Targeting Inflammation Using Salsalate for Type 2 Diabetes-stage II (TINSAL-T2D-II)

• Response rates for reduction in fasting glucose of ≥20 mg/dl, a reduction in HbA1c of ≥0.5%, and a reduction in HbA1c of ≥0.8% [ Time Frame: 24 and 48 weeks ] [ Designated as safety issue: No ]
• Change in lipids (low-density lipoprotein cholesterol [LDL-C], non-high-density lipoprotein cholesterol [non-HDL-C], triglycerides [TG], total cholesterol [TC], high-density lipoprotein cholesterol [HDL C], TC/HDL-C ratio, and LDL-C/HDL-C ratio) [ Time Frame: 48 weeks ] [ Designated as safety issue: Yes ]
• Change in insulin sensitivity [ Time Frame: 24 and 48 weeks ] [ Designated as safety issue: No ]
• Changes in WBC and differential, high-sensitivity C reactive protein (hsCRP), other inflammatory markers [ Time Frame: 24 and 48 weeks ] [ Designated as safety issue: No ]
• Change from baseline and trends in fasting glucose over time. [ Time Frame: 24 and 48 weeks ] [ Designated as safety issue: Yes ]
• Response rates for exceeding hyperglycemic targets between active and placebo treated groups; Need for rescue therapy; Need for discontinuation of study medication [ Time Frame: 24 and 48 weeks ] [ Designated as safety issue: Yes ]
• Response rates in patients initially treated with lifestyle modification, insulin secretagogue, metformin or combination therapy [ Time Frame: 24 and 48 weeks ] [ Designated as safety issue: No ]

Growing evidence over recent years supports a potential role for low grade chronic inflammation in the pathogenesis of insulin resistance and type 2 diabetes. In this study we will determine whether salsalate, a member of the commonly used Non-Steroidal Anti-Inflammatory Drug (NSAID) class, is effective in lowering sugars in patients with type 2 diabetes. The study will determine whether salicylates represent a new pharmacological option for diabetes management. The study is conducted in two stages. Enrollment in the first stage is complete. The primary objective of the first stage was to select a dose of salsalate that is both well-tolerated and demonstrates a trend toward improvement in glycemic control. The primary objective of Stage 2 of the study is to evaluate the effects of salsalate on blood sugar control in diabetes; the tolerability of salsalate use in patients with type 2 diabetes (T2D); and the effects of salsalate on measures of inflammation, the metabolic syndrome, and cardiac risk.

• Drug: Salsalate
  Salsalate 3.5 g/d orally, divided dosing
  Other Name: Disalsid
• Drug: Salsalate Placebo

• Active Comparator: 1
  Salsalate, 3.5 g/d orally, divided dosing
  Intervention: Drug: Salsalate
• Placebo Comparator: 2
  Salsalate Placebo, orally, divided dosing
  Intervention: Drug: Salsalate Placebo

• Shoelson SE, Lee J, Goldfine AB. Inflammation and insulin resistance. J Clin Invest. 2006 Jul;116(7):1793-801. Review. Erratum in: J Clin Invest. 2006 Aug;116(8):2308.
• Fleischman A, Shoelson SE, Bernier R, Goldfine AB. Salsalate Improves Glycemia and Inflammatory Parameters in Obese Young Adults. Diabetes Care. 2007 Oct 24; [Epub ahead of print]
• Goldfine AB, Silver S, Aldhahi W, Cai D, Tatro E, Lee J, Shoelson SE. Use of Salsalate to Target Inflammation in the Treatment of Insulin Resistance and Type 2 Diabetes, Clinical and Translational Science, 2008 May;1(1):36-43
• Goldfine AB, Fonseca V, Jablonski KA, Pyle L, Staten MA, Shoelson SE; for the TINSAL-T2D (Targeting Inflammation Using Salsalate in Type 2 Diabetes) Study Team. The Effects of Salsalate on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Trial. Ann Intern Med. 2010 Mar 16;152(6):346-357.

Inclusion Criteria:

1. Type 2 diabetes on diet and exercise therapy or monotherapy with metformin, insulin secretagogue (including SFU, non-SFU, and dipeptidyl peptidase IV (DPP-4) inhibitors), alpha-glucosidase inhibitors, or bile acid sequestrants (dosed once per day such that study drug can be administered ≥ 4 hours prior to sequestrant); or a combination of up to two of these at maximal dose. Dosing must be stable for 8 weeks prior to screening. Participant must have been diagnosed with T2D at least 8 weeks before screening.
2. FPG ≤ 225 mg/dL and HbA1c≥7% and ≤ 9.5% at screening.
3. Age ≥18 and <75
4. Women of childbearing potential agree to use an appropriate contraceptive method (hormonal, IUD, or diaphragm)

Exclusion Criteria:

1. No prior participation in Stage I of TINSAL-T2D ; exception: a participant who failed screening for HbA1c in Stage I will be allowed to re-screen for Stage II.
2. Type 1 diabetes and/or history of ketoacidosis determined by medical history
3. History of severe diabetic neuropathy including autonomic neuropathy, gastroporesis or lower limb ulceration or amputation
4. History of long-term therapy with insulin (>30 days) within the last year
5. Therapy with rosiglitazone (Avandia) or pioglitazone (Actos), alone or in combination in the previous 6 months; or extendin-4 (Byetta), alone or in combination in the previous 3 months
6. Pregnancy or lactation
7. Patients requiring oral corticosteroids within 3 months or recurrent continuous oral corticosteroid treatment (more than 2 weeks)
8. Use of weight loss drugs [e.g., Xenical (orlistat), Meridia (sibutramine), Acutrim (phenylpropanol-amine), or similar over-the-counter medications] within 3 months of screening or intentional weight loss of ≥ 10 lbs in the previous 6 months
9. Surgery within 30 days prior to screening
10. Serum creatinine >1.4 for women and >1.5 for men or eGFR <60 [possible chronic kidney disease stage 3 or greater calculated using the Modification of Diet in Renal Disease (MDRD) equation
11. History of chronic liver disease including hepatitis B or C
12. History of peptic ulcer or endoscopy demonstrated gastritis
13. History of acquired immune deficiency syndrome or human immunodeficiency virus (HIV)
14. History of malignancy, except participants who have been disease-free for greater than 10 years, or whose only malignancy has been basal or squamous cell skin carcinoma
15. New York Heart Association Class III or IV cardiac status or hospitalization for congestive heart failure
16. History of unstable angina, myocardial infarction, cerebrovascular accident, transient ischemic attack or any revascularization within 6 months
17. Uncontrolled hypertension (defined as systolic blood pressure >150 mmHg or diastolic blood pressure >95 mmHg on three or more assessments on more than one day). If on blood pressure medications, dosing should be stable for 2 weeks prior to randomization.
18. History of drug or alcohol abuse, or current weekly alcohol consumption >10 units/week (1 unit = 1 beer, 1 glass of wine, 1 mixed DCCktail containing 1 ounce of alcohol)
19. Hemoglobin <12 g/dL (males), <10 g/dL (females) at screening*
20. Platelets <100,000 cu mm at screening
21. AST (SGOT) >2.50 x ULN or ALT (SGPT) >2.50 x ULN at screening
22. Total Bilirubin >1.50 x ULN at screening
23. Triglycerides (TG) >500 mg/dL at screening
24. Poor mental function or any other reason to expect patient difficulty in complying with the requirements of the study
25. Previous allergy to aspirin
26. Chronic or continuous use (daily for more than 7 days) of nonsteroidal anti-inflammatory drugs within the preceding 2 months
27. Use of warfarin (Coumadin), clopidogrel (Plavix), dipyridamole (Persantine), heparin or other anticoagulants
28. Use of probenecid (Benemid, Probalan), sulfinpyrazone (Anturane) or other uricosuric agents
29. Macroalbuminuria, defined as spot urine protein >300 mcg/mg Cr at screening
30. Pre-existing chronic tinnitus