Continued Access to the Endogenex System for Participants in the ReCET Pivotal Study

Prior treatment

• Current use of insulin, or previous use of any types of insulin for \>1 month at any time (except for treatment of gestational diabetes) in last 2 years.
• Previous GI surgery that has changed GI anatomy or could limit treatment of the duodenum, such as Billroth 2, Roux-en-Y gastric bypass, gastric band or other similar procedures or conditions.
• Current use of P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) that cannot be discontinued for 7 days before the procedure.
• Unable to discontinue non-steroidal anti-inflammatory drugs (NSAIDs) from treatment through 4 weeks following the procedure. Alternative use of acetaminophen and low dose aspirin is allowed.
• Use of systemic glucocorticoids (excluding topical or ophthalmic application or inhaled forms) for more than 10 consecutive days within 12 weeks prior to the screening visit.
• Use of medications known to affect GI motility (e.g. metoclopramide/ Reglan)
• Current use of weight loss medications such as Saxenda \[liraglutide \], Xenical® \[orlistat\], Acutrim® \[phenylpropanolamine\], Sanorex® \[mazindol\], Adipex® \[phentermine\], BELVIQ® \[lorcaserin\], Qsymia® \[phentermine/topiramate combination\], Contrave® \[naltrexone/bupropion\], or other weight loss medications including over-the-counter \[OTC\] medications \[for example, Allī®\]) or have discontinued weight loss medications within 6 months.
• History of blood donation or transfusion within 3 months prior to the Screening Visit.
• Participating in another ongoing clinical trial of an investigational drug or device.
• Any other anatomical or endoscopic abnormalities/characteristics that, in the opinion of the investigator, would preclude safe use of the investigational device or procedure.

Other illness

• Diagnosed with type 1 diabetes.
• History of diabetic ketoacidosis or hyperosmolar nonketotic coma.
• History of ≥1 severe hypoglycemia episode in past 6 months
• Known autoimmune disease, including but not limited to, celiac disease, or pre-existing symptoms of systemic lupus erythematosus, scleroderma or other autoimmune connective tissue disorder, or as evidenced by a positive anti-glutamic acid decarboxylase (GAD) test.
• Known history of a structural or functional disorder of the upper GI tract that may impede passage of the device through the upper GI tract or increase risk of tissue damage during an endoscopic procedure, including eosinophilic esophagitis, stricture/stenosis, varices, diverticula, or other disorder of the esophagus, stomach and duodenum.
• History of gastroparesis.
• Acute gastrointestinal illness in the last 7 days.
• Known history of irritable bowel syndrome, radiation enteritis or other inflammatory bowel disease, such as Crohn's disease and Celiac disease.
• History of chronic or acute pancreatitis.
• Unstable or paroxysmal cardiac arrhythmia.
• History of valvular heart disease or chronic heart failure (NYHA III or IV).
• Known immunocompromised status, including but not limited to individuals who have undergone organ transplantation, chemotherapy, or radiotherapy within the past 12 months, who have clinically significant leukopenia, who are positive for the human immunodeficiency virus (HIV) or whose immune status makes the participant a poor candidate for clinical trial participation in the opinion of the investigator.
• History of secondary hypothyroidism or inadequately controlled primary hypothyroidism (TSH value outside the normal range at screening).
• Active malignancy within the last 5 years (excluding non-melanoma skin cancers).
• Binge eating disorder, or any other mental or physical condition which, in the opinion of the study investigator, makes the participant a poor candidate for clinical trial participation.
• Poorly controlled hypertension, as evidenced by a mean of 3 separate blood pressure measurements \>180 mmHg (systolic) or \>100 mmHg (diastolic)

Lab values

• Active hepatitis or active liver disease, or alanine aminotransferase (ALT) level \>3.0 times the 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.
• Persistent anemia, defined as hemoglobin \<10 g/dL.
• Known history of hemoglobinopathy, hemolytic anemia or sickle cell anemia, or any other traits of hemoglobin abnormalities known to interfere with the measurement of HbA1c.
• Any of the following cardiovascular conditions within 6-months prior to screening visit: acute myocardial infarction, unstable angina, cerebrovascular accident (stroke), hospitalization due to congestive heart failure, or history of other significant cardiovascular disease (unless documented clearance by cardiologist and/or treating endoscopy team).
• Estimated glomerular filtration rate (eGFR) ≤ 45 ml/min/1.73m2 calculated by CKD-EPI Creatinine Equation as determined by the central laboratory.
• Uncontrolled hyperglycemia with a glucose level \>270 mg/dl (\>15 mmol/L) after an overnight fast or \>360 mg/dl (\>20 mmol/l) in a randomly performed measurement that is confirmed by a second measurement (not on the same day) at baseline or prior to the procedure.

Age

• Critically ill or has a life expectancy \<5 years.

Other

• Hypoglycemic unawareness.
• Discontinuation of a GLP-1RA or a GLP-1/GIP dual-agonist within 6 months of the screening visit following at least one month of treatment.
• Current use of vitamin K antagonists such as warfarin, or current use of direct-action oral anticoagulants (DOCAs) that cannot be safely discontinued periprocedurally.
• Participation in any structured weight loss program or endoscopic weight loss intervention within 6 months of the screen visit.
• Presence of any implanted electronic devices that cannot be turned off during the procedure
• Presence of duodenal or biliary stents.
• Not a candidate for upper GI endoscopy or general anesthesia.
• Active illicit substance abuse or alcoholism (\>2 drinks/day regularly).
• Women who are breastfeeding.
• Are investigator site personnel directly affiliated with this study and/or their immediate family member. Immediate family is defined as a spouse, parent, child, or sibling, whether biological or legally adopted.
• Any severe hypoglycemic event between baseline and the index procedure visits.
• Women of child-bearing potential with a positive urine pregnancy test at baseline visit.
• LA Grade C or greater esophagitis on endoscopy.
• Abnormalities of the GI tract preventing endoscopic access to the duodenum.
• Anatomic abnormalities in the duodenum that would preclude the completion of the treatment procedure, including tortuous anatomy.
• Endoscopic observation of upper gastrointestinal abnormalities such as ulcers, duodenal polyps in the area to be treated, varices, strictures, congenital or intestinal telangiectasia.

• Randomized to the sham control arm in the ReCET Study and completed their 12-month study visit.
• HbA1c of 7.0-10.5%, inclusive
• BMI \<40 kg/m2, inclusive.
• Agree not to donate blood during participation in the study.
• Able to comply with study requirements and understand and sign the Informed Consent Form.
• Women of childbearing potential must be not pregnant and using an acceptable method of contraception throughout the study.
• Willing and able to comply with study visits and study tasks as required per protocol.