Pancreatic Clamp in NAFLD

Inclusion Criteria:

1. Men and women (using highly effective contraception if of childbearing potential,aged 18-65 years

2. Body mass index of 25-45 kg/m2

3. Able to understand written and spoken English and/or Spanish

4. Evidence of insulin resistance, represented by any or all of the following criteria: a. Meeting either of the American Diabetes Association's definitions for prediabetesor IFG within the previous year* and on screening labs: i. Prediabetes: HemoglobinA1c 5.7-6.4% ii. IFG: plasma glucose of 100-125 mg dL-1 after 8-h fast b.Homeostasis Model of Insulin Resistance (HOMA-IR) score ≥ 2.73

5. Fasting hyperinsulinemia (fasting insulin level ≥ 13 µIU/mL) on screening labs

6. Diagnosed with, or clinically judged to be at high risk for, non-alcoholic fattyliver disease (NAFLD), also known as metabolic-associated fatty liver disease (MAFLD), by hepatologist or other qualified specialist physician and the conditionis listed as an active problem in the electronic medical record

7. Written informed consent (in English or Spanish) and any locally requiredauthorization (e.g., Health Insurance Portability and Accountability Act) obtainedfrom the participant prior to performing any protocol-related procedures, includingscreening evaluations.

Exclusion Criteria:

1. Unable to provide informed consent in English or Spanish

2. Concerns arising at screening visit (any of the following):

i. Unwillingness to use only bedpan or urinal to void during the clamp

ii. Unwillingness to fast (except water) for up to 22 hours

iii. Documented weight loss of ≥ 5% of baseline within the previous 6 months

iv. Abnormal blood pressure (including on treatment, if prescribed)

• Systolic blood pressure < 90 mm Hg or > 160 mm Hg, and/or

• Diastolic blood pressure < 60 mm Hg or > 100 mm Hg v. Abnormal resting heart rate: <60 or ≥100 bpm

• Sinus brady- or tachycardia that has been extensively worked up and consideredbenign by the recruit's personal physician may be permitted at the PrincipalInvestigator's discretion

vi. Abnormal screening electrocardiogram (or if on file, performed within previous 90 d)

• Non-sinus rhythm

• Significant corrected QT segment (QTc) prolongation (≥ 480 ms)

• New or previously unknown ischemic changes that persist on repeat EKG: 1. STsegment elevations; 2. T-wave inversions

vii. Laboratory evidence of diabetes mellitus:

• Hemoglobin A1c ≥ 6.5%, and/or

• Fasting plasma glucose ≥ 126 mg/dL

viii. Positive qualitative β-hCG (i.e., pregnancy test) in women of childbearingpotential

ix. Liver function abnormalities (either of the following) - Transaminases (AST orALT) > 3.0 x the upper limit of normal - Total bilirubin > 1.25 x the upper limit ofnormal

x. Abnormal fasting triglycerides at screening ≥ 400 mg/dL

xi. Abnormal screening serum electrolytes (any of the following)

• Sodium, potassium, or bicarbonate outside of the reference range

• Creatinine equating to estimated glomerular filtration rate < 60 mL min-1 1.73m-2

xii. Abnormal complete blood count (CBC) (any of the following)

• Hemoglobin < 10 g dL-1 or hematocrit < 30%

• Platelet count < 100,000 µL-1

• Exempt from CBC requirement if previously obtained value within 2 months ofscreening is available

3. Unwillingness to comply with masking and COVID-19 testing requirements per NYP/CUMCpolicy

4. Reproductive concerns i. Women of childbearing potential not using highly effectivecontraception, defined as:

• Surgical sterilization (e.g., bilateral tubal occlusion, bilateral oophorectomyand/or salpingectomy, hysterectomy)

• Combined oral contraceptive pills taken daily, including during the study

• Intrauterine device (levonorgestrel-eluting or copper) active at the time ofstudy

• Medroxyprogesterone acetate (Depo-Provera®) injection active at the time ofstudy

• Etonogestrel implants (e.g., Implanon®, etc.) active at the time of the study

• Norelgestromin/ethinyl estradiol transdermal system (e.g., Ortho-Evra®) activeat the time of the study

ii. Women currently pregnant, measured by serum and/or urine human chorionicgonadotropin, beta subunit (β-hCG)

iii. Women currently breastfeeding

5. Concerns related to glucose metabolism i. History of having met any of the AmericanDiabetes Association's definitions of diabetes mellitus (i.e., overt diabetes) ii.History of gestational diabetes mellitus within the previous 5 years iii. Use ofantidiabetic medications other than metformin within the 90 days prior to screening,including those prescribed for other indications (e.g., weight control, restorationof ovulation in of polycystic ovarian syndrome) iv. Clinical concern for absoluteinsulin deficiency (e.g., type 1 diabetes, pancreatic disease) v. Fasting plasmaglucose < 89 mg/dL at screening

6. Concerns related to lipid metabolism i. Known diagnoses of familialhypercholesterolemia, familial combined hyperlipidemia, or familialhyperchylomicronemia in the participant or a first-degree relative ii. Use ofcertain lipid-lowering drugs other than statins for primary prevention within 90 dprior to screening visit, including: • Statins or PCSK9 inhibitors for secondaryprevention or treatment of familial hypercholesterolemia. Statins or PCSK9inhibitors for primary prevention of ASCVD are acceptable.

• Fibrates (e.g., fenofibrate, clofibrate, gemfibrozil)

• High-dose niacin (>100 mg daily)

7. Known, documented history, at the time of screening, of any of the following medicalconditions:

i. Pancreatic pathology ii. Significant cardiovascular diseases (N.B. uncomplicatedhypertension is not exclusionary) iii. Chronic kidney disease, Stage 3 or higher (estimated glomerular filtration rate < 60 mL / min / 1.73 m2), of any cause iv.Advanced or severe liver disease v. Gallstone disease vi. Chronic viral illnessincluding human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitisC virus (HCV) (N.B. diagnosis based only on medical history; we will not test forany of these viruses at any point in this study) vii. Active malabsorptiveconditions viii. Active seizure disorder (including controlled with antiepilepticdrugs) ix. Psychiatric diseases causing functional impairment that have beendecompensated within 1 year or require use of drugs associated with significantweight gain/metabolic dysfunction x. Other endocrinopathies (e.g., Cushing syndrome,adrenal insufficiency) xi. Venous thromboembolic disease (deep vein thrombosis orpulmonary embolism) or any required use of therapeutic anticoagulation xii. Bleedingdisorders, including due to anticoagulation, or significant anemia (see above) xiii.Dysautonomia, including post-vagotomy xiv. Active malignancy, or hormonally activebenign neoplasm, except for non-melanoma skin cancer or differentiated thyroidcancer (AJCC Stage I only)

8. Clinical concern for increased risk of volume overload, including due to medicationsand/or heart/liver/kidney problems, as listed above

9. Clinical concern for increased risk of hypokalemia, including low potassium onscreening labs (i.e., below lower limit of normal), use of certain medications, orany medical conditions listed above

10. Use of certain medications currently or within 90 d prior to screening:

i. Prescribed medications used for any of the indications in the preceding list ofexcluded conditions, or their use within 90 d prior to screening, except allowancesfor:

• Use of drugs prescribed for indications other than the exclusionarydiagnoses/purposes listed above (e.g., antiepileptic drugs used for non-seizureindications, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptorblocker (ARB) used for uncomplicated hypertension rather than for congestive heartfailure, etc.)

•• Note, as above, that antidiabetic drugs except metformin for any indicationwithin 90 d of screening are excluded ii. Oral or parenteral corticosteroids (atgreater than prednisone 5 mg daily, or equivalent) for more than 3 days within theprevious 90 days; topical and inhaled formulations are permitted iii.Fludrocortisone iv. Opioids other than dextromethorphan for cough

11. History of certain weight-loss (bariatric) surgery, including:

i. Roux-en-Y gastric bypass ii. Biliopancreatic diversion iii. Restrictiveprocedures (lap band, sleeve gastrectomy) performed within the past 6 months

12. Clinical concern for alcohol overuse, including recent documented history orphosphatidylethanol ≥ 0.05 µmol/L at screening and/or participant report ofregularly consuming more than 2 drinks per day for males or 1 drink per day forfemales.

13. Positive urine drug screen, with exceptions for:

i. Lawfully prescribed medications ii. Marijuana/THC positivity, provided that theparticipant agrees not to use it during the same period that they will abstain fromalcohol

14. History of severe infection or ongoing febrile illness within 30 days of screening

15. Any other disease, condition, or laboratory value that, in the opinion of theinvestigator, would place the participant at an unacceptable risk and/or interferewith the analysis of study data.

16. Known allergy/hypersensitivity to any component of the medicinal productformulations (including soy or dairy), IV infusion equipment, plastics, adhesive orsilicone, history of infusion site reactions with IV administration of othermedicines, or ongoing clinically important allergy/hypersensitivity as judged by theinvestigator.

17. Concurrent enrollment in another clinical study of any investigational drug therapywithin 6 months prior to screening or within 5 half-lives of an investigationalagent, whichever is longer.