Evaluation of the Efficacy and Safety of DMR Using the Revita® in Subjects With Inadequately Controlled Type 2 Diabetes

Inclusion Criteria

Subjects must meet all of the following criteria for inclusion in the study:

1. Males and non-pregnant non-lactating females

2. Age between 21 and 70 years (both inclusive)

3. Subjects on at least one glucose lowering agent (GLA) with no changes in GLA medications or dosing for at least 12 weeks prior to the screening visit

Permitted GLAs include:

• Metformin,

• GLP-1 RA including dual peptide agonists and related molecules (e.g., GLP-1/GIP RA),

• DPP-4i,

• TZDs,

• SGLT2is,

• SUs,

• Meglitinides,

• Insulin (basal or basal combined with short-acting), up to a total of 100 units daily

4. HbA1c of 7.5%-10% (both inclusive)

5. BMI >24 to ≤40 kg/m2

6. WOCBP should have a negative urine beta hCG pregnancy test and must agree to use two of the established contraceptive methods throughout the study duration

7. Able to sign an ICF and comply with study requirements

Exclusion Criteria

Subjects who meet any of the following exclusion criteria are not allowed to be included in the study:

1. FPG ≥270 mg/dL

2. Known case of absolute insulin deficiency as indicated by clinical assessment or a fasting plasma C-peptide of <0.6 ng/mL

3. Subjects on any other class of glucose-lowering agents other than GLAs listed in inclusion criteria Any drugs or concomitant medications (e.g., psychoactive drugs such as carbamazepine phenobarbital; sympathomimetics such as ephedrine corticosteroids; anabolic steroids and male sex hormones such as testosterone) that can interfere with glucose metabolism (refer to prohibited medication on Appendix D: Eligibility Criteria Checklist)

4. Recurrent or severe urinary tract or genital mycotic infections or history of GU infection within 4 weeks prior to informed consent, for those subjects on SGLT-2

5. ALT or AST >3 times upper limit of normal (ULN) for the reference range, as determined by the central laboratory at screening visit. Patients with NAFLD are eligible if their ALT level is ≤3.0 times the ULN.

6. Use of an investigational drug within 1 month or 5 half-lives (whichever is longer) before screening

7. Diagnosed with type 1 diabetes or with a recent history of DKA within one year prior to screening

8. Ketosis-prone T2D

9. Known diabetes related non-healing ulcers or amputations (with the exception of a finger or toe amputation occurring > 1 year prior to screening.

10. History of more than 1 severe hypoglycemia episode or hypoglycemia unawareness within the last 6 months

11. Clinically significant hypoglycemia occurring during the run-in period, defined as a) 2 or more glucose alert values of ≤70 mg/dL (3.9 mmol/L) unless a clear, correctable, precipitating factor can be identified; b) clinically significant hypoglycemia with self-monitored or laboratory plasma glucose level <54 mg/dL (3.0 mmol/L); or c) severe hypoglycemic episode requiring third party assistance

12. Known intestinal autoimmune disease including celiac disease, ulcerative colitis, Crohn's disease, lupus erythematosus, scleroderma, or other autoimmune connective tissue disorder that affects the small intestine

13. Secondary hypothyroidism or inadequately controlled primary hypothyroidism (thyroid stimulating hormone [TSH] value outside the normal range at screening as determined by the central laboratory).

14. Known thyroid cancer or hyperthyroidism with treatment within the past 12 months or inadequately controlled hyperthyroidism (TSH value outside the normal range at screening as determined by the central laboratory).

15. An uncontrolled endocrine condition such as multiple endocrine neoplasia (except T2D)

16. Known structural or functional disorder of the esophagus including any swallowing disorder, esophageal chest pain disorders, drug-refractory esophageal reflux symptoms, or active and uncontrolled gastroesophageal reflux disease (GERD) (defined as Los Angeles Grade C or D esophagitis)

17. Known structural or functional disorder of the stomach including active gastric ulcer, chronic gastritis, gastric varices, hiatal hernia (a large hiatal hernia or type II and higher paraoesophageal hernia), cancer, or any other disorder of the stomach

18. Previous GI surgery that could affect the ability to treat the duodenum such as subjects who have had a Billroth 2, Roux-en-Y gastric bypass, gastric sleeve, or other similar procedures or conditions

19. Known history of chronic pancreatitis or a recent history of acute pancreatitis within the past year

20. Presence of acute or chronic active hepatitis B or C (except if hepatitis C is cured) or cirrhosis, hepatic decompensation/acute liver disease during the last 6 months, or alcoholic or autoimmune chronic hepatitis

21. Symptomatic gallstones, symptomatic kidney stones, or acute cholecystitis

22. Clinically active systemic infection

23. Known immunocompromised status including but not limited to individuals who have undergone organ transplantation, chemotherapy, or radiotherapy within the past 12 months; have clinically significant leukopenia; are positive for the human immunodeficiency virus (HIV); are on potential immunosuppressants; or individuals whose immune status makes the subject a poor candidate for clinical trial participation in the opinion of the investigator

24. Known active malignancy or partial remission from clinically significant malignancy within the past 5 years (except basal or squamous cell skin cancer, carcinoma in situ, those who received curative treatment and are in complete remission for 5 years, or if the subject is confirmed as cancer free)

25. Known active coagulopathy or current upper gastro-intestinal bleeding conditions such as ulcers, gastric varices, strictures, or congenital or acquired intestinal telangiectasia

26. Known cases of sickle cell anemia, thalassemia, or conditions that affect red blood cell (RBC) turnover such as a recent blood transfusion within 90 days. Current persistent anemia, defined as hemoglobin <10g/dL

27. Use of anticoagulation therapy (e.g., warfarin, coumadin, or novel oral anticoagulants [NOACs]) or anti-platelet agents (e.g., thienopyridine) which cannot be discontinued for 5-7 days or 2 drug half-lives before the procedure

28. Use of systemic glucocorticoids (excluding topical or ophthalmic applications or inhaled forms) for more than 10 consecutive days within 90 days prior to screening

29. Use of non-GLA drugs known to affect GI motility (e.g., metoclopramide)

30. Known moderate to severe chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) of <45 mL/min/1.73m2 (estimated by Modification of Diet in Renal Disease [MDRD]), end-stage renal failure, or on dialysis

31. History of myocardial infarction, stroke, transient ischemic attack, coronary artery intervention, CHF exacerbation, or any other major cardiac event requiring hospitalization within the last 6 months prior to screening or any cardiac history that would deem subject not eligible for anesthesia (unless documented clearance by cardiologist and/or treating endoscopy team)

32. History of new or worsening signs or symptoms of coronary heart disease (CHD) within the last 3 months

33. Known case of severe peripheral vascular disease, defined as AMA Criteria Class 1 or greater75 (Appendix 19.8)

34. Known case of symptomatic heart failure with reduced ejection fraction (NYHA Class II-IV) requiring pharmacologic therapy to control symptoms

35. Clinically significant electrocardiogram (ECG) findings such as new clinically significant arrhythmia, ST segment changes, or other conduction disturbances that increase risk of heart disease and require intervention as determined by the investigator

36. Subjects who are at risk of pancreatitis, particularly those with a recent fasting triglyceride value of >600 mg/dL within the past 3 months

37. Actively participating in a weight-loss program and currently not in the maintenance phase

38. General contraindications to deep or conscious sedation, general anesthesia, high risk as determined by anesthesiologist (e.g., ASA score 4 or higher), or contraindications to upper GI endoscopy

39. History of substance use disorder based on the DSM-5 criteria76 within the last 12 months (American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition).

40. Use of weight loss medication such as Meridia, Xenical, over-the-counter weight-loss medications, or other prescribed medications used specifically for the purpose of weight loss

41. Use of dietary supplements or herbal preparations that may have unknown effects on glycemic control or risk of bleeding

42. Participating in another ongoing clinical trial of an investigational drug or device

43. History of non-adherence to treatment in the previous 6 months, as determined by the investigator based on patient history, HbA1c value, or drug accountability

44. Any other mental or physical condition which, in the opinion of the investigator, makes the subject a poor candidate for clinical-trial participation. Physical conditions assessed via endoscopy prior to participant study enrollment at visit 4 include, but not limited to:

45. Active and uncontrolled gastroesophageal reflux disease (GERD) defined as Los Angeles Grade C or D esophagitis

46. Abnormalities of the GI tract preventing endoscopic access to the duodenum

47. Anatomic abnormalities in the duodenum that would preclude the completion of the DMR procedure, including tortuous anatomy

48. Malignancy newly diagnosed by endoscopy

49. Upper GI conditions (esophageal, gastric, or intestinal) such as clinically significant ulcers, polyps, varices, strictures, congenital or acquired intestinal telangiectasia, or other conditions listed under exclusion criteria

50. Unwilling or unable to comply with study visits and other study procedures as required per protocol

51. Recovered from severe COVID-19 infection (requiring hospitalization) but with persistent long COVID-19 symptoms (i.e., the individual has not recovered for several weeks or months since the start of symptoms that were suggestive of COVID-19, irrespective if the individual was tested or not)