Methods and compositions for treating peripheral neuropathy

Abstract

A composition for treating peripheral neuropathy in a subject in need thereof. The composition comprises an effective amount of an agent selected from the group consisting of pirenzepine, oxybutynin, muscarinic toxin 7, muscarinic receptor antagonists, and combinations thereof, and a pharmaceutically acceptable carrier and / or excipient. The composition is used for treating peripheral neuropathy. Examples of the peripheral neuropathy are systemic disease-induced peripheral neuropathy, metabolic disease-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, compression-induced peripheral neuropathy, dichloroacetate-contact-induced peripheral neuropathy, immune-mediated peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy and chemotherapy-induced peripheral neuropathy. And infection-induced peripheral neuropathy and gene-obtained peripheral neuropathy.

Description

[0001] The present invention is a divisional application of the invention application with application number 201480075321.6, application date December 17, 2014, and invention name “Methods and compositions for treating peripheral neuropathy”. Field of the Invention

[0002] The present invention relates to compositions for treating peripheral neuropathy, uses of such compositions, and methods of using such compositions. Background Art

[0003] Peripheral neuropathy is a clinical problem in people who are troubled by diabetes or who use chemotherapy agents to treat. Infections such as HIV and leprosy can also cause peripheral neuropathy. Clinical symptoms can include upper back and / or abdominal pain (i.e., thoracic and abdominal neuropathy), loss of eye movement control (i.e., third nerve palsy), and gradual loss of nerve function (e.g., polyneuropathy, mononeuropathy, mononeuritis simplex, autonomic neuropathy) including peripheral nervous system. Peripheral neuropathy includes: neuropathy relevant to diabetes (diabetic neuropathy), neuropathy relevant to HIV, neuropathy relevant to nutritional deficiency, cranial nerve palsy, drug-induced neuropathy, industrial neuropathy, lymphoma neuropathy, myeloma neuropathy, multifocal motor neuropathy, immune-mediated disorders, chronic idiopathic sensory neuropathy, carcinogenic neuropathy, acute painful autonomic neuropathy, alcoholic neuropathy, compressive neuropathy, vasculitis / ischemic neuropathy, polyneuropathy and mononeuropathy. There are a range of genetically inherited peripheral neuropathies, with Charcot-Marie-Tooth Disease (CMT) and all its forms and Friedreich's ataxia being typical examples. Raynaud's phenomenon (including CREST syndrome), leprosy, and autoimmune diseases such as polycythemia vera and rheumatoid arthritis can cause other peripheral neuropathies.

[0004] The therapeutic composition can lead to the occurrence of peripheral neuropathy, particularly for the treatment of tumor diseases. In some cases, peripheral neuropathy is a major complication of cancer treatment and is a major factor limiting the dose of chemotherapy agents that can be given to patients (Cavaletti et al., 2013, The chemotherapy-induced peripheral neuropathy outcome measures standardization study: from consensus to the first validity and reliability findings. Ann. Oncol. 24: 454-462). Chemotherapy-induced peripheral neuropathy (CIPN) typically occurs in the process of treating various cancers and other conditions with various agents, including taxanes (i.e., paclitaxel / taxol), platinum drugs (i.e., cisplatin), vinka alkaloids (i.e., vincristine), proteasome inhibitors (e.g., bortezomib), and agents that change cancer cell metabolism (e.g., dichloroacetate). CIPN limits the dose and duration of treatment, thereby reducing the efficacy of chemotherapy regimens. Up to 40% of cancer patients treated with chemotherapy experience some form of CIPN, with sensory neuropathy often predominating. Symptoms range from numbness with tingling and loss of sensation to painful neuropathy, such as touch-evoked pain and spontaneous shooting pain in the hands and feet, often beginning before close movement. Conduction velocities in large sensory and motor fibers can also be impaired on electrophysiological testing. CIPN is dose-dependent, and reducing the chemotherapy dose or completely withdrawing treatment can reduce or eliminate symptoms over a period of days to months.

[0005] Paclitaxel is a microtubule-stabilizing drug that blocks cell division, and this is the presumed basis for its chemotherapeutic properties. Paclitaxel is commonly used to treat breast, lung, and ovarian cancers, but is limited by CIPN. The development of CIPN in paclitaxel-treated rodents is experimentally dependent, perhaps reflecting the dose-dependent nature of the clinical condition.

[0006] Studies of paclitaxel-induced neuropathy in patients and rodents have proposed a pathogenesis that involves disruption of axonal organelle transport through microtubule reorganization and damage to Schwann and satellite cells. There is growing evidence that paclitaxel and other causes of CIPN share a common pathogenic mechanism involving mitochondrial dysfunction. The resulting energy depletion has a high potential to impede ATP-consuming processes such as actin treadmilling and subsequent peripheral terminal plasticity. Shrinkage and degeneration of peripheral terminals of sensory C fibers have been documented in animals treated with paclitaxel.

[0007] Dichloroacetate (DCA) is an environmental toxin that is also used to treat mitochondrial diseases through its ability to inhibit pyruvate dehydrogenase (PDH) kinase, resulting in increased PDH activity and thereby increased pyruvate flux into the electron transport chain, ultimately resulting in increased ATP production. It has recently been recognized that DCA can kill cancer cells by disrupting the inherent anaerobic metabolism of certain cancer cells. Patients taking DCA for treatment of mitochondrial diseases or cancer develop the adverse side effect of peripheral neuropathy, which manifests as tingling, loss of sensation, and / or pain in the extremities, and can limit the dose to the point where DCA treatment is discontinued.

[0008] In most neuropathic diseases, the main form of neuropathy is distal symmetrical polyneuropathy, which initially affects the feet, legs and hands of the subject. The main symptoms include the loss of touch and / or perception and the loss of the ability to perceive the stimulus that causes pain. A subgroup in the patient has also developed the positive symptoms of neuropathic pain, such as unsuitable tingling, burning pain, shooting pain and the sensation of continuous intense pain, which can coexist with the negative symptoms of other sensory impairments. Such neuropathic pain is commonly referred to as tactile allodynia or mechanical hyperalgesia.

[0009] Peripheral sensory neuropathy is the main component of symmetrical polyneuropathy and can be detected by skin biopsy to determine the loss of intraepidermal nerve fibers (IENF) (Kennedy et al., 1996, Quantitation of epidermal nerves in diabetic neuropathy in diabetic neuropathy. Neurology 47: 1042-48). IENF loss represents the subsequent loss of sensation of sensory neuron nerve endings from the epidermis, which ultimately leads to a high incidence of ulcers, gangrene and amputation in subjects suffering from peripheral neuropathy. Currently, for degenerative symmetrical polyneuropathy, there is no regulatory approved treatment in North America. For the health system, the cost of providing relief for these symptoms is huge.

[0010] Muscarinic acetylcholine receptor antagonists block the binding of acetylcholine to muscarinic receptors (G protein-coupled receptors, or GPCRs, with subtypes M1, M2, M3, M4, and M5). Antimuscarinic drugs have been found to treat both the negative symptoms (decelerated nerve conduction and sensory loss) and the positive symptoms (allodynia / hyperalgesia) of diabetic symmetric polyneuropathy, not only ameliorating but also reversing nerve damage. Certain muscarinic acetylcholine receptor antagonists promote the growth of sensory neurons in vitro and significantly prevent and / or reverse the loss of intraepidermal and corneal nerve fibers, thermal hypoalgesia, large fiber conduction slowing, and allodynia, symptoms commonly associated with peripheral neuropathy. Pirenzepine, a selective M1 receptor antagonist that acts as a competitive inhibitor by interacting with the orthosteric site of the receptor, has been shown to be particularly effective. The most specific antagonist of the M1 receptor is muscarinic toxin 7 (MT7), a 64-66 amino acid protein derived from the African green mamba (Dendroaspis angusticeps). At low nanomolar concentrations, this protein binds to an allosteric site on the M1 receptor and exhibits 10,000-fold selectivity for the M1 receptor over M2-M5 (Max et al., 1993. Stable allosteric binding of m1-toxin to M1 muscarinic receptors. Mol. Pharmacol. 44: 1171-5). A less selective compound is the competitive antagonist oxybutynin (i.e., 4-diethylaminobut-2-ynyl-2-cyclohexyl-2-hydroxy-2-phenyl-acetate), which is commonly commercially available as an oral and / or transdermal composition, for example, (OXYTROL is a registered trademark of Actavis Inc., Parsippany, NJ, USA) DITROPAN (DITROPAN and DITROPAN XL are registered trademarks of AlzaCorp., Mountain View, CA, USA), (GELINQUE is a registered trademark of Actavis Inc., Parsippany, NJ, USA), Lyrinel XL, Ditrospam, and Urotrol. Oxybutynin is commonly prescribed to relieve urinary bladder disorders, including but not limited to urinary incontinence, overactive bladder, enuresis, neurogenic bladder, renal tuberculosis, neurogenic bladder, and detrusor overactivity. Oxybutynin is also effective in treating and / or managing postoperative pain associated with indwelling bladder catheters, hyperhidrosis, and intractable hot flashes in cancer patients. Oxybutynin acts as a selective competitive antagonist of acetylcholine at muscarinic receptors (M1, M2, and M3), resulting in relaxation of smooth muscle. SUMMARY OF THE INVENTION

[0011] Exemplary embodiments of the present disclosure relate to compositions for treating peripheral neuropathy. The exemplary therapeutic composition may include one or more of oxybutynin, pirenzepine, muscarinic toxin 7 (MT7), muscarinic receptor antagonists, and analogs thereof. Alternatively, the exemplary therapeutic composition may include one or more of a salt of oxybutynin, a salt of pirenzepine, a salt of MT7, a salt of a muscarinic receptor antagonist, and analogs thereof. Alternatively, the exemplary therapeutic composition may include one or more of a derivative of oxybutynin, a derivative of pirenzepine, a derivative of MT7, a derivative of a muscarinic receptor antagonist, and analogs thereof. The composition is suitable for treating negative symptoms of peripheral neuropathy such as slowed nerve conduction and sensory loss and positive symptoms of peripheral neuropathy such as tactile allodynia and mechanical hyperalgesia.

[0012] Other exemplary methods relate to methods for preparing the topical compositions disclosed herein. Other exemplary methods relate to methods for preparing the oral compositions disclosed herein. BRIEF DESCRIPTION OF THE DRAWINGS

[0013] The present disclosure is illustrated with reference to the following drawings, in which:

[0014] Figure 1 Demonstrates dose-dependent effects of a selective M1 receptor antagonist on neurite outgrowth from dissociated sensory neurons of adult Sprague Dawley rats;

[0015] Figure 2 (A) and 2(B) show the effects of pirenzepine (PZ) on nerve conduction velocity (NCV) in streptozotocin (STZ)-induced diabetic rats;

[0016] Figure 3 (A), 3(B), 3(C), and 3(D) show the difference between the control rats ( Figure 3 (A) and 3(B)) and diabetic rats ( Figure 3 Effects of pirenzepine treatment duration on AMP-activated protein kinase (AMPK) activation in (C) and 3 (D) );

[0017] Figure 4 (A)-4(D) are images of GFP fluorescence in adult sensory neuron cultures from STZ-induced diabetic rats, showing that neurite outgrowth induced by pirenzepine was blocked by a dominant-negative mutant of AMPK;

[0018] Figure 5 (A) and 5(B) show Figure 4 Total neurite outgrowth in cultures shown in (A)-4(D);

[0019] Figure 6 1 μM pirenzepine enhances the transcriptional activity of peroxisome proliferator-activated receptor-γ coactivator 1α (PGC-1α);

[0020] Figure 7 (A) and 7(B) show that respiration (and mitochondria-dependent oxidative phosphorylation) of sensory neurons is enhanced in (A) neuronal cultures from M1 receptor knockout mice (M1R KO) and (B) adult cultures from STZ-induced diabetic mice treated with 1 μM VU0255035;

[0021] Figure 8 (A) and 8(B) show the coupling efficiency in neuronal cultures of M1R KO mice (A) and STZ-induced diabetic rats treated with VU0255035 (B). Figure 8 (C) and 8(D) show respiratory control ratios in neuronal cultures of M1R KO mice (C) and STZ-induced diabetic rats treated with VU0255035 (D), and Figure 8 (E) and 8(F) show spare respirator capacity in neuronal cultures of M1R KO mice (E) and STZ-induced diabetic rats treated with VU0255035 (F);

[0022] Figure 9 (A) is a micrograph of sensory neurons in normal adult rats. Figure 9 (B) is a micrograph of the effect of muscarinic toxin (MT7) on neurite outgrowth in these sensory neurons.

[0023] Figure 10 MT7 dose-dependently promoted total neurite outgrowth in sensory neurons of normal adult rats;

[0024] Figure 11 (A) and 11 (B) show the effects of MT7 (A) and co-treatment with MT7 and Compound C (an inhibitor of AMPK) (B) on PGC-1α transcriptional activity in cultured adult sensory neurons from adult STZ-induced diabetic rats;

[0025] Figure 12 showed that in cultured adult sensory neurons of adult rats, Ca 2+ / Inhibition of pirenzepine-induced neurite outgrowth by the calmodulin-dependent kinase kinase (CaMKK) inhibitor STO-609;

[0026] Figure 13 (A) and 13 (B) show the inhibition of pirenzepine-induced activation of AMPK by the CaMKK inhibitor STO-609 in cultured adult sensory neurons from normal adult rats. Figure 13 (C) and 13(D) show the inhibition of MT7-induced activation of AMPK by the CaMKK inhibitor STO-609 in cultured sensory neurons of normal adult rats;

[0027] Figure 14 showed that oxybutynin promoted neurite outgrowth in cultured adult sensory neurons;

[0028] Figure 15 Demonstrates the ability of oxybutynin to reverse the loss of paw thermal sensitivity in a mouse model of type 2 diabetes (control, "C57"; diabetic, "db / db"; oxybutynin-treated, "db / db+oxy");

[0029] Figure 16 (A) Shows the effect of topical oxybutynin on intraepidermal nerve fiber (IENF) density in genetically diabetic db / db mice. Figure 16 (B) shows the effect of topical oxybutynin on nerve fibers in the cornea of ​​diabetic db / db mice;

[0030] Figure 17 To show the effects of systemic oxybutynin on the development of thermal hypoalgesia in STZ-induced diabetic Swiss Webster mice;

[0031] Figure 18 (A) shows that pirenzepine promotes neurite outgrowth in cultures of adult sensory neurons in the presence of the chemotherapeutic agent paclitaxel. Figure 18 (B) shows that pirenzepine promotes neurite outgrowth in cultures of adult sensory neurons in the presence of the chemotherapeutic agent oxaliplatin;

[0032] Figure 19Shown are the paw thermal response latency (left panel) and 50% tactile response threshold (right panel) in mice treated with paclitaxel (taxol) ± pirenzepine (Pz);

[0033] Figure 20 (A), 20(B), and 20(C) show the effects of pirenzepine (Pz) on paw thermal hypoalgesia (A), paw skin IENF failure (B), and slowed onset of MNCV (C) in mice treated with dichloroacetate (DCA);

[0034] Figure 21 To show the effects of atropine administered topically to the hind paws and eyes of STZ-induced diabetic mice on MNCV;

[0035] Figure 22 To show the effect of topical atropine administration to the hind paw and eyes of STZ-induced diabetic mice on paw thermal latency;

[0036] Figure 23 Shown are the effects of topical administration of MT7 to the eyes of control mice for 11 days on nerve fiber occupancy in the subbasal nerve plexus (SBNP 1-5) of the cornea and in the corneal stroma (stroma 1-10);

[0037] Figure 24 Shows the protective effects of pirenzepine and MT7 on neurite outgrowth in an in vitro model of HIV-induced neuropathy. Detailed Description of the Invention

[0038] Unless otherwise defined, in the context of this specification, all technical and scientific terms used herein have the meanings commonly understood by those skilled in the art. Any methods and materials similar or equivalent to those described herein can also be used in the practice or testing disclosed in the present invention, and preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference to disclose and describe the methods and / or materials described herein, including the publications cited.

[0039] It must be noted that, as used herein and in the appended claims, the singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "an agent" includes a plurality of such agents and reference to "the subject" refers to one or more subjects and equivalents thereof known to those skilled in the art, and so forth.

[0040] “Optional” or “optionally” or “alternatively” means that the subsequently described event, circumstance or material can or cannot occur or exist, and that the description includes instances where the event, circumstance or material occurs and instances where it does not.

[0041] When a range of values ​​is provided, unless the context clearly dictates otherwise, it is understood that each intervening value is included within the scope of the invention, as are one-tenth of the unit between the upper and lower limits of the range and any other specified or intervening values ​​in the range. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges, and any specifically excluded limits in the range are also included within the scope of the invention. When the range includes one or both limits, ranges excluding one or both of these included limits are also included within the scope of the invention.

[0042] "Inhibit," "inhibiting," and "inhibition" refer to a decrease in an activity, response, state, disease, or other biological parameter. This can include, but is not limited to, complete elimination of the activity, response, state, or disease. It can also include, for example, a 10% decrease in the activity, response, state, or disease compared to a natural state or control level. Thus, such a decrease can be 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, or any amount between the specifically recited percentages, compared to a natural state or control level.

[0043] "Promote," "promotion," and "promoting" refer to increasing an activity, response, state, disease, or other biological parameter. This can include, but is not limited to, initiation of an activity, response, state, or disease. It can also include, for example, a 10% increase in an activity, response, state, or disease compared to a natural state or control level. Thus, such an increase in an activity, response, state, disease, or other biological parameter can be 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, or any amount between the specifically recited percentages, compared to a natural state or control level.

[0044] As used herein, the term "subject" refers to any target of administration. The subject can be a vertebrate, such as a mammal. Thus, the subject can be a human. The term does not denote a particular age or sex. Thus, adults, juveniles, and newborns, whether male or female, are intended to be included. A patient refers to a subject afflicted with a disease or condition. The term "patient" includes both human and veterinary subjects.

[0045] As used herein, the term "treat" refers to obtaining a desired pharmacological and / or physiological effect. The effect may be prophylactic, i.e., completely or partially preventing the disease or its symptoms and / or may be therapeutic, i.e., partially or completely curing the disease and / or attributing the deleterious effects of the disease. As used herein, "treat" encompasses any treatment of a disease in mammals, particularly humans, and includes: (a) preventing the disease from occurring in a subject who may be susceptible to the disease but has not yet been diagnosed as having the disease; (b) inhibiting the disease, i.e., arresting its development; and (c) alleviating the disease, i.e., causing the disease to regress.

[0046] The term "therapeutically effective" means that the amount of the composition used is sufficient to ameliorate one or more causes or symptoms of the disease or condition. Such amelioration need only be reduced or altered, not eliminated. The "therapeutically effective amount" will vary depending on the compound, the disease and its severity, and the age, weight, etc. of the subject being treated.

[0047] As used herein, the term "pharmaceutical composition" includes any composition of oxybutynin, pirenzepine, muscarinic toxin (hereinafter referred to as "MT7"), muscarinic receptor antagonists and their analogs for (i) topical administration, (ii) transdermal administration, (iii) parenteral administration, or (iv) oral administration to a subject in need thereof for the treatment of peripheral neuropathy. In addition to oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists and their analogs, the pharmaceutical composition may include a carrier, a thickening agent, a diluent, a buffer, a preservative, a surfactant, and the like. The pharmaceutical composition may also include one or more active ingredients, such as antibacterial agents, anti-inflammatory agents, anesthetics, analgesics, and the like.

[0048] Muscarinic acetylcholine receptor antagonists reverse the loss of intraepidermal nerve fibers and thermal hypoalgesia in peripheral neuropathy. Muscarinic acetylcholine receptor antagonists are agents that reduce the activity and / or function of muscarinic acetylcholine receptors, found in the plasma membranes of neurons and other cells. Muscarinic acetylcholine receptors are GPCRs that are stimulated by acetylcholine released from several cell types, including sensory neurons, keratinocytes, and postganglionic fibers in the parasympathetic nervous system, and act as signaling molecules, initiating signaling cascades within cells in their immediate area. Examples of well-known muscarinic acetylcholine receptor antagonists used to treat conditions such as central nervous system dysfunction, lung diseases and gastric diseases include atropine, scopolamine, pirenzepine, telenzepine, hyoscine, hyoscine, ipratropium, tropicamide, cyclopentolate, glycopyrronium, 4-diphenylacetoxy-1,1-dimethylpiperidine, quinidine, o-phenhydramine, oxybutynin, anweiling, emepronium, procyclidine, propantheline, 4-fluorohexahydrosiladifenidol, octylonium, quinuclidinyl benzilate, phenadrine, benzophenone ... benzilate), tolterodine, benacylamine, fesoterodine (fesoterodine fumarate), trospium chloride, solifenacin, galamine, bipreiden, dicyclomine, benztropine, dextrobenzidamide, hexahydrosiladifenidol, etc.

[0049] In addition to pirenzepine, there are many selective antagonists for type 1 muscarinic receptors (M1R) and other muscarinic receptor subtypes that are expected to show beneficial activity similar to the activity of pirenzepine on neuronal neurite outgrowth. Some of these compounds have more excellent M1R selective activity. For example, telanzepine, an analog of pirenzepine, which has an altered tricyclic structure but no altered piperazine side chain, is 4 to 10 times more effective than pirenzepine. VU0255035 is a thiadiazole derivative that is 75 times more selective for M1R than for M2, M3, M4, and M5 receptors. Among the new generation of M1R antagonists, promising and effective M1R antagonists include PD150714, 77-LH-28-1, and spirotramine. Muscarinic acetylcholine receptor antagonists suitable for incorporation into compositions for treating peripheral neuropathy include: muscarinic toxin (MT7) green mamba venom; tricyclic benzodiazepinone derivatives (e.g., pirenzepine, telenzepine); 1,4-disubstituted tetrahydropyridine carboxylic acids, such as PD150714; benzhexyphenidyl analogs, such as benzhexyphenidyl and p-fluorotrihexyphenidy; thiadiazole sulfonamide derivatives, such as VU0255035; hexacyclam and sila-hexacyclam, such as O-methoxy-sila-hexacyclam; polymethylenetetramine or spiro-4-damp (4-diphenyl- Acetoxy-n-methylpiperidines, such as spirotramine; n-(4-(4-ethylpiperazin-1-yl)phenylamide analogs; McN-A-343 analogs; alkoxy-oxadiazolyl-tetrahydropyridines, such as MB-OXTP; caramiphene, aprofen and related derivatives, such as nitrocaramiphene and aprofen; (-)-S-ET126; N-desmethylclozapine; MDL74019DG; glycopyrrolate; and dicyclomine. Also included are M1R mixed antagonists, i.e., compounds that exhibit antagonist effects on multiple subtypes of muscarinic receptors, including M1, such as risperidone, R-procyclidine and DAU 5750. Other muscarinic antagonists include nurkiazepine, 4-fluorohexahydrosiladifenidol, 4-diphenylacetoxy-N-methyl-piperidinium methyliodide, tolterodine, PD 102807, oxybutynin, iptratropium bromide, and their analogs.

[0050] Variations in the structure of the muscarinic antagonists described above can make these compounds more selective M1R antagonists or alter their stability, safety, or efficacy. Thus, general formulas can be designed to encompass the structural features of antagonists, including those that are M1R selective and M1R non-selective. Examples of suitable general formulas are shown in Formula I and Formula II.

[0051] General formula I:

[0052]

[0053] R1 can be one of a 5-membered unsaturated ring, a 6-membered unsaturated ring or a ring containing heteroatoms;

[0054] R2 can be one of a 5-membered unsaturated ring, a 6-membered unsaturated ring or a ring containing heteroatoms;

[0055] R3 can be one of H-piperidyl, 2-piperidyl, 3-piperidyl, 4-piperidyl, 2-piperazinyl, 3-piperazinyl, which is connected through methyl, ethyl, propyl, butyl. In addition, piperidyl or piperazinyl can be connected to methyl, trifluoromethyl or ethyl moiety.

[0056] R4 can be a hydrogen ion or a chloride ion.

[0057] R5 can be a hydrogen ion or a chloride ion.

[0058] R6 can be a hydrogen ion or a chloride ion.

[0059] R7 can be a hydrogen ion or a chloride ion.

[0060] General formula II:

[0061]

[0062] X can be a methyl group or an "NR" group, ie, a primary, secondary or tertiary amino group.

[0063] R1 can be

[0064]

[0065] Wherein " " represents the connection point between R1 and the above structure in general formula II.

[0066] R2 can be a hydroxide ion or a hydrogen ion or a ketone.

[0067] R3 may be a hydroxide ion or a hydrogen ion or a ketone.

[0068] The term "unit dosage forms" as used herein refers to physically discrete units suitable as unitary dosages for human and animal subjects, each unit containing a predetermined quantity of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonist, and the like calculated to produce the desired effect in association with a pharmaceutically acceptable diluent, carrier, or excipient.

[0069] The term "carrier" refers to a compound, composition, substance, or structure that, when combined with oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, analogs thereof, or compositions, facilitates or enhances the preparation, storage, administration, delivery, efficacy, selectivity, or other properties of the oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, analogs thereof, or compositions for their intended use or purpose. For example, the carrier can be selected to minimize degradation of the oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, analogs thereof, and to minimize adverse side effects in a subject.

[0070] Suitable pharmaceutically acceptable carriers essentially comprise chemically inert and non-toxic pharmaceutical compositions that do not interfere with the effectiveness and / or safety of the primary biological activity of the pharmaceutical composition. Suitable carriers and their dosage forms are described in Remington (1995, The Science and Practice of Pharmacy (19th Edition), ed. A. R. Gennaro, Mack Publishing Company, Easton, PA). Typically, a suitable amount of a pharmaceutically acceptable salt is used in the formulation to make the formulation isotonic. Examples of suitable pharmaceutical carriers include, but are not limited to, saline solutions, glycerol solutions, ethanol, N-(1(2,3-dioleyl)propyl)-N,N,N-trimethylammonium chloride (DOTMA), dioleylphosphatidylethanolamine (DOPE), and liposomes. Such pharmaceutical compositions should comprise a therapeutically effective amount of the compound and a suitable amount of carrier to provide a form suitable for administration to a subject. For example, oral administration requires an enteric coating to protect oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof from degradation in the gastrointestinal tract. In another example, oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof can be administered in the form of a liposomal formulation to facilitate transport through the subject's vascular system and effect delivery across cell membranes to intracellular sites.

[0071] As used herein, the term "excipient" refers to any substance, other than the therapeutic agent itself, that can be used in a composition to deliver oxybutynin, pirenzepine, MT7, a muscarinic receptor antagonist, or its analogs to a subject, or to be combined with oxybutynin, pirenzepine, MT7, a muscarinic receptor antagonist, or its analogs (e.g., to form a pharmaceutical composition) to improve their handling or storage properties, or to allow or facilitate the formation of a dosage unit of the composition (e.g., the formation of a topical hydrogel, which can then optionally be incorporated into a transdermal patch). Excipients include, by way of example and not limitation, binders, disintegrants, flavoring agents, solvents, thickeners or gelling agents (and any neutralizing agents, if desired), penetration enhancers, solubilizers, wetting agents, antioxidants, lubricants, emollients, substances added to mask or counteract unpleasant odors, fragrances or flavorings, and substances added to improve the appearance and feel of the composition and substances used to form the pharmaceutical composition. Any such excipient can be used in any dosage form according to the present invention. The above types of excipients are not meant to be exhaustive, but are merely illustrative, as those skilled in the art will recognize that other types and combinations of excipients may be used to achieve the desired goal of delivering oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof.

[0072] Peripheral neuropathy is an urgent unmet clinical need. Nerve degeneration and impaired regeneration are the pathological characteristics of peripheral neuropathy. Diabetic neuropathy is most often manifested as terminal symmetrical polyneuropathy, suffering from somatic and autonomic nerve division of the peripheral nervous system. Diabetic neuropathy is usually initially described as small fiber neuropathy and skin biopsy shows early retraction of small sensory nerve fibers from the epidermis (Said, 2007, Diabetic neuropathy-a review. Nat. Clin. Pract. Neurol. 3: 331-340). After suffering from diabetes for many years, segmental demyelination and axonal degeneration of large fibers are seen in patient nerve biopsies (Kalichman et al., 1998, Reactive, degenerative, and proliferative Schwann cell responses in experimental galactose and human diabetic neuropathy Acta Neuropath. 95: 47-56). Repeated skin biopsies from diabetic subjects have shown that the ability of injured small fibers to regenerate is impaired (Polydefkis et al., 2004. The timecourse of epidermal nerve fiber regeneration: studies in normal controls and in people with diabetes, with and without neuropathy. Brain 127: 1606-1615). This suggests that peripheral nerves are in a constant dynamic equilibrium between nerve retraction and regrowth, and that the diverse metabolic stresses of systemic diabetes enhance retraction and hinder regeneration, leading to distal nerve degeneration.

[0073] Patients typically recognize peripheral neuropathy at the onset of sensory symptoms such as pain, dysesthesia, and / or loss of sensation in the extremities. Physicians can confirm the diagnosis using simple sensory tests (15g monofilament and tuning fork) or a comprehensive scoring system that includes pain scores, sensory and autonomic function tests, and detailed large-fiber electrophysiology. Historically, most clinical trials of treatments aimed at preventing or alleviating peripheral neuropathy used large-fiber electrophysiology as the primary efficacy endpoint, even when the treatment targeted small-fiber neuropathy. Trials sometimes included sural nerve biopsy to assess underlying pathology, but this approach is invasive and not recommended. An emerging focus on small-fiber pathology to measure peripheral neuropathy and the efficacy of interventions is driven by the ability to quantitatively and repeatedly assess small sensory fiber endings in longitudinal studies using minimally invasive skin biopsies or noninvasive corneal confocal microscopy. IENF and corneal nerve failure, indicating that most small, unmyelinated sensory fibers are converted to thermal sensation, correlate well with symptoms such as pain and loss of sensation and also with measures of large-fiber neuropathy such as conduction slowing. Furthermore, rodent models of peripheral neuropathy have also developed IENF and corneal nerve failure. This provides a logical and scientifically consistent approach for developing therapies to promote postoperative nerve regeneration, starting with in vitro studies to evaluate the potential to promote axonal growth after injury to the dissected dorsal root ganglion (DRG), followed by in vivo studies in rodent models of peripheral neuropathy to evaluate IENF number and function, followed by clinical studies measuring the same parameters.

[0074] The term "neuropathy" includes any pathology or abnormality of neural tissue that causes neural dysfunction. The function of the nerve that is damaged may be related to the rate of electrical current flow through the nerve, or may be related to ectopic discharge of the nerve (discharge without a stimulus), or may be related to inappropriate or insufficient discharge of the nerve in response to a stimulus. As used herein, peripheral neuropathy is defined as a condition caused by damage to the peripheral nerves. It is caused by a neurological disease or is the result of a systemic disease.

[0075] Many factors can cause, induce, or be associated with peripheral neuropathy, and within the scope of the present invention, factors associated with peripheral neuropathy include diabetes, infections such as HIV infection, toxic agents, alcoholism, nutritional deficiencies, systemic / metabolic diseases, paralysis, autoimmune diseases, hereditary or genetic diseases, cancer and tumors, entrapment neuropathy, vasculitic / ischemic neuropathy, mononeuropathy, and polyneuropathy. In further embodiments, the peripheral neuropathy manifests as a postoperative complication.

[0076] Preferably, the term neuropathy includes neuropathy associated with the following diseases: uremia; childhood cholestatic liver disease; chronic respiratory insufficiency; alcoholic polyneuropathy; multiple organ failure; sepsis; hypoalbuminemia; eosinophilia-myalgia syndrome; hypoglycemia; vitamin or nutrient deficiencies (such as B-12 deficiency, vitamin A deficiency, vitamin E deficiency, vitamin B1 deficiency); primary biliary cirrhosis; hyperlipidemia; sensory perineuritis; allergic granulomatosis with polyangiitis; allergic vasculitis; Bell's palsy; Wegener's granulomatosis; rheumatoid arthritis; systemic lupus erythematosus; mixed connective tissue disease; scleroderma; systemic vasculitis; acute carpal tunnel syndrome; panvegetative dysregulation; Hypothyroidism; chronic obstructive pulmonary disease; acromegaly; malabsorption disorders (sprue sprue, celiac disease); cancer (sensory, sensorimotor, advanced, and demyelinating); lymphoma (including Hodgkin lymphoma); polycythemia vera; multiple myeloma (osteolytic, osteosclerotic, or solitary plasmacytoma); tropical myeloneuropathies; pernicious anemia; Churg-Strauss syndrome; cranial nerve palsies; drug-induced neuropathy; industrial neuropathy; lymphoma neuropathy; myeloma neuropathy, chronic idiopathic sensory neuropathy; carcinogenic neuropathy; acute painful autonomic neuropathy; entrapment neuropathy; mononeuropathy and polyneuropathy; or diabetes mellitus.

[0077] In a preferred embodiment, the peripheral neuropathy is diabetic neuropathy. It will be understood that the diabetic neuropathy may be diabetic neuropathy or prediabetic neuropathy associated with type 1 (insulin-dependent) diabetes, type 2 (non-insulin-dependent) diabetes, or both.

[0078] In other embodiments, the peripheral neuropathy is induced by a toxic agent or by the secondary effects of a toxic agent, such as a drug, industrial chemical, or environmental toxin. For example, peripheral neuropathy can be caused by chemotherapeutic agents, such as paclitaxel (or other paclitaxel derivatives); alkaloids such as vincristine or vinblastine; platinum compounds such as cisplatin, carboplatin, oxaliplatin; dichloroacetates; topoisomerase inhibitors; intercalating agents such as bleomycin; or agents such as chloramphenicol, colchicine, dapsone, disulfiram, amiodarone, gold, isoniazid, misonidazole, nitrofurantoin, guanxinling, propranolol, vitamin B6, phenytoin, simvastatin, tacrolimus, thalidomide, cyclophosphamide, or zalcitabine; agents used to treat infectious diseases, such as streptomycin, dideoxycytidine, or zalcitabine; or other chemical toxic agents, such as acrylamide, arsenic, carbon disulfide, hexavalent drugs, lead, mercury, platinum, organophosphates, thallium, or alcohols.

[0079] In another preferred embodiment, the peripheral neuropathy caused by systemic or metabolic diseases is selected from diabetic neuropathy or prediabetic neuropathy, acquired primary demyelinating neuropathy, peripheral symmetrical sensory polyneuropathy, peripheral symmetrical sensory motor polyneuropathy, vasculitic neuropathy, infectious neuropathy, idiopathic neuropathy, immune-mediated neuropathy, nutrition-related neuropathy, renal or liver failure and paraneoplastic neuropathy.

[0080] In other embodiments, the peripheral neuropathy is induced by an infection or infectious disease, such as leprosy, Lyme disease, HIV or acquired immunodeficiency syndrome (AIDS), post-polio syndrome, herpes simplex and herpes zoster (aka shingles), hepatitis B, hepatitis C, AIDS HIV, cytomegalovirus, or diphtheria.

[0081] In preferred embodiments, immune-mediated neuropathies such as acquired primary demyelinating neuropathy include chronic inflammatory demyelinating polyneuropathy (CIDP); Guillain-Barré syndrome; acute inflammatory demyelinating polyneuropathy (AIDP); sarcoidosis; vasculitis / ischemic neuropathy (e.g., polyarteritis nodosa, rheumatoid arthritis, systemic lupus erythematosus (Lupus), and Sjögren's syndrome; celiac disease (sprue); multifocal motor neuropathy (MNN); or peripheral neuropathy associated with protein abnormalities (e.g., monoclonal gammopathy, amyloidosis, cryoglobulinemia, macroglobulinemia, POEMS).

[0082] In a preferred embodiment, the compression causing the peripheral neuropathy is selected from carpal tunnel syndrome, ulnar neuropathy at the elbow or wrist, common peroneal nerve at the knee, tibial nerve at the knee, amyloidosis, and sciatic nerve.

[0083] Also included within the scope of the term neuropathy are hereditary or genetically acquired neuropathies including Charcot-Marie-Tooth disease, hereditary amyloid neuropathy, hereditary sensory neuropathy (types I and II), macular neuropathy, hereditary (neuropathy) with responsibility for pressure palsy (HNPP), Fayble's disease, adrenomyeloneuropathy, Riley-Day syndrome, Dejerine-Sottas neuropathy (hereditary motor sensory neuropathy type III), Refsum's disease, Raynaud's disease including CREST syndrome, Krasper's disease, ataxia-telangiectasia, hereditary tyrosinemia, anaphalipoproteinemia, betalipoproteinemia, giant axonal neuropathy, metachromatic leukoencephalopathy, globoid cell leukodystrophy, or Friedreich's ataxia

[0084] The compositions and methods disclosed herein are also used to treat or prevent neuropathy associated with or induced by the following diseases, traumas, or conditions: general neurological conditions such as peripheral neuropathy, phantom limb pain, reflex sympathetic dystrophy, causalgia, syringomyelia, painful scars; specific neuralgia anywhere in the body; back pain; diabetic neuropathy; alcoholic neuropathy; metabolic neuropathy; inflammatory neuropathy; chemotherapy-induced neuropathy, herpetic neuralgia; traumatic toothache; root canal toothache; thoracic outlet syndrome; cervical, thoracic, and lumbar radiculopathy with nerve compression; Cancer with nerve invasion; traumatic lacerations; mastectomy; thoracotomy pain; spinal cord injury; stroke; abdominal cutaneous nerve entrapment; neuralgia; arachnoiditis; stump pain; fibromyalgia; regional sprains or strains; myofascial pain; psoriatic arthropathy; polyarteritis nodosa; osteomyelitis; burns involving nerve damage; AIDS-related pain syndrome; connective tissue diseases, such as systemic lupus erythematosus, systemic sclerosis, polymyositis, and dermatomyositis; and inflammatory conditions, such as acute inflammation (e.g., trauma, surgery, and infection) or chronic inflammation (e.g., arthritis and gout).

[0085] Peripheral neurons undergo continuous cholinergic restraint. Structurally clear and selective (e.g., pirenzepine) or specific (e.g., MT7) M1 muscarinic receptor antagonists promote neurite outgrowth in primary cultures of adult rodent sensory neurons. Importantly, neurite outgrowth is also enhanced in cultured sensory neurons from mice lacking the M1 receptor compared to normal mice. Together with the following preclinical data, this suggests the general hypothesis that peripheral sensory neurons exist under "cholinergic restraint," which prevents excessive growth of peripheral terminals. This cholinergic restraint may utilize autocrine and / or paracrine mechanisms involving the neurotransmitter acetylcholine, the primary endogenous ligand for muscarinic receptors. Adult rat sensory neurons contain a peripheral form of the acetylcholine (ACh) synthase choline acetyltransferase (pChAT), which exhibits ChAT activity and expresses vesicular ACh transporters and M1 receptors. This explains why M1 receptor antagonists have shown efficacy in cell culture systems. Paracrine mechanisms can also operate by epidermal keratinocytes and corneal cells secreting ACh and communicating through cholinergic receptors.

[0086] The concept of endogenous constraints on axonal growth is a leading concept in CNS research. Furthermore, studies in rodents with type 1 and type 2 diabetes and those with CIPN and DCA-induced neuropathy have demonstrated that therapeutic strategies to prevent neuronal degeneration and promote regeneration by targeting endogenous cholinergic constraints with muscarinic receptor antagonists are feasible. Muscarinic receptor antagonists are not new drugs and are used extensively in clinical practice worldwide to treat a variety of conditions distinct from diabetes and other peripheral neuropathies.

[0087] The common feature of the etiology of nerve degeneration in many peripheral nerve diseases is related to impaired mitochondrial function. Mitochondria cannot produce enough ATP to cause nerve degeneration and make nerve unable to regenerate after compression and / or injury (Roy Chowdhury et al., 2013, The role of aberrant mitochondrial bioenergetics in diabetic neuropathy, Neurobiol. Dis. 51: 56-65).

[0088] diabetic neuropathy :

[0089] Sensory neurons in animal models of type 1 and type 2 diabetes exhibit impaired mitochondrial gene expression and function. Studies of neurons in diabetic rodents have shown that their mitochondrial membrane potential decreases (Huang et al., 2003, Insulin prevents depolarization of the mitochondrial inner membrane in sensory neurons of type 1 diabetic rats in the presence of sustained hyperglycemia, Diabetes 52:2129-36). Bioenergetics analysis of sensory neurons in diabetic rodents revealed suboptimal maximal respiratory capacity and loss of activity of electron transport complexes (Roy Chowdhury et al., 2012. Impaired AMP-activated protein kinase signaling in dorsal root ganglia neurons is linked to mitochondrial dysfunction and peripheral neuropathy in diabetes. Brain 135:1751-66). Changes in the mitochondrial proteome underlie these changes and are driven by impaired activation of AMP-activated protein kinase (AMPK)—a master regulator of mitochondrial function and fidelity (Roy Chowdhury et al., 2012; Akude et al., 2011. Diminished superoxide generation is associated with respiratory chain dysfunction and changes in the mitochondrial proteome of sensory neurons from diabetic rats. Diabetes 60:288-97).In diabetic neuropathy, this downregulation of mitochondrial function in adult sensory neurons is associated with inhibition of AMPK and PGC-1α activity. Impaired AMP-activated protein kinase signaling in dorsal root ganglion neurons is linked to mitochondrial dysfunction and peripheral neuropathy in diabetes (Brain 135:1751-66). The mechanism of M1 receptor-mediated inhibition of axonal growth involves downregulation of mitochondrial bioenergetics and function. Freeing neurons from this confinement using M1 receptor antagonists leads to activation of AMPK, increased transcriptional activity of PGC-1α, and an associated increase in mitochondrial respiration. This pathway is regulated at the proximal level by the M1 receptor via CaMKKβ (or CaMKK2), a described activator of AMPK. AMPK is a multicomponent Ser / Thr kinase that is activated by AMP binding upon an increase in the AMP / ATP ratio. Activated AMPK primarily optimizes mitochondrial function, opening up catabolic pathways to produce ATP and simultaneously shutting down energy-consuming anabolic processes. AMPK activation increases phosphorylation of the transcription factor PGC-1α, and AMPK requires PGC-1α activity to regulate the expression of several key players in metabolism, including components of the mitochondrial electron transport system. Deacetylation of PGC-1α by cytoplasmic sirtuins, SIRT1, and SIRT2, enhances its transcriptional activity. Coupled regulation of PGC-1α by AMPK and sirtuins plays a major role in metabolic adaptation to energy metabolism in various tissues.

[0090] The positive effects of pirenzepine on neurite outgrowth, AMPK phosphorylation, and PGC-1α transcriptional activation were replicated by MT7. Oxybutynin also promoted neurite outgrowth in cultured sensory neurons and, like pirenzepine, prevented the development of sensory neuropathy in mice with both type 1 and type 2 diabetes.

[0091] Chemotherapy-induced peripheral neuropathy (CIPN) :

[0092] Paclitaxel and oxaliplatin induce CIPN by blocking mitochondrial function and driving peripheral axonal loss. (Bennett et al., 2011. Terminal arbor degeneration—a novel lesion produced by the antineoplastic agent paclitaxel. Eur. J. Neurosci. 33:1667-76; Xiao et al., 2011. Mitochondrial abnormality in sensory, but not motor, axons in paclitaxel-evoked painful peripheral neuropathy in the rat. Neuroscience 199:461-9; Zheng et al., 2011. Functional deficits in peripheral nerve mitochondria in rats with paclitaxel-and oxaliplatin-evoked painful peripheral neuropathy. Neuropathy, Exp. Neurol. 232: 154-61). In rodent models of CIPN, analysis of mitochondrial electron transport activity revealed functional defects and was associated with axonal death in the skin (Zheng et al., 2011). Pirenzepine prevented the degeneration of cultured neurons induced by the CIPN-inducing agents paclitaxel and oxaliplatin. In vivo studies in mice treated with paclitaxel showed that pirenzepine prevented the development of heat- and touch-induced pain. Pirenzepine also prevented the development of thermal hypoalgesia, IENF loss, and MNCV reduction in DCA-treated mice.

[0093] Charcot-Marie-Tooth Disease (CMT) :

[0094] In Charcot-Marie-Tooth disease type 2 (CMT2), axonal degeneration with terminal apoptosis predominates and is associated with mutations in the GTPase and mitochondrial fusion protein mitofusin 2 (MFN2) in 19% to 33% of cases (Zuchne et al., 2004. Mutations in the mitochondrial GTPase mitofusin 2 cause Charcot-Marie-Tooth neuropathy type 2A. Nat. Genet. 36:449-51). Overexpression of mutant MFN2 in sensory neurons also leads to peripheral paralysis neuropathy in a mouse model characterized by impaired axonal transport of mitochondria (Baloh et al., 2007. Altered axonalmitochondrial transport in the pathogenesis of Charcot-Marie-Tooth disease from mitofusin 2 mutations. J. Neurosci. 27:422-30). Mitochondrial bioenergetics are not significantly altered, and the role of MFN2 in mediating transport is thought to be separate from the regulation of mitochondrial fusion (Baloh et al., 2007; Misko et al., 2010. Mitofusin 2 is necessary for transport of axonal mitochondria and interacts with the Miro / Milton complex. J. Neurosci. 30:4232-40).

[0095] HIV-induced neuropathy :

[0096] Post-mortem examination of peripheral nerve samples from patients with HIV-induced neuropathy showed increased mutations in mitochondrial DNA (mutated mtDNA 4977) is associated with defects in mitochondrial protein expression (Lehmann et al., 2011, Mitochondrial dysfunction indistal axons contributes to human immunodeficiency virus sensory neuropathy, Ann Neurol. 69, 100-10). These deficiencies are more pronounced at the distal level compared to more proximal nerve segments. Rhesus macaques infected with simian immunodeficiency virus (SIV) exhibit similar abnormalities, with abnormal features of mitochondrial function and an increase in mitochondrial-dependent reactive oxygen species (ROS) generation (Lehmann et al., 2011). Studies on cultured human DRG treated with supernatant of HIV-infected macrophages also showed mitochondrial dysfunction (manifested as cell membrane depolarization), with signals of oxidative stress in the perikarya but not in the axons (Hahn et al., 2008, Differential effects of HIV infected macrophages on dorsal root ganglia neurons and axons, Exp. Neurol. 210: 30-40). Changes in the mitochondrial phenotype (e.g., inner membrane depolarization and protein suppression) mirror the defects seen in diabetic neuropathy.

[0097] Friedrich's ataxia :

[0098] This is an autosomal recessive neurodegenerative disease caused by a GAA repeat expansion in intron 1 of the frataxin gene. The resulting reduced expression is associated with antidepressant neuropathy affecting sensory neurons and spinocerebellar and corticospinal motor tracts (Puccio et al., 2002, Friedreichataxia: a paradigm for mitochondrial diseases, Curr. Opin. Genet. Dev. 12:272-77). Frataxin is an iron chaperone required for the formation of iron-sulfur (Fe-S) clusters, but its loss is associated with reduced activity of Fe-S-containing enzymes (important for optimal mitochondrial respiratory chain function) and impaired protection against oxidative stress (Bencze et al., 2006, The structure and function of frataxin, Crit. Rev. Biochem. Mol. Biol. 41:269-91). In mouse models of the disease, mitochondrial dysfunction occurs in the absence of any increased oxidative stress (Seznec et al., 2005. Friedreich ataxia: the oxidative stress paradox. Hum. Mol. Genet. 14:463-74). Some clarity on the etiology of the disease comes from work in Drosophila, where, in the absence of oxidative stress, depolarization of the mitochondrial inner membrane precedes impaired mitochondrial trafficking and loss of fiber terminals (Shidara & Hollenbeck, 2010. Defects in mitochondrial axonal transport and membrane potential without increased reactive oxygen species production in a Drosophila model of Friedreich ataxia. J. Neurosci. 30:11369-78). There are clear parallels with the mitochondrial dysfunction observed in diabetic neuropathy. In animal models, inner membrane depolarization in sensory neurons is identified in this disease, and respiratory chain dysfunction is observed without any concomitant increase in ROS generation (Akude et al., 2011; Huang et al., 2003; Roy Chowdhury et al., 2012).

[0099] By controlling cellular AMPK levels and thereby mitochondrial function, antimuscarinic drugs can prevent peripheral nerve degeneration in many common diseases. The data presented below show that these drugs can repair nerve damage in diabetes, CIPN, HIV, and DCA toxicity. These diseases are caused by very different initial stressors, but share common mitochondrial components in the etiology or progression of the disease. Importantly, in the etiology of the diseases, the ability of these drugs to repair mitochondrial fidelity and drive nerve regeneration arises independently of any effects on muscarinic signaling. These drugs' inhibition of cholinergic pathways can enhance nerve regeneration and repair in a wide range of diseases.

[0100] The present invention provides compositions comprising agents including, but not limited to, oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and their analogs, for treating peripheral neuropathy induced by diabetes, chemotherapy agents including DCA, HIV, genetic diseases such as Charcot-Marie-Tooth disease, etc. The agents can be formulated into pharmaceutical compositions for various delivery routes.

[0101] In another embodiment, agents such as oxybutynin, pirenzepine, MT7, other muscarinic receptor antagonists and their analogs are used to restore decreased AMPK activity and PGC-1α transcriptional activity.

[0102] Each of the aforementioned agents (eg, oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof) can be formulated into pharmaceutical compositions for a variety of routes of administration.

[0103] In one embodiment, the pharmaceutical compositions disclosed herein comprise from about 0.1% to about 95% by weight of an agent as described above (e.g., oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof), based on the total amount of the composition. For example, the amount of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof, based on the weight of the pharmaceutical composition, is about 0.1%, about 0.2%, about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1%, about 1.1%, about 1.2%, about 1.3%, about 1.4%, about 1.5%, about 1.6%, about 1.7%, about 1.8%, about 1.9%, about 2.5%, about 3.0%, about 4.5%, about 5.0%, about 6.0%, about 7.0%, about 8.0%, about 9.0%, about 10.0%, about 11.0%, about 12.0%, about 13.0%, about 14.0%, about 15.0%, about 16.0%, about 17.0%, about 18.0%, about 19.0%, about 20.0%, about 21.0%, about 22.0%, about 23.0%, about 24.0%, about 25.0%, about 26.0%, about 27.0%, about 28.0%, about 29.0%, about 30.0%, about 31.0%, about 32.0%, about 33.0%, about 34.0%, about 35.0%, about 36.0%, about 37.0%, about 38.0%, about 39.0%, about , about 2%, about 2.1%, about 2.2%, about 2.3%, about 2.4%, about 2.5%, about 2.6%, about 2.7%, about 2.8%, about 2.9%, about 3%, about 3.1%, about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about 3.8%, about 3.9%, about 4%, about 4.1%, about 4.2%, about 4.3%, about 4.4%, about 4.5%, about 4.6%, About 4.7%, about 4.8%, about 4.9%, about 5%, about 5.1%, about 5.2%, about 5.3%, about 5.4%, about 5.5%, about 5.6%, about 5.7%, about 5.8%, about 5.9%, about 6%, about 6.1%, about 6.2%, about 6.3%, about 6.4%, about 6.5%, about 6.6%, about 6.7%, about 6.8%, about 6.9%, about 7%, about 7.1%, about 7.2%, about 7.3%, about 7.4%, about 7.5%, about 7.6%, about 7.7%, about 7.8%, about 7.9%, about 8%, about 8.1%, about 8.2%, about 8.3%, about 8.4%, about 8.5%, about 8.6%, about 8.7%, about 8.8%, about 8.9%, about 9%, about 9.1%, about 9.2%, about 9.3%, about 9.4%, about 9.5%, about 9.6%, about 9.7%, about 9.8%, about 9.9%, about 10%, about 1 1%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90% or about 95%.

[0104] The pharmaceutical compositions disclosed herein containing the agents can be formulated for topical administration, or alternatively for transdermal administration.

[0105] The pharmaceutical composition for topical administration can be provided in the form of, for example, ointment, emulsifiable concentrate, suspension, lotion, powder, solution, paste, gel, hydrogel, spray, aerosol, dressing or oil. When active ingredient is formulated in ointment, active ingredient can adopt paraffin (paraffmic) or water miscible ointment base. Alternatively, active ingredient can be formulated in the emulsifiable concentrate with oil-in-water base or water-in-oil base. The composition can be mixed in other dosage forms, including oil, suppository, foam, liniment, aerosol, buccal agent and sublingual tablet or for the topical device absorbed by skin or mucous membrane.

[0106] Ointments and creams can be formulated, for example, with an aqueous or oily base and with the addition of a suitable thickener and / or gelling agent. Lotions can be formulated with an aqueous or oily base and typically contain one or more emulsifiers, stabilizers, dispersants, suspending agents, thickeners, or colorants. Liquid sprays can be conveniently delivered from pressurized packs, for example, through specially shaped closures. Oil-in-water emulsions can be used in compositions, patches, bandages, and articles. These systems are semisolid emulsions, microemulsions, or foam emulsions. Typically, such systems have a "milky" appearance. The oil phase can include, but is not limited to, long-chain alcohols (hexadecyl alcohol, octadecyl alcohol); long-chain esters (myristate, palmitate, stearate); long-chain acids (palmitic acid, stearic acid); vegetable and animal oils, and wax blends. These can be formulated with anionic, cationic, nonionic, or amphoteric surfactants, or particularly with a combination of nonionic surfactants. Provided herein for exemplary purposes only, a typical inventive gel matrix may comprise lecithin, isopropyl palmitate, poloxamer 407, and water. Topical carriers having varying viscosities and feel are known in the art. The active ingredients can be dispersed in a pharmaceutically acceptable carrier in a therapeutically effective amount to treat the neuropathy and other conditions described above.

[0107] The pharmaceutical composition for transdermal administration can be provided in the form of a hydrogel such as medicament described herein, and the hydrogel is mixed in the patch composition and is intended to be used for maintaining close contact with the subject's epidermis for a long time. Exemplary patch compositions can include a monolayer, the preparation of which is by mixing oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists and the like with silicone adhesives or with optional acrylate-vinyl acetate adhesives in a solvent, the example of which is methylene chloride, ethyl acetate, isopropyl myristate and propylene glycol. The mixture is then extruded onto a polyester backing film with a precision wet film applicator to form a uniform thickness of approximately more than 100 microns. The solvent is then evaporated in a drying oven and the resulting " patch " is trimmed to a suitable size.

[0108] Medicaments for topical or, optionally, transdermal administration of the agents described above (e.g., oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists and their analogs) may also be admixed with a penetration enhancer and / or a thickener or gelling agent and / or a lubricant and / or an antioxidant and / or an antimicrobial preservative and / or an emulsifier and / or a water-soluble solvent and / or alcohol and / or water.

[0109] According to a first aspect, a pharmaceutical composition for topical or transdermal administration of an agent as described above (e.g., oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and the like) may comprise one or more penetration enhancers or cosolvents for transdermal or topical delivery. A penetration enhancer is an excipient that aids in the diffusion of the active ingredient through the stratum corneum. Many penetration enhancers can also serve as cosolvents, which are believed to increase the thermodynamic activity or solubility of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and the like in the composition. A penetration enhancer is also referred to as an enhancer, adjuvant, or adsorption enhancer. Suitable penetration enhancers for use in the pharmaceutical compositions and methods described herein should be: (i) highly potent, having a specific mechanism of action; (ii) exhibit rapid onset of action upon administration; (iii) have a predictable duration of action; (iv) have only non-permanent or reversible effects on the skin; (v) be chemically stable; (vi) have no or minimal pharmacological effects; (vii) be physically and chemically compatible with the other composition components; (viii) be odorless; (ix) be colorless; (x) be hypoallergenic; (xi) be non-irritating; (xii) be non-phototoxic; (xiii) be non-comedogenic; (xiv) have a solubility parameter similar to that of the skin (10.5 cal / cm3); (xv) be readily available; (xvi) be inexpensive; and (xvii) be capable of being formulated into pharmaceutical compositions for topical or transdermal delivery of the active agent.

[0110] Several classes of compounds with different mechanisms of action can be used as penetration enhancers. Described below are non-limiting examples of penetration enhancers, many of which are also suitable cosolvents. Sulfoxides, such as dimethyl sulfoxide and decylmethyl sulfoxide, can be used as penetration enhancers. Dimethyl sulfoxide promotes penetration by increasing lipid fluidity and facilitating drug distribution. In contrast, decylmethyl sulfoxide promotes penetration by reacting with proteins in the skin to alter their structure, resulting in the creation of aqueous channels.

[0111] Other types of penetration enhancers are alkanones such as n-heptane, n-octane, n-nonane, n-decane, n-undecane, n-dodecane, n-tridecane, n-tetradecane and n-hexadecane. Alkanones are considered to promote the penetration of active agents by changing the stratum corneum. Another type of penetration enhancer is an alkanol, for example ethanol, propyl alcohol, butanol, 2-butanol, amyl alcohol, 2-amyl alcohol, hexanol, octanol, nonanol, decanol and benzyl alcohol. Low molecular weight alkanols, i.e. those alkanols with 6 or less carbons can partially promote penetration as solubilizing agents, and more hydrophobic alcohol can increase diffusion by extracting lipid from the stratum corneum. Another type of penetration enhancer is a fatty alcohol, for example oleyl alcohol, octanol, decanol, lauryl alcohol, 2-lauryl alcohol, myristyl alcohol, cetyl alcohol, stearyl alcohol, oleyl alcohol, linoleyl alcohol and linolenic alcohol. Polyols including propylene glycol, polyethylene glycol, ethylene glycol, diethylene glycol, triethylene glycol, dipropylene glycol, glycerol, propylene glycol, butylene glycol, pentylene glycol, hexanetriol, propylene glycol monolaurate, and diethylene glycol monomethyl ether (transcutol) can also promote penetration. Certain polyols, such as propylene glycol, act as penetration enhancers by solvating α-keratin and occupying hydrogen bonding sites, thereby reducing the amount of active tissue binding.

[0112] Another class of penetration enhancers is amides, including urea, dimethylacetamide, diethyltoluamide, dimethylformamide, dimethyloctamide, dimethyldecamide, and biodegradable cyclic ureas (e.g., 1-alkyl-4-imidazolin-2-ones). Amides have various mechanisms of promoting penetration. For example, certain amides, such as urea, increase the hydration of the stratum corneum as a channel for keratin separation and hydrophilic diffusion. In contrast, other amides, such as dimethylacetamide and diethylformamide, increase the distribution of keratin at low concentrations and increase lipid mobility and disrupt lipid packaging at high concentrations. Another type of penetration enhancer is a pyrrolidone derivative, such as 1-methyl-2-pyrrolidone, 2-pyrrolidone, 1-lauryl-2-pyrrolidone, 1-methyl-4-carboxy-2-pyrrolidone, 1-hexyl-4-carboxy-2-pyrrolidone, 1-lauryl-4-carboxy-2-pyrrolidone, 1-methyl-4-methoxycarbonyl-2-pyrrolidone, 1-hexyl-4-methoxycarbonyl-2-pyrrolidone, 1-lauryl-4-methoxy Carbonyl-2-pyrrolidone, N-methyl-pyrrolidone, N-cyclohexylpyrrolidone, N-dimethylaminopropyl-pyrrolidone, N-cocoalkypyrrolidone and N-tallowalkypyrrolidone, as well as biodegradable pyrrolidone derivatives, including fatty acid esters of N-(2-hydroxyethyl)-2-pyrrolidone. Pyrrolidone derivatives promote penetration, in part, by interacting with keratin in the stratum corneum and lipids in the skin structure. Another class of penetration enhancers is the cyclic amides, including those known as AZONE is a registered trademark of AZONE, Philadelphia, PA, USA, 1-dodecylazacycloheptan-2-one, 1-farnesylazacycloheptan-2-one, 1-geranylgeranylazacycloheptan-2-one, 1-(3,7-dimethyloctyl)-azacycloheptan-2-one, 1-(3,7,1-trimethyldodecyl)azacycloheptan-2-one, 1-geranylazacyclohexan-2-one, 1-geranylazacyclopentan-2,5-dione and 1-farnesylazacyclopentan-2-one. The cyclic amides promote the penetration of active ingredients in part by affecting the lipid structure of the stratum corneum, increasing partitioning and improving membrane fluidity.

[0113] Another class of penetration enhancers includes diethanolamine, triethanolamine, and hexamethylene lauramide and its derivatives.

[0114] Other penetration enhancers include straight-chain fatty acids, such as caprylic acid, linoleic acid, valeric acid, enanthic acid, nonanoic acid, caproic acid, capric acid, lauric acid, myristic acid, stearic acid, oleic acid and caprylic acid. Straight-chain fatty acids promote penetration by the selective perturbation of the lipid bilayer between molecules. In addition, some straight-chain fatty acids, such as oleic acid, promote penetration by reducing the phase transition temperature of lipids and improving the freedom of movement and mobility of lipids. Branched-chain fatty acids are another type of penetration enhancer, including isovaleric acid, neopentanoic acid, neoheptanoic acid, nonanoic acid, trimethylhexanoic acid, neodecanoic acid and isostearic acid. Another type of penetration enhancer is aliphatic fatty acid esters, such as ethyl oleate, isopropyl butyrate, isopropyl hexanoate, isopropyl decanoate, isopropyl myristate ("IPM"), isopropyl palmitate and octyldodecyl myristate. Aliphatic fatty acid esters promote penetration by improving the diffusion capacity and / or partition coefficient in the stratum corneum. In addition, specific aliphatic fatty acid esters, for example IPM, promote penetration by directly acting on the stratum corneum and infiltrating the liposome bilayer to improve fluidity. Alkyl fatty acid esters can be used as penetration enhancers, for example ethyl acetate, butyl acetate, methyl acetate, methyl valerate, methyl propionate, diethyl sebacate, ethyl oleate, butyl stearate and methyl laurate. Alkyl fatty acid esters promote penetration by increasing the lipid fluidity portion.

[0115] Another class of penetration enhancers is anionic surfactants, including sodium laurate, sodium lauryl sulfate, and sodium octyl sulfate. Anionic surfactants work by changing the barrier function of the stratum corneum and causing it to remove water-soluble agents that normally act as plasticizers. Another class of penetration enhancers is cationic surfactants, such as cetyltrimethylammonium bromide, tetradecyltrimethylammonium, octyltrimethylammonium bromide, benzalkonium chloride, octadecyltrimethylammonium chloride, cetylpyridinium chloride, dodecyltrimethylammonium chloride, and cetylammonium chloride. Cationic surfactants promote penetration by adsorbing on the interface of biological membranes and interacting with them, causing skin damage. Another class of penetration enhancers is amphoteric surfactants, such as cetyltrimethylammonium propane sulfonate, oleyl betaine, cocamidopropyl hydroxysulfobetaine, and cocamidopropyl betaine. Nonionic surfactants, such as Polyxamer 231, Polyxamer 182, Polyxamer 184, Polysorbate 20, Polysorbate 60, 30. 93. 96. 99 (BRIJ is a registered trademark of Brij Image & Information Inc., Greensboro, NC, USA), 20, 40, 60, 80, 85 (SPAN is a registered trademark of Croda International PLC, East Yorkshire, UK) 20. 40. 60. 80 (TWEEN is a registered trademark of Uniqema Americas LLC, Wilmington, DE, USA), Myrj 45, 51. (MYRJ is a registered trademark of Uniqema Americas LLC, Wilmington, DE, USA) and 840 (MIGLYOL is a registered trademark of Cremer Oleo GMBH & Co., Hamburg, Fed. Rep. Germany), and the like. Nonionic surfactants promote penetration by emulsifying sebum and increasing the thermodynamic activity or solubility of active ingredients.

[0116] Another type of penetration enhancer increases the thermodynamic activity or solubility of the active ingredient and includes, but is not limited to, n-octanol, sodium oleate, D-limonene, glyceryl monooleate, eucalyptol, oleyl oleate, and isopropyl myristate.

[0117] Other penetration enhancers are bile salts, such as sodium cholate; sodium salts of taurocholic acid, glycolic acid, and deoxycholic acid. Lecithin has also been found to have penetration-enhancing properties. Another class of penetration enhancers is the terpenes, which include hydrocarbons such as d-limonene, α-pinene, and β-carene; alcohols such as α-terpineol, terpinen-4-ol, and carawayol; ketones such as ascarvone, pulegone, piperitone, and menthone; oxides such as cyclohexene oxide, limonene oxide, α-epoxypinene, cyclopentene oxide, and 1,8-cineole; and oils such as ylang-ylang essential oil, anise, chenopogon, and eucalyptus. Terpenes enhance penetration in part by disrupting the intercellular lipid bilayer, thereby increasing the diffusivity of active ingredients and opening polar pathways within or across the stratum corneum. Organic acids are penetration enhancers, such as salicylic acid and salicylates (including methyl salicylate, ethyl salicylate, and propyl glycol salicylate); citric acid and succinic acid. Other types of penetration enhancers are cyclodextrins, including 2-hydroxypropyl-β-cyclodextrin and 2,6-dimethyl-β-cyclodextrin. Cyclodextrins promote the penetration of lipophilic active agents by forming inclusion complexes with them and increasing their solubility in aqueous solutions.

[0118] A penetration enhancer and / or solubilizing agent is present in the pharmaceutical composition for topical or transdermal administration of the above-described agents (e.g., oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof) in an amount sufficient to provide the desired level of drug delivery through the stratum corneum and epidermis or to increase the thermodynamic activity or solubility of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof. The amount of one or more pharmaceutically acceptable penetration enhancers and / or solubilizers is about 0.1%, about 0.2%, about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1.0%, about 1.1%, about 1.2%, about 1.3%, about 1.4%, about 1.5%, about 1.6%, about 1.7%, about 1.8%, about 1.9%, about 2.0%, about 2.1%, about 2.2%, about 2.3%, about 2.4%, about 2.5%, about 2.6%, about 2.7%, about 2.8% of the total weight. , about 2.9%, about 3.0%, about 3.1%, about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about 3.8%, about 3.9%, about 4.0%, about 4.1%, about 4.2%, about 4.3%, about 4.4%, about 4.5%, about 4.6%, about 4.7%, about 4.8%, about 4.9%, about 5.0%, about 5.1%, about 5.2%, about 5.3%, about 5.4%, about 5.5%, about 5.6%, about 5.7%, about 5.8%, about 5.9%, about 6.0%, about 6.1%, about 6.2%, about 6.3%, about 6.4%, about 6.5%, about 6.6%, about 6.7%, about 6.8%, about 6.9%, about 7.0%, about 7.1%, about 7.2%, about 7.3%, about 7.4%, about 7.5%, about 7.6%, about 7.7%, about 7.8%, about 7.9%, about 8.0%, about 8.1%, about 8.2%, about 8.3%, about 8.4%, about 8.5%, about 8.6%, about 8.7%, about 8.8%, about 8.9%, about 9.0%, about 9.1%, about 9.2%, about 9.3%, about 9.4%, about 9. 5%, about 9.6%, about 9.7%, about 9.8%, about 9.9%, or about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 1%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%., about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52%, about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 61%, about 62%, about 63%, about 64%, about 65%, about 66%, about 67%, about 68%, about 69%, about 70%, about 71%, about 72%, about 73%, about 74%, about 75%, about 76%, about 77%, about 78%, about 79%, about 80%, about 81%, about 82%, about 83%, about 84%, about 85%, about 86%, about 87%, about 88%, about 89%, about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, about 100%, about 101%, about 102%, about 103%, about 104%, about 105%, about 106%, about 107%, about 108%, about 109%, about 110%, about 111%, about 112%, about 113%, about 114%, about 115%, about 116%, about 117%, about 118%, about 119%, about 0%, about 71%, about 72%, about 73%, about 74%, about 75%, about 76%, about 77%, about 78%, about 79%, about 80%, about 81%, about 82%, about 83%, about 84%, about 85%, about 86%, about 87%, about 88%, about 89%, about 90%, about 91%, about 92%, about 93%, about 94%, or about 95%.

[0119] The selected penetration enhancer should be pharmacologically inert, non-toxic, and non-allergenic, have a rapid and reversible onset of action, and be suitable for the composition of the present invention. Examples of penetration enhancers include diethylene glycol monoethyl ether (transcutol P), ethanol, isopropyl alcohol, lauryl alcohol, salicylic acid, octolyphenylpolyethylene glycol, polyethylene glycol 400, propylene glycol, N-decylmethyl sulfoxide, DMSO, and nitrogen heterocyclic compounds.

[0120] In one embodiment, the present invention relates to a composition for topical administration of a muscarinic acetylcholine receptor antagonist in a pharmaceutically acceptable amount sufficient to treat peripheral neuropathy. As used herein, the term "topical" refers to a limited area near the site of administration, typically a nerve at or near the skin, with no or limited systemic penetration across the skin, including the epidermis, dermis, dermatomes, and the like.

[0121] Preferably, topical delivery is intended to maximize drug delivery through the stratum corneum into the epidermis, dermis, or dermatome, and to minimize absorption into the circulatory system. More preferably, the agents that can be used in topical formulations prevent the active ingredient or excipients from passing into the underlying skin layers. These so-called skin retarders have been readily developed for use in many over-the-counter (OTC) skin formulations, such as sunscreens and insecticides, where the site of action is limited to the skin surface or upper skin layers. Studies on penetration enhancement or retardation have yielded valuable insights into the structure-activity relationships of enhancers and retarders, including compounds such as ketorolac stearate, caprolactam analogs, dicarboxylates, sodium citrate, and the like (Asbill et al., 2000, Percutaneous penetration enhancers: local versus transdermal activity. Pharm. Sci. Tech. Today, 3(1):36-41; Kaushik et al., 2008, Percutaneous permeation modifiers: enhancement versus retardation. Exp. Opin. Drug Del. 5(5):517-529; Trommer et al., 2006, Overcoming the Stratum Corneum: The Modulation of Skin Penetration. Skin Pharmacol. Physiol. 19:106-121).

[0122] The compositions described herein may further include components commonly incorporated into such preparations. For example, the compositions may also include other ingredients, such as other carriers, humectants, oils, fats, waxes, surfactants, thickeners, antioxidants, viscosity stabilizers, chelating agents, buffers, preservatives, fragrances, dyes, lower alkanols, wetting agents, lubricants, dispersants, sunscreens such as radiation blocking compounds or, in particular, UV blockers, antibacterial agents, antifungal agents, disinfectants, vitamins, antibiotics or other anti-acne medications, and other suitable materials that do not significantly adversely affect the activity of the topical composition. Other ingredients used for inclusion in the carrier are sodium acid phosphate humectants, witch hazel extract carriers, glycerin humectants, almond oil lubricants, corn oil dispersants, and the like, which are described in detail below. Those skilled in the art will readily recognize other ingredients that can be incorporated into the compositions described herein.

[0123] According to another aspect, the pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may comprise a thickening agent or gelling agent suitable for use in the compositions and methods described herein to increase the viscosity of the composition. Examples of suitable agents (also known as gelling agents) are neutral anionic polymers or neutral carbomers, such as polyacrylic acid, carboxyvinyl polymer, carboxymethylcellulose, and analogs thereof, including derivatives of Ultrez 10; polymers, e.g. 940, 941, 954, 980, 981, ETD 2001, EZ-2 and EZ-3 (CARBOPOL is a registered trademark of Lubrizol Advanced Materials Inc., Cleveland, OH, USA). As used herein, "neutral carbomer" is a synthetic high molecular weight polymer composed primarily of neutral polyacrylic acid. In addition, when a base is added to neutralize the carbomer, the viscosity of the solution increases. Other known polymeric thickeners, such as Polymer emulsifiers, Polycarbophil (PEMULEN and NOVEON are registered trademarks of Lubrizol Advanced Materials Inc.), and (KLUCEL is a registered trademark of Hercules Inc., Wilmington, DE, USA.) Other thickeners, enhancers, and adjuvants are generally found in Remington's, The Science and Practice of Pharmacy and Handbook of Pharmaceutical Excipients (Arthur H. Kibbe ed. 2000). Alternatively, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may comprise an anionic thickener precursor, such as a carbomer, combined with a sufficient amount of a neutralizing agent to form a gel or gel-like composition having a viscosity greater than 1000 cps as measured using a Brookfield RV DVII+ viscometer, spindle CPE-52, torque greater than 10%, and maintained at 25°C. Alternatively, the anionic polymeric thickener precursor can be combined with a neutralizing agent selected from the group consisting of sodium hydroxide, ammonium hydroxide, potassium hydroxide, arginine, aminomethyl propanol, tetrahydroxypropyl ethylenediamine, triethanolamine ("TEA"), tromethamine, PEG-15 cocamine, diisopropanolamine, and triisopropanolamine, or combinations thereof, in an amount sufficient to neutralize the anionic polymeric thickener precursor to form a gel or gel-like composition during formation of the composition. The amount of the thickening or gelling agent is sufficient to provide the desired rheological properties of the composition, including a composition having sufficient viscosity to form a gel or gel-like composition capable of being applied to human skin. On a weight basis, the amount of the thickener or gelling agent is about 0.1%, about 0.25%, about 0.5%, about 0.75%, about 1%, about 1.25%, about 1.5%, about 1.75%, about 2.0%, about 2.25%, about 2.5%, about 2.75%, about 3.0%, about 3.25%, about 3.5%, about 3.75%, about 4.0%, about 4.25%, about 4.5%, about 4.75%, about 5.0%, about 5.25%, about 5.5%, about 5.75%, about About 6.0%, about 6.25%, about 6.5%, about 6.75%, about 7.0%, about 7.25%, about 7.5%, about 7.75%, about 8.0%, about 8.25%, about 8.5%, about 8.75%, about 9.0%, about 9.25%, about 9.5%, about 9.75%, about 10%, about 11%, about 11.5%, about 12%, about 12.5%, about 13%, about 13.5%, about 14%, about 14.5% or about 15%, and values ​​intermediate to these values.

[0124] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may comprise a lubricant. Examples of suitable lubricants are mineral oil, a mixture of mineral oil and lanolin alcohol, cetyl alcohol, cetostearyl alcohol, petrolatum, petrolatum and lanolin alcohol, cetyl esters wax, cholesterol, glycerin, glyceryl monostearate, isopropyl myristate, isopropyl palmitate, lecithin, allyl hexanoate, marshmallow extract, arachidyl alcohol, argobase EUC, butylene glycol, dicaprylate / dicaprate, gum arabic, allantoin, carrageenan, cetyl dimethicone, cyclomethicone, hicone, diethyl succinate, dihydroabietyl behenate, dioctyl adipate, ethyl laurate, ethyl palmitate, ethyl stearate, isoamyl laurate, caprylic acid, PEG-75, lanolin, sorbitan laurate, walnut oil, wheat germ oil, super refined almond oil, super refined sesame oil, super refined soybean oil, octyl palmitate, caprylic / capric triglyceride and cocoglyceryl. Lubricants, if present in the compositions described herein, are present in an amount by weight of about 1% to about 30%, about 3% to about 25%, or about 5% to about 15% by weight of the composition. Illustratively, the amount of one or more lubricants is about 1%, about 2%, about 3%, about 4%, about 5%, about 6%, about 7%, about 8%, about 9%, about 10%, about 11%, about 12%, about 13%, about 14%, about 1%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, or about 30% of the total weight, and values ​​intermediate to these values.

[0125] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may comprise an antioxidant. Examples of suitable antioxidants are citric acid, butylated hydroxytoluene (BHT), ascorbic acid, glutathione, retinol, α-tocopherol, β-carotene, α-carotene, ubiquinone, butylated hydroxyanisole, ethylenediaminetetraacetic acid, selenium, zinc, lignans, uric acid, lipoic acid, and N-acetylcysteine. The antioxidant, if present in the compositions described herein, is present in an amount selected from the range of about 0.025% to about 1.0% by weight of the total amount.

[0126] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may contain an antimicrobial preservative. Examples of antimicrobial preservatives include acids, including but not limited to benzoic acid, phenolic acid, sorbic acid; alcohols; benzethonium chloride; bronopol; butylparaben; cetrimide; chlorhexidine; chlorobutanol; chlorocresol; cresol; ethylparaben; imidurea; methylparaben; phenol; phenoxyethanol; phenylethyl alcohol; phenylmercuric acetate; phenylmercuric borate; phenylmercuric nitrate; potassium sorbate; propylparaben; sodium propionate, or thimerosal. Antimicrobial preservatives, if present in the compositions described herein, are present in an amount from about 0.1% to about 5%, from about 0.2% to about 3%, or from about 0.3% to about 2%, by weight, of the composition, for example, about 0.2%, about 0.4%, about 0.6%, about 0.8%, about 1%, about 1.2%, about 1.4%, about 1.6%, about 1.8%, about 2%, about 2.2%, about 2.4%, about 2.6%, about 2.8%, about 3.0%, about 3.2%, about 3.4%, about 3.6%, about 3.8%, about 4%, about 4.2%, about 4.4%, about 4.6%, about 4.8%, or about 5%.

[0127] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may comprise one or more emulsifiers. The term "emulsifier" refers to a chemical agent capable of reducing the surface tension between a non-polar phase and a polar phase and includes self-emulsifiers. Suitable emulsifiers may be from any class of pharmaceutically acceptable emulsifiers, examples being carbohydrates, proteins, high molecular weight alcohols, wetting agents, waxes, and finely divided solids. The optional emulsifier, if present in the composition, may be present in an amount, by weight, of from about 1% to about 25%, from about 1% to about 20%, or from about 1% to about 15% by weight of the composition. Illustratively, the amount of one or more emulsifiers is about 1%, about 2%, about 3%, about 4%, about 5%, about 6%, about 7%, about 8%, about 9%, about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, or about 25% of the total weight.

[0128] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof can include a water-soluble solvent, an example of which is propylene glycol. A suitable water-soluble solvent is any solvent that can be used in a pharmaceutical composition and is soluble in water. If present in the composition, the water-soluble solvent can be present in an amount of about 1% to about 95%, about 2% to about 75%, about 3% to about 50%, about 4% to about 40%, or about 5% to about 25% by weight of the total weight of the composition.

[0129] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may comprise one or more alcohols. In another embodiment, the alcohol is a lower alcohol. The term "lower alcohol," as used herein, alone or in combination, refers to a straight or branched chain alcohol moiety containing from one to about six carbon atoms. In one embodiment, the lower alcohol contains from one to about four carbon atoms, and in another embodiment, the lower alcohol contains two or three carbon atoms. Examples of such alcohol moieties include methanol, ethanol, ethanol USP (i.e., 95% v / v), n-propanol, isopropanol, n-butanol, isobutanol, sec-butanol, and tert-butanol. As used herein, the term "ethanol" refers to C2H5OH. Dehydrated alcohol USP, alcohol USP, or any common form, including in combination with varying amounts of water, may be used. The alcohol, if present, is in an amount sufficient to form a composition suitable for human contact. For example, the amount is about 1%, about 2%, about 3%, about 4%, about 5%, about 6%, about 7%, about 8%, about 9%, about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25% of the total amount by weight.

[0130] According to another aspect, pharmaceutical compositions for topical or transdermal administration of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof may independently comprise water in an amount sufficient to obtain the desired weight of the pharmaceutical composition.

[0131] The amount of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists and analogs thereof by weight is about 0.1%, about 0.2%, about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1%, about 1.1%, about 1.2%, about 1.3%, about 1.4%, about 1.5%, about 1.6%, about 1.7%, about 1.8%, about 1.9%, about 2%, about 2.1%, about 2.2%, about 2.3%, about 2.4%, about 2.5%, about 2.6%, about 2.7%, about 2.8%, about 2.9%, about 3.0%, about 3.1%, about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about 3.8%, about 3.9%, about 4.0%, about 4.1%, about 4.2%, about 4.3%, about 4.4%, about 4.5%, about 4.6%, about 4.7%, about 4.8%, about 4.9%, about 5.1%, about 5.2%, about 5.3%, about 5.4%, about 5.6%, about 5.7%, about 5.8%, about 5.9%, about 6. .9%, about 3%, about 3.1%, about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about 3.8%, about 3.9%, about 4%, about 4.1%, about 4.2%, about 4.3%, about 4.4%, about 4.5%, about 4.6%, about 4.7%, about 4.8%, about 4.9%, about 5%, about 5.1%, about 5.2%, about 5.3%, about 5.4%, about 5.5%, about 5.6%, about 5.7%, about 5.8%, about 5.9%, about 6%, about 6.1%, about 6.2%, about 6.3%, about 6.4%, about 6.5%, about 6.6%, about 6 .7%, about 6.8%, about 6.9%, about 7%, about 7.1%, about 7.2%, about 7.3%, about 7.4%, about 7.5%, about 7.6%, about 7.7%, about 7.8%, about 7.9%, about 8%, about 8.1%, about 8.2%, about 8.3%, about 8.4%, about 8.5%, about 8.6%, about 8.7%, about 8.8%, about 8.9%, about 9%, about 9.1%, about 9.2%, about 9.3%, about 9.4%, about 9.5%, about 9.6%, about 9.7%, about 9.8%, about 9.9%, about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, About 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90% or about 95%.

[0132] Another embodiment relates to a pharmaceutical composition comprising oxybutynin, pirenzepine, MT7, a muscarinic receptor antagonist, and analogs thereof, formulated for parenteral administration by injection. The injectable pharmaceutical composition of the present invention may comprise a suitable carrier solution, examples of which are sterile water, saline, and a buffered solution at physiological pH. Examples of suitable buffered solutions are Ringer's dextrose solution and Ringer's lactate solution. The amount of the carrier solution may be about 0.1%, about 0.2%, about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%, about 0.9%, about 1.0%, about 1.1%, about 1.2%, about 1.3%, about 1.4%, about 1.5%, about 1.6%, about 1.7%, about 1.8%, about 1.9%, about 2.0%, about 2.1%, about 2.2%, about 2.3%, about 2.4%, about 2.6%, about 2.7%, about 2.8%, about 2.9%, about 3.0%, about 3.1%, about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about 3.8%, about 3.9%, about 4.0%, about 4.1%, about 4.2%, about 4.3%, about 4.4%, about 4.5%, about 4.6%, about 4.7%, about 4.8%, about 4.9%, about 5. .3%, about 2.4%, about 2.5%, about 2.6%, about 2.7%, about 2.8%, about 2.9%, about 3.0%, about 3.1%, about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about 3.8%, about 3.9%, about 4.0%, about 4.1%, about 4.2%, about 4.3%, about 4.4%, about 4.5%, about 4.6%, about 4.7%, about 4.8 %, about 4.9%, about 5.0%, about 5.1%, about 5.2%, about 5.3%, about 5.4%, about 5.5%, about 5.6%, about 5.7%, about 5.8%, about 5.9%, about 6.0%, about 6.1%, about 6.2%, about 6.3%, about 6.4%, about 6.5%, about 6.6%, about 6.7%, about 6.8%, about 6.9%, about 7.0%, about 7.1%, about 7.2%, about 7.3%, About 7.4%, about 7.5%, about 7.6%, about 7.7%, about 7.8%, about 7.9%, about 8.0%, about 8.1%, about 8.2%, about 8.3%, about 8.4%, about 8.5%, about 8.6%, about 8.7%, about 8.8%, about 8.9%, about 9.0%, about 9.1%, about 9.2%, about 9.3%, about 9.4%, about 9.5%, about 9.6%, about 9.7%, about 9.8%, about 9.9% or about 10%, about 11%, about 12%, about 13%, about 14%, about 15%, about 16%, about 17%, about 18%, about 19%, about 20%, about 21%, about 22%, about 23%, about 24%, about 25%, about 26%, about 27%, about 28%, about 29%, about 30%, about 31%, about 32%, about 33%, about 34%, about 35%, about 36%, about 37%, about 38%, about 39%, about 40%, about 41%, about 42%, about 43%, about 44%, about 45%, about 46%, about 47%, about 48%, about 49%, about 50%, about 51%, about 52% , about 53%, about 54%, about 55%, about 56%, about 57%, about 58%, about 59%, about 60%, about 61%, about 62%, about 63%, about 64%, about 65%, about 66%, about 67%, about 68%, about 69%, about 70%, about 71%, about 72%, about 73%, about 74%, about 75%, about 76%, about 77%, about 78%, about 79%, about 80%, about 81%, about 82%, about 83%, about 84%, about 85%, about 86%, about 87%, about 88%, about 89%, about 90%, about 91%, about 92%, about 93%, about 94%, or about 95%.

[0133] According to one aspect, the injectable pharmaceutical composition may further comprise one or more non-aqueous solvents, examples of which are propylene glycol, polyethylene glycol, vegetable oils such as olive oil, and injectable organic esters, an example of which is ethyl oleate.

[0134] According to another aspect, the injectable pharmaceutical composition may further comprise one or more antimicrobial agents, antioxidants, chelating agents and the like.

[0135] The injectable pharmaceutical composition can be in the form of unit dose or multi-dose containers, examples of which are sealed ampoules and vials. The injectable pharmaceutical composition can be stored in a freeze-dried (lyophilized) condition and, before use, requires immediate addition of a sterile liquid carrier such as a sterile saline solution for injection.

[0136] Another embodiment relates to a pharmaceutical composition comprising oxybutynin, pirenzepine, MT7, a muscarinic receptor antagonist, and the like, which is formulated for oral administration. The oral pharmaceutical composition can be provided in the form of capsules or tablets; powders or granules; solutions, syrups, and suspensions (in aqueous or non-aqueous liquids). Tablets or hard gelatin capsules can contain, for example, lactose, starch or its derivatives, magnesium stearate, sodium saccharin, cellulose, magnesium carbonate, stearic acid or its salts. Soft gelatin capsules can contain, for example, vegetable oils, waxes, fats, semisolid or liquid polyols, etc. Solutions and syrups can contain, for example, water, polyols, and sugars. Oxybutynin, pirenzepine, MT7, a muscarinic receptor antagonist, and the like can be coated with or mixed with materials (e.g., glyceryl monostearate or glyceryl distearate) to delay the decomposition of the active agent in the gastrointestinal tract or affect its absorption. Thus, for example, sustained release of the active agent over many hours can be achieved and, if necessary, the active agent can be protected from degradation in the gastrointestinal tract. Pharmaceutical compositions for oral administration can be formulated to promote release of the active agent at specific gastrointestinal locations, taking advantage of the various pH and enzyme conditions along the gastrointestinal tract.

[0137] As used herein, the pharmaceutical compositions are used in a "pharmaceutically effective amount." A "pharmaceutically effective amount" is the amount of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof in the composition sufficient to deliver a therapeutic amount of the active agent during the dosing interval in which the composition is administered. Thus, the amount of the pharmaceutical composition administered to deliver a therapeutically effective amount of oxybutynin, pirenzepine, MT7, muscarinic receptor antagonists, and analogs thereof is about 0.01 g, about 0.05 g, about 0.1 g, about 0.2 g, about 0.3 g, about 0.4 g, about 0.5 g, about 0.6 g, about 0.7 g, about 0.8 g, about 0.9 g, about 1 g, about 1.1 g, about 1.2 g, about 1.3 g, about 1.4 g, about 1.5 g, about 1.6 g, about 1.7g, about 1.8g, about 1.9g, about 2g, about 2.1g, about 2.2g, about 2.3g, about 2.4g, about 2.5g, about 2.6g, about 2.7g, about 2.8g, about 2.9g, about 3g, about 3.1g, about 3.2g, about 3.3g, about 3.4g, about 3.5g, about 3.6g, about 3.7g, about 3.8g, about 3.9g, about 4g, about 4.1g, about 4.2g, about 4.3g, about 4.4g, about 4.5g, about 4.6g, about 4.7g, about 4.8g, about 4.9g, about 5g, about 5.1g, about 5.2g, about 5.3g, about 5.4g, about 5.5g, about 5.6g, about 5.7g, about 5.8g, about 5.9g, about 6g, about 6.1g, about 6.2g, about 6.3g, about 6.4g, about 6.5g, about 6.6g, about 6.7g, about 6.8g, about 6.9g, about 7g, about 7.1g, about 7.2g, about 7.3g, about 7.4g, about 7.5g, about 7.6g, about 7.7g, about 7.8g, about 7.9g, about 8g, about 8.1g, about 8.2g, about 8.3g, about 8.4g, about 8.5g, about 8.6g, about 8.7g, about 8.8g, about 8.9g, about 9g, about 9.1g, about 9.2g, about 9.3g, about 9.4g, about 9.5g, about 9.6g, about 9.7g, about 9.8g, about 9.9g or about 10g.

[0138] The following examples are provided to more fully describe the invention and are provided for non-limiting illustrative purposes. Example

[0139] The basic hypothesis is that blocking endogenous cholinergic confinement using muscarinic receptor antagonists will promote the re-growth of nerve cells in patients with established peripheral neuropathy. This occurs through the activation of AMPK and PGC-1α and the subsequent enhancement of mitochondrial function. This involves a proximal step involving the M1 receptor antagonist-dependent activation of CaMKKβ (or CaMKK2). This hypothesis is supported by extensive preclinical data using in vitro and in vivo model systems. Experiments have shown that muscarinic receptor antagonists dose-dependently promote neurite outgrowth of sensory neurons in adult rodents ( Figure 1 Increased neurite outgrowth of sensory neurons in M1R KO mice demonstrates a specific requirement for M1 receptor antagonism.

[0140] Example 1 :

[0141] In previous work, we showed that pirenzepine can prevent and reverse small fiber neuropathy in diabetes. We now demonstrate that pirenzepine can also prevent the slowing of large fiber motor nerve conduction velocity (MNVC) in streptozotocin-induced (STZ-induced) diabetic rats. Figure 2 (A)) and sensory nerve conduction velocity (SNCV) slowed ( Figure 2(B)). The STZ rats are a model of type 1 diabetes. Rats were treated with 5 mg / kg (sc) pirenzepine for 8 weeks according to the method taught by Calcutt et al. (2003, Therapeutic efficacy of sonic hedgehog protein in experimental diabetic neuropathy, J. Clin. Invest. 111: 507-514). Nerve conduction velocity (NCV) was measured according to the method taught by Mizisin et al. (2004, Ciliary Neurotrophic Factor Improves Nerve Conduction and Ameliorates Regeneration Deficits in Diabetic Rats, Diabetes 53: 1807-1812). Data show a time-dependent reduction in diabetes-induced large-fiber motor and sensory NCV (all p < 0.01 vs. controls at 8 weeks of diabetes), and pirenzepine treatment attenuated these changes (all p < 0.05 vs. vehicle-treated diabetic rats). All data are group means ± SEM (N = 5-6 groups). Statistical analysis was performed using one-way ANOVA with Dunnett's post-hoc test. These data show that pirenzepine can preserve the function of large-diameter myelinated fibers of motor and sensory nerves.

[0142] Example 2 :

[0143] Subpopulations of cultured adult sensory neurons from age-matched control rats or 3-5 month old STZ-induced diabetic rats were treated with a 1.0 μM dose of pirenzepine-HCl. The first subpopulation was treated immediately, while the second, third, and fourth subpopulations of neurons from control and diabetic rats were treated 15, 30, and 60 minutes after pirenzepine treatment, respectively. Cell cultures were lysed and used to prepare Western blots, which were then probed with antibodies against phosphorylated AMPK (P-AMPK), total AMPK (T-AMPK), and total ERK (T-ERK). Figure 3 (A) shows gels produced by cultures from age-matched control rats, whereas Figure 3 (C) shows the gel produced by cultures of diabetic rats. Figure 3(B) and 3(D), where the Y axis represents protein levels quantified from the blots in (A) and (C) and normalized to the control, show that pirenzepine significantly activated the normal rat ( Figure 3 (B)) and type 1 diabetic rats ( Figure 3 (D) P-AMPK in cultures of 147 healthy volunteers. Values ​​are mean ± SEM, N = 3 / group. Statistical significance was analyzed using one-way ANOVA with Tukey's post hoc test.

[0144] Example 3 :

[0145] Adult sensory neuron cultures from STZ-induced diabetic rats were treated with 1.0 μM pirenzepine according to the protocol of Roy Chowdhury et al. (2012) and transduced two days after treatment with two adenoviral overexpression dominant negative mutants of AMPK, AMPK subunit 1 and 2 mutants, designated “AdDN1” and “AdDN2” (the adenoviral overexpression dominant negative mutants were a gift from Dr. Jason Dyck of the University of Alberta). Figure 4 (A) and 4(B) are GFP fluorescence micrographs of adult rat sensory neuron cultures transduced with a control adenoviral vector expressing only GFP, where Figure 4 (A) did not receive pirenzepine treatment Figure 4 (B) Received pirenzepine treatment. Figure 4 (C) and 4(D) are GFP fluorescence micrographs of adult rat sensory neurons transduced with the "AdDN" dominant negative AMPK mutant, where Figure 4 (C) did not receive pirenzepine treatment Figure 4 (D) Received pirenzepine treatment. Figure 5 The data in (A) and 5(B) show that blockade of AMPK signaling using an adenovirally delivered dominant negative mutant completely inhibited pirenzepine-induced neurite outgrowth.

[0146] Example 4 :

[0147] according to PGC-1α transcriptional activity was measured in dissociated adult sensory neurons of STZ-induced diabetic rats 2 days after transfection with a luciferase reporter plasmid (a gift from Dr. Michael Czubryt, University of Manitoba) according to the methods taught in the NIH II Manual (www.amaxa.com; AMAX and NUCLEOFECTOR are registered trademarks of Amaxa GmBH Corp., Koln, Fed. Rep. Germany) and Saleh et al. (2013, Ciliary neurotrophic factor activates NF-κB to enhance mitochondrial bioenergetics and prevent neuropathy in sensory neurons of streptozotocin-induced diabetic rodents, Neuropharmacology 65:65-75). Figure 6 Pirenzepine at 1 μM was shown to enhance the transcriptional activity of PGC-1α in cultured adult sensory neurons from STZ-induced diabetic rats (mean ± SEM, N = 3 replicate cultures, one-way ANOVA with Tukey's post hoc test, values ​​normalized to control for reporter gene (PGL3) expression). However, in this assay, the mutant PGC-1α plasmid exhibited zero activity. Therefore, these data suggest that pirenzepine signaling drives neurite outgrowth through activation of the AMPK / PGC-1α axis.

[0148] Example 5 :

[0149] Mitochondrial respiration was assessed in adult mouse sensory neuron cultures from wild-type control mice, M1 receptor knockout mice (M1R KO), and diabetic mice that received 1 μM VU0255035 for three hours, following the methods taught by Roy Chowdhury et al. (2012). M1R knockout mice were a gift from Dr. Jurgen Wess (Molecular Signaling Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health).

[0150] Figure 7 The data in (A) show that the oxygen consumption rate (OCR) in neuronal cultures from M1 receptor knockout mice (M1R KO) is significantly enhanced, and Figure 7 The data in (B) show that treatment with VU0255035 results in increased OCR in neuronal cultures from STZ-induced diabetic rats. Figure 8 The data in (A) and 8(B) show that the coupling efficiency in neuronal cultures from wild-type mice, M1R KO mice, and diabetic mice receiving VU0255035 administration is different, as is their respiratory control rate ( Figure 8 (C) and 8(D)). However, spare respirator capacity was significantly increased in neuronal cultures from M1R KO mice and in cultures from diabetic rats treated with VU0255035 compared to controls ( Figure 8 (E) and 8(F))( Figure 8 Data in (A)-8(F) are mean ± SEM, N = 4-5 replicate cultures, group comparisons were performed using Student's t-test. Decreased bioenergetics parameters in diabetes are associated with the ability of cells to control respiration under conditions of stress or high ATP demand. We propose that stress is caused by the presence of high intracellular glucose concentrations. Therefore, we propose that muscarinic receptor antagonism enhances AMPK / PGC-1α signaling to enhance mitochondrial function, which provides energy in the form of ATP (derived from oxidative phosphorylation) for inducing axon regeneration.

[0151] Example 6 :

[0152] The highly potent M1 receptor antagonist MT7 (muscarinic toxin 7) promotes neurite outgrowth in cultured adult rat sensory neurons ( Figure 9 (A) Figure 9 (B) and Figure 10 ). Figure 10 Data in are mean ± SEM of 9 replicate cultures. Significant differences were determined by one-way ANOVA with Dunnett's post-hoc test.

[0153] Figure 11 The data in (A) and 11 (B) show that MT7 treatment activated PGC-1α transcription in cultured adult sensory neurons from STZ-induced diabetic rats, whereas co-treatment with 0.3 μM Compound C (CC), a pharmacological inhibitor of AMPK, blocked the stimulatory effect of MT7 ( Figure 11 Data points in the are mean ± SEM, N = 3 replicate cultures, significant differences determined by one-way ANOVA with Tukey's post-hoc test). These data establish that the AMPK / PGC-1α pathway is regulated by the M1 receptor and that specific blockade of the M1 receptor leads to enhanced AMPK / PGC-1α activity.

[0154] Figure 12 The data in show that pirenzepine-induced neurite outgrowth in cultured adult sensory neurons from rat is dose-dependently inhibited by the CaMKK inhibitor STO-609 (data are mean ± SEM, N = 8-10 replicate cultures, significant differences determined by one-way analysis of variance ANOVA followed by Dunnett's post hoc test).

[0155] Figure 13 The data in (A)-13(D) show that blocking CaMKK with 1.0 μM STO-609 inhibits the pirenzepine-induced or MT7-induced enhancement of AMPK phosphorylation in cultured adult sensory neurons from age-matched control rats (data are mean ± SEM, N = 3 replicate cultures, significant differences determined by one-way analysis of variance ANOVA followed by Dunnett's post hoc test). These data establish that induction of CaMKK, particularly CaMKKβ (or CaMKK2), is a proximal step in the pathway from blockade of the M1 receptor to activation of AMPK.

[0156] Example 7 :

[0157] Figure 14The data in show that oxybutynin, a broad-range M1, M2, and M3 receptor antagonist, promotes neurite outgrowth in cultured adult sensory neurons. This confirms that selective antagonists of fewer muscarinic receptors are effective in promoting axon regeneration in vitro (data are mean ± SEM, N = 6 replicate cultures, significant differences determined by one-way analysis of variance ANOVA followed by Dunnett's post hoc test).

[0158] To test the efficacy of the muscarinic receptor antagonist oxybutynin on functional scores of sensory neuropathy in the db / db mouse model of type 2 diabetes ( Figure 15 Thermal latency was analyzed according to the teaching of Calcutt et al. (2004, Prevention of sensory disorders in diabetic Sprague-Dawley rats by aldose reductase inhibition or treatment with ciliary neurotrophic factor, Diabetologia 47:718-24). Female db / db mice were made diabetic and showed small fiber sensory neuropathy as evidenced by decreased paw thermal allodynia when compared to age-matched non-diabetic C57 mice (p<0.01). Some diabetic mice were then treated with oxybutynin (Oxy: 2% hydrogel) applied to the right paw for 20 minutes per day, 5 days a week, while other mice were treated with hydrogel vehicle alone. Treatment with oxybutynin for 8 weeks reversed paw thermal hypoalgesia in db / db mice, resulting in values ​​significantly (p<0.01) lower than those in vehicle-treated mice, although they were significantly (p<0.05) higher than those in non-diabetic C57 mice. Data are group means ± SEM, N = 8-9 per group. At week 8, all other groups = p<0.01 vs. the db / db group by one-way analysis of variance (ANOVA) followed by Dunnett's post hoc test.

[0159] These data show that thermal hypoalgesia is reversed in adult type 2 diabetic (db / db) mice treated with topical oxybutynin for 4-8 weeks. Thus, this drug, currently used in humans to treat overactive bladder syndrome, is effective in reversing small fiber neuropathy in type 2 diabetes.

[0160] In the same study, treatment with oxybutynin had an adverse effect on the prevention of intraepidermal nerve fibers (IENF; Figure 16 (A)) and corneal nerves ( Figure 16The IENF levels were quantified by the method taught by Beiswenger et al. (2008, Epidermal nerve fiber quantification in the assessment of diabetic neuropathy, Acta Histochem. 110:351-63). Figure 16 Data shown in (A) are group means ± SEM, N = 6-8 / group. Significant differences were determined by one-way analysis of variance (ANOVA) followed by Dunnett's post hoc test. Vehicle-treated diabetic (db / db) mice showed a significant (p < 0.05) decrease in IENF density in paw skin, which was attenuated by oxybutynin treatment to values ​​not significantly different from controls. Figure 16 Data in (B) show the effect of oxybutynin on corneal nerve fiber levels (calculated as percentage occupancy of the cornea by nerve fibers) in db / db diabetic mice. After 8 weeks of topical oxybutynin treatment, eyes were evaluated using corneal confocal microscopy according to the method taught by Chen et al. (2013, Repeated monitoring of corneal nerves by confocal microscopy as an index of peripheral neuropathy in type-1 diabetic rodents and the effects of topical insulin, J. Periph. Nerv. Syst. 18; 306-315). Vehicle-treated diabetic (db / db) mice showed a significant (p < 0.05) decrease in corneal nerve fiber occupancy, and this significant decrease was attenuated by oxybutynin treatment, resulting in values ​​that were not significantly different from controls.

[0161] These data confirm that oxybutynin delivered by local route can reverse or prevent a range of microfibril deficits in type 2 diabetic mice. In Swiss Webster mice with STZ-induced type 1 diabetes, systemic delivery of oxybutynin at 3 mg / kg sc or 10 mg / kg sc for 9 weeks also reversed thermal hypoalgesia after an initial 8 weeks without diabetes treatment. Figure 17Together, these data support the idea that a selective M1R antagonist containing, among other ingredients, pirenzepine, VU0255035, MT7, and oxybutynin can reverse small fiber neuropathy and prevent functional markers of large fiber neuropathy in established diabetic patients ( Figure 2 ).

[0162] Example 8 :

[0163] Given the phenotypic similarities between diabetic and chemotherapeutic induced peripheral neuropathy, we have demonstrated that in vitro exposure to paclitaxel ( Figure 18 (A)) or oxaliplatin ( Figure 18 (B) Neurite outgrowth of sensory neurons that was reduced in the presence of (A) paclitaxel (PX; 0.1 μM or 0.3 μM) or (B) oxaliplatin (OX; 3.0 μM) was blocked by pirenzepine. Adult sensory neurons from normal rats were cultured for 24 hours in the presence of (A) paclitaxel (PX; 0.1 μM or 0.3 μM) or (B) oxaliplatin (OX; 3.0 μM). Some cultures were treated with 0.1, 1.0, or 10 μM pirenzepine (PZ) starting from plating. Total neurite outgrowth levels were determined and expressed as mean ± SEM, N = 6-8 / group, and significant differences were evaluated by (A) T-test and (B) one-way analysis of variance ANOVA with Dunnett's post hoc test.

[0164] Swiss Webster mice were treated with paclitaxel (taxol; 5 mg / kg on days 1, 3, 5, and 7) to induce peripheral neuropathy. Following paclitaxel treatment, some of the paclitaxel-treated mice were also treated with pirenzepine (Pz: 10 mg / kg / day sc) for 4 weeks, while other mice were treated with vehicle alone. Figure 19 Paw thermal response latency (left panel) and paw 50% tactile response threshold (right panel) are shown in mice treated with paclitaxel ± pirenzepine (PZ). Four weeks after paclitaxel treatment, mice developed significant (p < 0.01) paw thermal hyperalgesia and tactile allodynia, indicating that small and large sensory fibers, respectively, transduce painful neuropathy. Data points are group means ± SEM, n = 9-12 / group. Significant differences were determined by one-way analysis of variance (ANOVA) followed by Dunnett's post hoc test. Figure 19 Data in show that paclitaxel (taxol)-treated mice develop peripheral neuropathy characterized by tactile allodynia and thermal hyperalgesia, which is protected against by daily treatment with pirenzepine at 1 mg / kg / day sc.

[0165] Example 9 :

[0166] Another chemotherapeutic agent, dichloroacetate (DCA), was also studied and shown to induce peripheral neuropathy in mice, characterized by sensory loss. Following the teachings of Calcutt et al. (2009, Peripheral neuropathy in rats exposed to dichloroacetate, J. Neuropath. Exp. Neurol. 68:985-93), Swiss Webster mice were treated with DCA (1 mg / kg / day sc) for 8 weeks to induce peripheral neuropathy. Some DCA-treated mice were also treated with pirenzepine (Pz: 10 mg / kg / day sc) for the duration of the study, while other mice were treated with vehicle only. After 8 weeks of DCA treatment, mice developed significant (p<0.01) paw thermal hypoalgesia ( Figure 20 (A) shows small sensory fiber dysfunction accompanied by a significant (p < 0.01) loss of IENF in the paw skin ( Figure 20 (B) Treatment with pirenzepine prevented both of these symptoms. Pirenzepine also delayed the onset of MNCV slowing (an indicator of large fiber dysfunction) in DCA-treated mice after 4 weeks of exposure, but not 8 weeks ( Figure 20 (C)). Figure 20 Data in (A)-20(C) represent group means ± SEM, n = 9-12 / group. Significant differences were determined by one-way analysis of variance (ANOVA) followed by Dunnett's post hoc test.

[0167] Taken together, these data suggest that treatment with pirenzepine prevents indicators of painful peripheral neuropathy, exemplified by thermal hyperalgesia and tactile allodynia, and degenerative neuropathy, exemplified by thermal hypoalgesia, IENF loss, and reduced MNCV. Thus, systemic treatment with pirenzepine prevents small- and large-fiber dysfunction and / or fiber loss in two different models of chemotherapy-induced peripheral neuropathy (CIPN).

[0168] Example 10 :

[0169] To extend our investigation of muscarinic receptor antagonists, we treated STZ-induced diabetic mice with the broad-spectrum drug atropine, which is known to block the activity of all muscarinic receptors.

[0170] Groups of adult Swiss Webster mice were made diabetic with STZ and then treated with atropine delivered topically to one eye (2% solution) or one paw (2% gel) 5 days per week for 12 weeks. Measurements were performed on treated and untreated hind paws. Gross motor fiber function (MNCV; Figure 21 ) and sensory sensory fiber function (paw thermal latency; Figure 22 ) and compared with age-matched control mice treated in an identical manner. Diabetic mice showed significantly (p < 0.01) decreased large fiber MNCV ( Figure 21 ), whereas diabetic mice treated with atropine delivered to the eyes or feet had values ​​that were no different from controls treated in the same way ( Figure 21 Compared with control mice, diabetic mice also showed significant (p < 0.01) hypoalgesia of thermal sensation mediated by small sensory fibers in the paws ( Figure 22 ), whereas diabetic mice treated with atropine delivered to the eyes or feet had values ​​that were no different from controls treated in the same way ( Figure 22 ). Figure 21 and 22 The data shown are group means ± SEM, N = 6-10 / group. Significant differences were determined by unpaired T-test to compare control and diabetic animals under each condition (vehicle, atropine applied to the eyes, atropine applied to the feet).

[0171] These data establish that atropine delivered either ocularly (instilled) or through the skin (topically applied as a hydrogel) can prevent both large and small fiber dysfunction in type 1 diabetic mice. Therefore, selective M1 receptor antagonists such as pirenzepine, VU0255035, and MT7, as well as broad-spectrum muscarinic receptor antagonists such as oxybutynin and atropine, are effective in preventing and reversing peripheral neuropathy.

[0172] Example 11 :

[0173] To further extend our studies on the effects of muscarinic receptor antagonists on nerve growth, we treated normal mice with the M1 receptor-specific antagonist MT7 delivered daily to the eye for 11 days and used confocal microscopy to provide non-invasive and thus repeated assessments of corneal nerve density.

[0174] A group of adult Webster mice (n=8) received daily MT7 treatment via eye drops (20 μl volume) in saline. On the second and 11th day of treatment, nerve occupancy in the subbasal nerve plexus (SBNP 1-5) and upper stroma (stroma 1-10) regions of the cornea was determined. Figure 23 When compared with the values ​​measured on day 2 (black bars), nerve occupancy was significantly (p < 0.05, paired test) increased in both regions on day 11 (white bars). Data are group means (N = 8) ± SEM.

[0175] These data demonstrate the efficacy of MT7 on the growth of small sensory neurons of the cornea in vivo.

[0176] Example 12 :

[0177] To further extend our studies on the effects of muscarinic receptor antagonists on nerve growth, cultured adult sensory neurons were treated for 24 hours with the recombinant protein gp120 (HIV coat protein), which causes toxicity to sensory neurons in HIV neuropathy ( Figure 24 ).

[0178] This toxicity leads to axonal degeneration and neuronal cell death. Cultures were treated with 1 μM pirenzepine and total neurite outgrowth was measured. Pirenzepine treatment provided comprehensive protection against gp120-induced axonal degeneration (P < 0.05, one-way ANOVA with Tukey's post hoc test). MT7 also exhibited approximately 50% protection against gp120 treatment (not shown). Values ​​are mean ± SEM, n = 6.

Claims

1. A composition for treating peripheral neuropathy in a subject in need thereof, the composition comprising: an effective amount of an agent selected from the group consisting of pirenzepine, oxybutynin, a muscarinic toxin 7 muscarinic receptor antagonist, and combinations thereof; and Pharmaceutically acceptable carriers and / or excipients.

2. The composition of claim 1, wherein the composition is injectable.

3. The composition of claim 1, wherein the composition is administered by topical application.

4. The composition of claim 3, wherein the composition is one of a lotion, a cream, a gel, and a viscous fluid.

5. The composition of claim 3, further comprising one or more penetration enhancers, lubricants, emulsifiers, water-soluble solvents, alcohols, and mixtures thereof.

6. The composition of claim 1, wherein the composition is administered via a transdermal patch.

7. The composition of claim 1, wherein the composition is administered by oral dosage.

8. compositions as claimed in claim 1, wherein said peripheral neuropathy is systemic disease induced peripheral neuropathy, metabolic disease induced peripheral neuropathy, chemotherapy induced peripheral neuropathy, compression induced peripheral neuropathy, contact dichloroacetate induced peripheral neuropathy, immune-mediated peripheral neuropathy, infection-induced peripheral neuropathy and gene-acquired peripheral neuropathy.

9. Use of the composition of claim 1 for treating peripheral neuropathy in a subject in need thereof.

10. purposes as claimed in claim 9, wherein said peripheral neuropathy is one of systemic disease-induced peripheral neuropathy, metabolic disease-induced peripheral neuropathy, chemotherapy-induced peripheral neuropathy, compression-induced peripheral neuropathy, contact dichloroacetate-induced peripheral neuropathy, immune-mediated peripheral neuropathy, infection-induced peripheral neuropathy and gene-acquired peripheral neuropathy.

11. A method for treating peripheral neuropathy in a subject in need thereof, said method comprising administering at least one dose of the composition of claim 1.

12. The method of claim 10, wherein the administration is by injection.

13. The method of claim 11, wherein administration is by subcutaneous injection.

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