out-patient clinic, who would primarily visit
 for management of type 2 diabetes and other co-morbidities. The study will be conducted in
 Medanta-The Medicity Hospital, Gurugram, Haryana, which is a tertiary care center in North
 India. Patients deemed eligible will be screened for the trial. The clinical trial protocol
 will be presented for approval to the institutional ethics review board. Informed written
 consent will be obtained from all the participants before enrolment into the study.

 Inclusion and Exclusion Criteria

 Patients will be enrolled in the study if they met all of the following criteria:

 1. A man or woman, 20 years of age or above with the diagnosis of type 2 diabetes for at
 least 3 months who meets all of the following two criteria:

 1. On standard anti-diabetic agents (metformin, DPP-4 inhibitors, sulphonylureas or
 insulin, in any combination) with an HbA1c of ≤ 7.0% and ≥10.0% (≤53 and ≥86
 mmol/mol) at screening

 2. Have documented hepatic steatosis (MRI-PDFF >6%) on screening MRI-PDFF

 2. Subjects must be medically stable on the basis of medical history, physical examination
 and laboratory investigations.

 3. Subjects must be willing and able to adhere to the prohibitions and restrictions
 specified in this protocol.

 4. Each subject must sign an informed consent form (ICF) indicating that he or she
 understands the purpose of the study and are willing to participate in the study.

 In addition, all the conditions described below will be considered exclusion criteria:

 1. History of diabetic ketoacidosis, type 1 diabetes, pancreas or beta-cell
 transplantation, or diabetes secondary to pancreatitis or pancreatectomy.

 2. History of brittle or labile glycemic control, with widely varying glucose measurements
 by FPG or SMBG such that stable glucose control over the treatment period would be
 unlikely.

 3. History of drug or alcohol abuse according to Diagnostic and Statistical Manual of
 Mental Disorders (5th edition) (DSM-V) criteria within 3 years before Screening, or an
 Alcohol Use Disorders Identification Test (AUDIT) with a score ≥8, or alcohol
 consumption of more than 20 g per day in the case of women and more than 30 g per day in
 the case of men for at least three consecutive months during the previous 5 years.

 4. Thyroid stimulating hormone (TSH) value that is either < 0.45 mIU/L or >10 mIU/L at
 Screening.

 Note: Subjects on thyroid hormone replacement therapy must be on a stable dose and
 dosing regimen for at least 4 weeks prior to enrollment.

 5. Use of a PPARγ agonist [e.g., a thiazolidinedione (pioglitazone], an SGLT2 inhibitor
 (e.g., canagliflozin, empagliflozin) or another GLP-1 receptor agonist (e.g.,
 liraglutide) within 24 weeks before the enrollment.

 6. BMI ≥23 kg/m2 or ≥40 kg/m2.

 7. Ongoing eating disorder, or a significant weight loss or weight gain within 12 weeks
 before the Screening visit, defined as an increase or decrease of 5% in body weight
 based upon clinic-based measurement or, if not available, based on subject's report.

 8. Use of weight loss medication (prescription and/or over-the-counter) within 3 months
 prior to Screening or have participated in a weight loss/diet program within 12 months
 prior to Screening.

 9. Renal disease that required treatment with immunosuppressive therapy or a history of
 dialysis or renal transplant.

 10. Myocardial infarction, unstable angina, pulmonary hypertension, revascularisation
 procedure (e.g., stent or bypass graft surgery), or cerebrovascular accident within 3
 months before Screening, or revascularisation procedure is planned, or subject has a
 history of New York Heart Association (NYHA) Class III-IV cardiac disease.

 11. History of hepatitis B surface antigen (HBsAg) or hepatitis C antibody (anti-HCV)
 positive, or other clinically active liver disease, or tests positive for HBsAg or
 anti-HCV at Screening.

 12. Use of vitamin E within 3 months before screening.

 13. History of prior bariatric (e.g., Roux-en-Y gastric bypass) or other major upper
 gastrointestinal surgical procedure (including gastric resection).

 14. History of diabetic gastroparesis (or symptoms suggestive of this disorder, including
 postprandial bloating or vomiting), malabsorption, inflammatory bowel disease, or any
 other chronic, clinically important gastrointestinal disorder.

 15. Estimated glomerular filtration rate (eGFR) <65 mL/min/1•73 m2 using the Modification of
 Diet in Renal Disease Study (MDRD) equation.

 16. Subjects with a history of having or possibly having metallic material in the body or
 any contraindication for a MR examination.

 17. Screening fasting serum triglycerides ≥600 mg/dL (6•74 mmol/L).

 18. Claustrophobia, or anxiety related to previous negative experiences with magnetic
 resonance imaging procedures or if the subject is unwilling to participate in magnetic
 resonance imaging procedures.

 19. Clinically important hematologic disorder (e.g., symptomatic anemia, proliferative bone
 marrow disorder, thrombocytopenia) at Screening.

 20. History of human immunodeficiency virus (HIV) antibody positive at Screening.

 21. Major surgery (e.g., requiring general anaesthesia) within 12 weeks before Screening, or
 will not have fully recovered from surgery, or has surgery planned during the time the
 subject is expected to participate in the study.

 22. Contraindications to the use of dulaglutide (per DULAGLUTIDE US Prescribing
 Information).

 23. Current use of a corticosteroid medication or immunosuppressive agent, or likely to
 require treatment with a corticosteroid medication or an immunosuppressive agent.

 Note: Subjects using inhaled, intranasal, intra-articular, or topical corticosteroids,
 or corticosteroids in therapeutic replacement doses may participate.

 24. Pregnancy or women breastfeeding or planning to become pregnant while enroled in this
 study.

 25. History of significant cardiac, vascular, pulmonary, renal, gastrointestinal, endocrine,
 neurologic, hematologic, rheumatologic, psychiatric, or metabolic disturbances.

 26. Use of drugs known to cause hepatic steatosis like methotrexate.

 Baseline assessment at screening All patients will undergo a baseline assessment before
 randomization, including detailed medical history and physical examination.

 Randomization A research assistant will randomize the patients into either dulaglutide group
 or control group in a 1:1 ratio using computer-generated numbers. SPSS software will be used
 to generate 60 random numbers between 000 to 999. The random numbers will be divided by 2 and
 the reminder noted. The reminders 0, & 1 will correspond to dulaglutide and control group
 respectively. It will be ensured that these are equal in number. Opaque envelopes will be
 prepared with serial number on the top and the assigned group inside the envelop. After
 recruiting the subjects, the envelop with corresponding serial number will be opened and the
 subjects assign to the relevant groups after opening the envelop. The patients will then be
 sent back to their respective consultants (MSK, SKM, KJF, AM) in the endocrine department for
 initiation and/or adjustment of treatment for type 2 diabetes (according to randomization
 into dulaglutide or control groups) and other co-morbidities. Treatment allocation will be
 open-label.

 Study visits After careful assessment at the baseline visit, patients meeting all inclusion
 and exclusion criteria will be randomized to receive dulaglutide 0.75 mg weekly for 4 weeks
 followed by 1.5 mg weekly for 20 weeks plus standard treatment for type 2 diabetes. The
 control group will receive standard treatment for type 2 diabetes and up titration of
 treatment will be done by anti-diabetic medicines other than the GLP-1 receptor agonist.
 Patients will be advised to return to the out-patient endocrine clinic for follow-up visits
 at weeks 12 and 24.

 Primary and secondary outcomes The primary outcome measure is change in liver fat quantified
 by MRI-PDFF in colocalized regions of interest (ROI) within each of the nine liver segments.
 The secondary outcome measures are change in serum AST, ALT and GGT values; Fibroscan, change
 in cardiometabolic markers namely IL-1, TNF-alpha, hs-CRP, leptin, adiponectin and
 homocysteine and fibrosis markers.

 MRI-PDFF protocols MRI-PDFF for fat quantification MRI-PDFF is a non-invasive, objective, and
 quantitative MR imaging-based biomarker that can accurately estimate liver fat. MRI-PDFF has
 been demonstrated to be a robust technique for assessing treatment response in NASH clinical
 trials. In this study, the time interval from obtaining the baseline MRI-PDFF to initiating
 the study drug will be less than one week.

 MRI-PDFF for detailed fat mapping of the entire liver All MR examinations will be done by an
 experienced MR technologist in the Medanta Radiology department under the direction of the
 radiologist investigator (SK). The radiologist investigator, blinded to the patients'
 treatment group allocation, clinical and biochemical data, and order of scans (baseline and
 follow-up), will perform the image analyses.

 ROI colocalization before and after treatment To assess longitudinal changes in liver fat
 content, one colocalized ROI will be placed in each of the nine liver segments (nine separate
 ROIs) on the baseline and follow-up MRI examinations.

 Statistical analysis Plan The analysis will include profiling of patients on different
 demographic, clinical and laboratory parameters etc. Quantitative data will be presented in
 terms of means and standard deviation and qualitative/categorical data will be presented as
 absolute numbers and proportions. To compare between the two groups, the Chi-squared test or
 Fisher's exact test will be used for categorical variables, and the independent samples t
 test or Wilcoxon-Mann-Whitney U test will be used for the differences between continuous
 variables. Pearson correlation coefficient will be used to evaluate correlations between
 variables. Additional analyses of primary and secondary outcomes within treatment groups will
 be performed by using two-tailed independent sample t tests, paired t tests, or
 non-parametric tests, when indicated. P-value < 0.05 is considered statistically significant.
 SPSS software will be used for analysis.

 Sample size calculation Investigator assumed that a 5% difference between dulaglutide and
 control groups would be the minimally appreciable and clinically relevant difference. Based
 on the results of previous similar clinical studies involving colesevelam and ezetimibe,
 Investigatorexpected the empagliflozin group to have a liver fat reduction of >5% compared to
 baseline, the control group to have <1% reduction in liver fat compared to baseline, and a
 dropout rate of <10%. With these assumptions the sample size per group works out as ≥20 to
 achieve a power of at least 90% with a β of 0.05. Therefore, Investigator plan to randomize
 60 patents, 30 in each group to ensure adequate study power even with dropouts.

 Method of sample size calculation

 Assumptions:

 Change in liver fat from baseline to week 20 in dulaglutide group (m1) = 5.0 unit Change in
 liver fat from baseline to week 20 in control group (m2) = 1.0 unit Confidence level -95%
 Power - 90% Coefficient of variation = 80%

 Formula for sample size calculation:

 n = (Zα+Zβ)2 * (σ12 + σ22)) / (m1-m2)2, where Zα is the value of normal distribution
 corresponding to desired confidence level Zβ is the value of the Normal distribution
 corresponding to desired power σ1 and σ2 are the standard deviation of the two groups With
 these assumptions the sample size per group works out as 20. Investigator will randomize 30
 in each group to ensure adequate power even after dropouts.

 Patient confidentiality Precautions will be taken to ensure confidentiality. Data collection
 forms will not reveal the name of patients included in study. All the participants will be
 covered by insurance to cover the cost of any untoward effect directly resulting from
 enrolment in the study.
Inclusion Criteria:

 1. A man or woman, 20 years of age or above with the diagnosis of type 2 diabetes for at
 least 3 months who meets all of the following two criteria:

 1. On standard anti-diabetic agents (metformin, DPP-4 inhibitors, sulphonylureas or
 insulin, in any combination) with an HbA1c of ≤ 7.0% and ≥10.0% (≤53 and ≥86
 mmol/mol) at screening

 2. Have documented hepatic steatosis (MRI-PDFF >6%) on screening MRI-PDFF

 2. Subjects must be medically stable on the basis of medical history, physical
 examination and laboratory investigations.

 3. Subjects must be willing and able to adhere to the prohibitions and restrictions
 specified in this protocol.

 4. Each subject must sign an informed consent form (ICF) indicating that he or she
 understands the purpose of the study and are willing to participate in the study

 Exclusion Criteria:

 1. History of diabetic ketoacidosis, type 1 diabetes, pancreas or beta-cell
 transplantation, or diabetes secondary to pancreatitis or pancreatectomy.

 2. History of brittle or labile glycemic control, with widely varying glucose
 measurements by FPG or SMBG such that stable glucose control over the treatment period
 would be unlikely.

 3. History of drug or alcohol abuse according to Diagnostic and Statistical Manual of
 Mental Disorders (5th edition) (DSM-V) criteria within 3 years before Screening, or an
 Alcohol Use Disorders Identification Test (AUDIT) with a score ≥8, or alcohol
 consumption of more than 20 g per day in the case of women and more than 30 g per day
 in the case of men for at least three consecutive months during the previous 5 years.

 4. Thyroid stimulating hormone (TSH) value that is either < 0.45 mIU/L or >10 mIU/L at
 Screening.

 Note: Subjects on thyroid hormone replacement therapy must be on a stable dose and
 dosing regimen for at least 4 weeks prior to enrollment.

 5. Use of a PPARγ agonist [e.g., a thiazolidinedione (pioglitazone], an SGLT2 inhibitor
 (e.g., canagliflozin, empagliflozin) or another GLP-1 receptor agonist (e.g.,
 liraglutide) within 24 weeks before the enrollment.

 6. BMI ≥23 kg/m2 or ≤40 kg/m2.

 7. Ongoing eating disorder, or a significant weight loss or weight gain within 12 weeks
 before the Screening visit, defined as an increase or decrease of 5% in body weight
 based upon clinic-based measurement or, if not available, based on subject's report.

 8. Use of weight loss medication (prescription and/or over-the-counter) within 3 months
 prior to Screening or have participated in a weight loss/diet program within 12 months
 prior to Screening.

 9. Renal disease that required treatment with immunosuppressive therapy or a history of
 dialysis or renal transplant.

 10. Myocardial infarction, unstable angina, pulmonary hypertension, revascularisation
 procedure (e.g., stent or bypass graft surgery), or cerebrovascular accident within 3
 months before Screening, or revascularisation procedure is planned, or subject has a
 history of New York Heart Association (NYHA) Class III-IV cardiac disease.

 11. History of hepatitis B surface antigen (HBsAg) or hepatitis C antibody (anti-HCV)
 positive, or other clinically active liver disease, or tests positive for HBsAg or
 anti-HCV at Screening.

 12. Use of vitamin E within 3 months before screening.

 13. History of prior bariatric (e.g., Roux-en-Y gastric bypass) or other major upper
 gastrointestinal surgical procedure (including gastric resection).

 14. History of diabetic gastroparesis (or symptoms suggestive of this disorder, including
 postprandial bloating or vomiting), malabsorption, inflammatory bowel disease, or any
 other chronic, clinically important gastrointestinal disorder.

 15. Estimated glomerular filtration rate (eGFR) <65 mL/min/1•73 m2 using the Modification
 of Diet in Renal Disease Study (MDRD) equation.

 16. Subjects with a history of having or possibly having metallic material in the body or
 any contraindication for a MR examination.

 17. Screening fasting serum triglycerides ≥600 mg/dL (6•74 mmol/L).

 18. Claustrophobia, or anxiety related to previous negative experiences with magnetic
 resonance imaging procedures or if the subject is unwilling to participate in magnetic
 resonance imaging procedures.

 19. Clinically important hematologic disorder (e.g., symptomatic anemia, proliferative
 bone marrow disorder, thrombocytopenia) at Screening.

 20. History of human immunodeficiency virus (HIV) antibody positive at Screening.

 21. Major surgery (e.g., requiring general anaesthesia) within 12 weeks before Screening,
 or will not have fully recovered from surgery, or has surgery planned during the time
 the subject is expected to participate in the study.

 22. Contraindications to the use of dulaglutide (per DULAGLUTIDE US Prescribing
 Information).

 23. Current use of a corticosteroid medication or immunosuppressive agent, or likely to
 require treatment with a corticosteroid medication or an immunosuppressive agent.

 Note: Subjects using inhaled, intranasal, intra-articular, or topical corticosteroids,
 or corticosteroids in therapeutic replacement doses may participate.

 24. Pregnancy or women breastfeeding or planning to become pregnant while enroled in this
 study.

 25. History of significant cardiac, vascular, pulmonary, renal, gastrointestinal,
 endocrine, neurologic, hematologic, rheumatologic, psychiatric, or metabolic
 disturbances.

 26. Use of drugs known to cause hepatic steatosis like methotrexate