Muscarinic Receptor Antagonists as a Therapy for Diabetic Neuropathy

Patient selection and characterization A total of 60 adults of both sexes and varying
ethnicities, 30-80 years of age, will be recruited from Dr. Vinik's clinic. All participants
will be diagnosed with established type 2 diabetes (>2 years) and diabetic peripheral
neuropathy. Potential subjects will undergo a complete physical exam and a neurological exam
to assess motor function and sensory perception28.

Randomizing and blinding an investigational drug will be done by assigning each
patient/subject a study number in the order they are recruited. The patients are randomized
using a randomizing web site at (www.randomizer.org). The randomized patient numbers are
recorded. This code is then placed in an envelope and sealed. This envelope will remain
sealed until the study is concluded. A blinding/randomization patient form will be completed
for each patient and sealed in the individual envelopes. The outside of the envelopes will
contain patient numbers for identification purposes. This will allow the research coordinator
to break the individual blind in emergency situations without compromising the rest of the
blinding data. All instances where the blind is broken will be documented appropriately.

Subject Recruitment Subjects of both sexes and all ethnicities will be recruited locally
using the database of subjects available at The Strelitz Diabetes Research Center (SDRC) at
Eastern Virginia Medical School (EVMS) as well as locally distributed flyers and notices, if
needed. Approximately 60 randomized subjects are needed in this study to make a useful
determination for current and future studies. Subjects who are dropped or withdraw from the
study will be replaced.

Sample size estimation and data analysis:

Investigators have primarily powered the study based on variance data obtained in studies
demonstrating efficacy of Topiramate on IENF density in diabetic subjects11. The sample size
of 20 in each group (placebo vs. active drug) reflects the ability to detect a 20% deviation
following treatment and was also sufficient to to identify therapy-induced improvements in
SkBF and NTTS-6 score using a similar study design28. We intend to use ANOVA and MANOVA where
data is normally distributed in raw form or in some cases after simple log-transformations.
Based on these considerations, the 20 subjects in each group provide power greater than 0.80
for observing statistical significance at the p < 0.05 level. Relationships among measures of
neurovascular function and changes in IENF will be determined with Spearman's rank
correlation. If data are not normally distributed, the Wilcoxon signed-rank (within group) or
Mann Whitney (between group) tests may be employed. The level of significance will be set at
p<0.05.

FUTURE USE OF BIOLOGICAL SPECIMENS AND BANKING PROTOCOL After all of the required tests are
finished, subjects will be asked if their leftover specimen may be stored for future research
instead of throwing it away. Subjects will be asked to sign an addendum IRB approved consent
form (#07-08-FB-0167) that allows the storage of biological specimen. An IRB application will
be submitted for the use of any stored samples.

Study activity will take place after review and approval by the EVMS IRB (or other approved
IRB). The IRB has the fundamental charge of protecting the rights and welfare of human
participants in research. The EVMS Federal Wide Assurance assures that all research
activities are guided by the ethical principles of The Belmont Report (respect for persons,
beneficence, and justice) and activities comply with 45CFR46, regardless of funding source.
These principles will be implemented through the process of informed consent by sharing
information, ensuring subject comprehension and selecting volunteers without coercion or
undue influence.

SAFETY EVALUATIONS AND ADVERSE EVENT REPORTING

Adverse events (AE's) will be recorded for all subjects. Relationship to study procedures
performed will be documented by the investigator. Serious Adverse Events (SAEs) and
pregnancies, which occur during this study, will be reported immediately upon their discovery
to all appropriate agencies (Institutional Review Board (IRB). Serious Adverse Events are
defined as any adverse event from this study that results in one of the following outcomes,
or is significant for any other reason:

- Death

- Initial or prolonged inpatient hospitalization

- A life-threatening experience (that is, immediate risk of dying)

- Persistent or significant disability/incapacity

- Congenital anomaly/birth defect

The principal investigator will review the safety and progress of this study on a monthly
basis. The principal investigator will review this protocol on a continuing basis for subject
safety.

Risks and Protection Against Risk All subjects will be monitored for adverse and/or
unexpected events. All information and data are kept in strict confidence. No information
will be given to anyone without permission from the study participant.

Risks to participants will be minimized through subject selection, documented informed
consent from the study participant, provisions made for the protection of privacy and
confidentiality of data, and data monitoring to ensure subject safety. Data will be coded so
that linkages to participants will only be available to the investigators. The database will
be password protected and only the investigative staff will have access to the database. All
subject names and personally identifiable data will be coded so that personal information
(e.g., name, social security number, drivers' license number, address and phone number)
remains private. Only the study investigators will have access to the information.
Participants will not be personally identified in reports or publications.

Reproductive Risk Gelnique 3% is classified as a pregnancy category class B drug. Animal
reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate
and well-controlled studies in pregnant women. Serum HcG testing for pregnancy will be
performed at the screening. All participants will be asked to use birth control such as
barrier methods (i.e. condoms, diaphragms), oral contraceptives, or intrauterine devices if
they have not been surgically sterilized. Pregnancies will be treated as adverse events and
will be followed to term.

Database Protection All data will be locally monitored according to the Strelitz Diabetes
Center Standard Operating Procedures (see procedures below) and standard precautions will be
made to protect personal health information.

1. Assign unique and secure User ID/password combination for each clinical research team
member who has access to the computerized system(s). Ensure that users login using this
unique User ID/password combination or other electronic signature when preparing to
perform computer data entry or management functions.

2. Establish and maintain a schedule for changing each team member's User ID/password
combination at appropriate intervals.

3. Invalidate stolen, lost or otherwise compromised User ID/password combinations and
replace with a new combination.

4. Ensure that proper computer system function is routinely monitored.

5. Ensure that computerized systems are securely stored when not in use.

6. Log off when computer data entry/management activities are completed.

Inclusion Criteria:

- Presence of type 2 diabetes

- Participants between the ages of 30 and 80

Exclusion Criteria:

1. Presence of type 1 diabetes

2. Presence of renal insufficiency or pulmonary disease

3. Presence of clinically significant neuropathy that is clearly of non-diabetic origin

4. Amputations of lower extremities or presence of foot ulcers

5. Major macrovascular events such as myocardial infarction or stroke within the past 3
months

6. Uncontrolled or untreated hypothyroidism

7. Abnormalities of liver function defined as any liver enzymes (AST, ALT, SGPT, SGOT)
greater than 3 times the upper limit of normal

8. Other serious medical conditions which, in the opinion of the investigator, would
compromise the subject's participation in the study

9. Stable use (> 3 months) of antioxidant supplements or drugs known to affect oxidative
stress and PDN

10. Allergy to oxybutynin or other ingredients in Gelnique 3%

11. Pregnancy or breastfeeding

13) History of alcohol abuse in the last year 14) Urinary retention or an enlarged prostate
15) Uncontrolled glaucoma 16) Gastric retention or gastroparesis (hard to digest food) 17)
Currently taking other medicines to treat overactive bladder (Anticholinergics)