Clinical trial NCT04867707
Conditions: Diabetes Mellitus, Type 2
Keywords: endothelial dysfunction vascular function glycocalyx integrity assessment
Sponsor: University of Missouri-Columbia
Start date: 2021-07-14; Completion date: 2024-10-18
Enrollment: 14 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The objective is to determine if neuraminidase inhibition with zanamivir is efficacious as a therapeutic strategy to restore endothelial function in T2D patients.

Detailed description:
Twenty subjects will complete five days of treatment with zanamivir. Baseline measurements will be taken before the initiation of treatment, as well as after the conclusion of the treatment period (i.e., a total of two assessment visits per subject). Assessment visits will include: vitals (such as blood pressure, heart rate), fasting blood work for plasma neuraminidase activity, plasma sialic acid, plasma glucose and plasma insulin, brachial artery FMD, and glycocalyx integrity assessment via Glycocheck.

Arms: arm 1: Study participants will receive 5 days of treatment with a zanamivir inhaler.
Interventions: intervention 1: Zanamivir
Intervention descriptions: intervention 1: 5 days of treatment with 10mg zanamivir inhaler BID

Protocol documents:
Prot_SAP_000.pdf: 
Page 1 of 11 
BIOMEDICAL RESEARCH PROTOCOL 
UNIVERSITY OF MISSOURI 
 
Project Title: Role of neuraminidase activity on endothelial dysfunction in type 2 diabetes 
IRB Number: 2038203 
Version Number: 6 
Version Date: 09/02/2022 
Principal Investigator (s): Luis Martinez-Lemus, PhD, Jaume Padilla, PhD 
Collaborating Investigator: Camila Manrique-Acevedo, MD 
Funding Source: National Institutes of Health 
Clinicaltrials.gov Number: NCT04867707 
Study Drug/Study Device: Zanamivir (Relenza, GlaxoSmithKline) 
 
 
 
 
Neuraminidase inhibition as a novel treatment to improve endothelial function in 
type 2 diabetes (T2D) 
 
The endothelial glycocalyx is a thin layer of interwoven glycoproteins and proteoglycans 
that forms a luminal mesh separating the vascular wall from the flow of blood. One of the 
glycocalyx’s primary functions is to serve as a mechanosensor of shear stress in flow-
mediated dilation (FMD).78, 79 In this regard, our preliminary data, and published work by 
others, show that neuraminidase activity decreases the volume of the glycocalyx on the 
endothelial surface of arteries, and consequently impairs FMD responses. In this research 
project, we will determine the role that neuraminidase inhibition has on T2D-associated 
glycocalyx degradation and FMD impairment.  
Currently, the only neuraminidase inhibitors approved for use in humans are those 
devised as influenza treatments. Therefore, they primarily target viral neuraminidases 
with IC50s in the nanomolar range. However, of the four FDA approved inhibitors, 
zanamivir has the highest IC50 for mammalian neuraminidases. In our preliminary 
experiments, we show that neuraminidase inhibition with zanamivir in cultured endothelial 
cells protects the glycocalyx from degradation.  
Moreover, to test the in vivo effectiveness of neuraminidase inhibition with zanamivir on 
improving endothelial function in diabetes, we treated T2D mice with zanamivir for five 
days, which is the treatment regimen approved for influenza. Results indicate that 
treatment with zanamivir reduced plasma neuraminidase activity and improved 
endothelial function. On the basis of these exciting results, we are taking a fully 
translational approach and will determine the capacity of a five-day treatment with 
zanamivir to improve endothelial function in T2D human subjects in a clinical trial. 
The objective is to determine if neuraminidase inhibition with zanamivir is efficacious as 
a therapeutic strategy to restore endothelial function in T2D patients. 
Twenty subjects will complete five days of treatment with zanamivir. Baseline 
measurements will be taken before the initiation of treatment, as well as after the 
I. 
Research Objectives/Background 


Page 2 of 11 
conclusion of the treatment period (i.e., a total of two assessment visits per subject). 
Assessment visits will include: vitals (such as blood pressure, heart rate), fasting blood 
work for plasma neuraminidase activity, plasma sialic acid, plasma glucose and plasma 
insulin, brachial artery FMD, and glycocalyx integrity assessment via Glycocheck. 
 
 
 
 
Drug treatment, dose, route and regimen:  
Subjects will be treated with 10mg zanamivir twice a day for five days (same dose 
currently FDA-approved for influenza treatment). Zanamivir will be administered via oral 
inhalation. Dr. Camila Manrique, MD (co-investigator) and Dr. Guido Lastra, MD (safety 
officer) will oversee the trial. 
Rationale for choosing the drug and dose: 
As stated above, the proposed dose and administration route of zanamivir for this study 
are the same as the dose and administration route currently approved by the FDA for the 
treatment of influenza. Zanamivir was chosen from the four currently approved 
neuraminidase inhibitors because of its highest IC50 for mammalian neuraminidases. 
Risks and safety information 
Per Relenza (zanamivir) packaging insert:  
- 
Medication will not be administered in patients with a history of allergic reaction to 
any ingredients in the medication, including lactose (which contains milk proteins).  
- 
Most common adverse events are: sinusitis, dizziness (in treatment studies) and 
fever and/or chills, arthralgia, and articular rheumatism (in prophylaxis studies). 
Zanamivir will not be administered until two weeks following administration of live 
attenuated influenza vaccine and the live attenuated influenza vaccine should not 
be given until 48 hours following cessation of zanamivir.  
- 
Zanamivir also carries warnings/precautions for: bronchospasm, allergic reaction, 
neuropsychiatric events. 
IND: 
An Investigational New Drug (IND) is not included as part of this protocol because the 
study medication, zanamivir is being used at an FDA approved dose in a population that 
is not anticipated to have increased risk or decreased acceptability of risk. Furthermore, 
individuals who have COPD or asthma will be excluded from the trial as these 
conditions may increase risk of adverse events. Lastly, no information will be submitted 
to the FDA to support a labeling indication, a labeling change, or a change in 
advertising, as this is not the intent of the current study. 
 
 
 
II. 
Drugs/Biologics/Devices 


Page 3 of 11 
 
 
Patients with T2D (n=20) will be recruited from the MU Cosmopolitan Diabetes Center, 
MU Department of Medicine clinics, and the Columbia community by our research team.  
MU Health Care's electronic medical record has informatics tools and databases used for 
developing research studies, including i2b2 (Informatics for Integrating Biology and the 
Bedside) and RedCap (Research Electronic Data Capture). As in prior studies, with IRB 
approval, we contact patients and inform them of the potential to participate in this 
research. 
Recruitment:  
Subjects will be recruited from the University of Missouri-Columbia as well as the local 
community by Dr. Manrique and our research team.  
1. A chart review of clinic patients from the Division of Endocrinology, the 
Department of Medicine, and the Department of Medicine, and the Department of 
Family Medicine who are between the ages of 45 and 64 and have been 
diagnosed with type 2 diabetes will be completed in Powerchart by study 
coordinator/staff based on the study inclusion/exclusion criteria.  A letter, chart 
message, or phone call will be utilized to notifying them of their eligibility to 
participate in a research study.  Study coordinator/staff will work in conjunction 
with healthcare providers that have a direct patient care relationship to recruit 
subjects from clinics. If patients indicate an interest in the study after they are 
initially contacted by the study team, they will be sent a follow up email with a 
Qualtrics screening link and more details about the study.  
2. Subjects may respond to the recruitment flyers, word of mouth, or 
advertisements posted in MU Hospital clinics, MU Hospital television screens, 
MU Info, or any place generally accessible to the public (i.e., grocery stores, 
community centers, newspapers, Facebook, etc.). Only recruitment materials 
approved by IRB will be posted. For all recruitment, subjects will be given an 
email address and/or a phone number to contact. After email or phone contact is 
established, subjects will be given a link to complete a screening questionnaire 
via Qualtrics: (https://missouri.qualtrics.com/jfe/form/SV_2truBrLOYWemj3g). 
3. Subjects may also be identified and contacted via Studykik services. (Studykik 
will be provided with copies of IRB-approved recruitment materials to post) 
 
 
 
 
 
Preliminary screening 
As part of preliminary screening, all individuals who are interested in participating in the 
research study will be required to complete a screening questionnaire (via Qulatrics or 
phone) to determine preliminary eligibility before being scheduled for a study screening 
visit. These questions are for preliminary screening only and are not used as study data. 
Questions include queries about health history/habits, age, sex, height, weight, tobacco 
III. 
Recruitment Process 
IV. 
Consent Process 


Page 4 of 11 
use, medications/ supplements, over the counter medications use, illness, and chronic 
conditions. The study design is described in general terms to subjects, with mention of 
factors most likely to impact subject interest in participating. If the subject is considered 
to fulfill the inclusion/exclusion criteria, an appointment will be scheduled for a review of 
medical history and written consent. 
 
Screening and Consenting Visit 
For all subjects, informed written consent will be obtained using HIPAA Research 
Description and Consent Forms approved by the MU IRB.  The study physician will be 
available to answer any potential questions.  During that process, the subject will be asked 
to describe, in their own words, what the study procedures will be like. They will be 
provided with the study details. Review of the consent form will occur with study personnel 
in a quiet, unhurried setting. Comprehension will be assessed by asking the subject to 
explain the study in their own words.  Participants will have adequate opportunity to review 
the informed consent and to ask any questions they may have about the research 
protocol, compensation, risks, and benefits of taking part in the study. This study visit will 
also include collection of medical history and payment information and Glycocheck 
instruction and practice with the participant.   
 
 
 
Inclusion: 
1. Men and women with a BMI of 25-39 kg/m2 
2. Ages 45-64 years at randomization 
3. Diagnosis of T2D based on physician diagnosis 
4. No vulnerable populations (e.g., prisoners, pregnant, children) will be enrolled 
 
Exclusion criteria: 
1. Cardiovascular disease including myocardial infraction, heart failure, coronary 
artery disease, stroke 
2. History of chronic renal or hepatic disease  
3. Active cancer 
4. Autoimmune diseases 
5. Immunosuppressant therapy 
6. Hormone replacement therapy  
7. Excessive alcohol consumption (>14 drinks/week for men, >7 drinks/week for 
women) 
8. Current tobacco use 
9. Pregnancy (premenopausal women will be required to complete a urine pregnancy 
test before participation) 
10. History of asthma or chronic obstructive pulmonary disease 
11. History of allergic reaction to lactose or milk proteins 
12. Intranasal live attenuated influenza vaccine (LAIV) given within 2 weeks before 
zanamivir administration or a planned dose within 48 hours after zanamivir 
administration. Product insert states to avoid zanamivir administration with 
intranasal live attenuated influenza vaccine (LAIV). 
V. 
Inclusion/Exclusion Criteria 


Page 5 of 11 
 
 
 
 
The design for this clinical trial is a 5-day pharmaceutical treatment with pre- and post- 
assessment.   
 
The clinical trial is powered to detect a 25% effect of zanamivir on FMD.  Based on pilot 
data, this represents approximately one-third of the distance in mean response between 
healthy and T2D subjects.  Our pilot data were also used to estimate the within-subject 
variance, assuming a correlation of r=0.6 between serial measurements on the same 
subject (Harris, Padilla et al., 2006). Sample size was estimated using the software 
package PASS and confirmed using code from Jones & Kenward (2015).  A total size of 
18 subjects will provide 80% power to detect a 25% difference when testing a two-sided 
alternative with alpha of 0.05.  The final sample size will be increased to 20 to 
accommodate as much as a 10% drop-out rate.  A p<0.05 will be considered significant 
throughout all analyses.     
 
 
 
Assessment Visits 
Subjects will complete two separate assessment visits over the course of five days. Pre-
menopausal women will be required to complete a urine pregnancy test at both 
assessment visits, prior to the completion of other study activities. Subjects will undergo 
brachial artery FMD, Glycocheck, and blood chemistries taken at baseline testing. They 
will then complete a five-day treatment course with zanamivir. At the end of the treatment 
course, subjects will have all measurements repeated. Study procedures take 
approximately 3 hours to complete at each assessment. 
Special consideration in case of unforeseeable hardships such as public health 
emergencies or weather-related events 
If subjects are not able to complete study visits, the following remedial steps will be taken: 
1. Medication may be mailed to the subject through the investigational pharmacy.  
2. In the case that subjects are unable to complete their follow up assessments at the 
originally scheduled dates, their medication course maybe delayed to better 
accommodate scheduling availability. Treatment duration will remain the same. 
3. In the event of the Clinical Research Center (CRC) not being available or if it is 
considered by the study physician that performing studies there can be an 
increased risk of exposure to infectious agents or related hazards, the following 
alternative sites will be made available for screening, safety and study visits:  
a. MUPAW, Diabetes Center. 
These locations are not carpeted, and we do not anticipate an increased risk for the 
subjects given that medical supervision and nursing staff assistance will be unchanged. 
 
Study procedures: 
VI. 
Number of Subjects 
VII. 
Study Procedures/ Design/Treatment Plan 


Page 6 of 11 
Brachial artery FMD: Arterial measurements will be performed by imaging the brachial 
artery longitudinally using high-resolution duplex ultrasonography. Arterial vasodilatory 
responses to hyperemia (i.e., FMD) will be examined by inflating a forearm cuff up to 250 
mmHg for five minutes.  Before, during and after rapid release of the cuff, brachial artery 
blood flow velocity and diameter will be continuously measured. In addition, during the 
FMD measurements, near-infrared spectroscopy (NIRS) probes will be placed on the 
forearm; the probe will be secured via an elastic tensor bandage which will be loosely 
wrapped around the site. These probes will stay attached to the participant for the duration 
of testing. The FMD procedure will be performed in duplicate.  
 
Glycocheck: The Glycocheck video microscope instrument will be placed under the 
subject’s tongue to measure capillaries, blood vessel density, red blood cell 
concentration, flow rate, and red blood cell penetration of the glycocalyx lining.  
Glycocheck is an FDA Class 1 Medical Device.  This procedure takes approximately 1 
hour to complete. 
 
Study medications 
Zanamivir: Used as the study medication. Subjects will inhale 10mg of zanamivir twice 
daily for five days.  
 
Sources of research material 
Sources will include the subject’s medical history, physical exam, blood tests, brachial 
artery FMD, and Glycocheck. Demographic data (plus other related data: emergency 
contact person, pregnancy status), blood pressure, and anthropometrics (height and 
weight) will be measured.  Each subject will donate up to 40 mL of blood. 
 
Changes to existing therapies 
For scientific purposes, it would be best to have patients who are not on medications; 
however, it would neither be safe nor ethical to completely discontinue medications. 
Therefore, we will study patients on their existing drug therapy but will limit recruitment to 
patients on the fewest medications. Common medications in T2D (e.g., insulin, metformin, 
gliptins, GLP-1 analogs, SGTL2i, antihypertensives, antidepressants, statins) will be 
considered during recruitment, analyses (e.g., using covariate analysis) and 
interpretation. 
 
Subject safety 
Should subjects exhibit changes in their health status across any system related or 
unrelated to the study treatment, Dr. Guido Lastra, the safety officer, will be consulted for 
advice.  
 
 
 
 
The following are potential risks: 
 
VIII. 
Potential Risks/Adverse Events 


Page 7 of 11 
Venous blood draw: The potential risks of a venous blood draw include infection, 
swelling and discomfort at the puncture site. Some bleeding may occur as well after the 
needle is removed. There is also the possibility of fainting, dizziness, and possible pain 
and bruising as a result of the puncture. These risks will be greatly minimized by using 
sterile procedures and having an experienced registered nurse do the blood draw.  Risk 
of bleeding is reduced by applying pressure at the site of puncture. Bruising is treated 
with ice.  Fainting is prevented by drawing blood in the semi-recumbent position.   
 
Brachial artery FMD with NIRS: This is a measurement of endothelial function. There 
are no risks associated with this procedure. When assessing FMD, the blood pressure 
cuff will squeeze the arm tightly; however, any discomfort will be alleviated as soon as 
the pressure in the cuff is released. 
 
Glycocheck: This procedure poses no risks.  
 
Zanamivir: Potential side effects are outlined in package insert. Medication should not 
be administered to individuals with COPD or asthma.  
 
Protection against risks 
Risks to loss of confidentiality are reduced by assigning all subjects a data identifier code.  
Hard copies of data are stored in a locked office, and only the study personnel have access 
to the locked files. Individual names or initials are not used in any discussions or 
publications of the data. We have assembled a research team which includes scientists, 
physicians, and clinician-scientists with significant experience in human research and 
cardiometabolic diseases to help anticipate and reduce the risks to subjects.   
 
Plan for reporting study deviations 
Any minor problem/deviation will be summarized and reported to the IRB within five 
working days of awareness, including any event that does not: 1) increase the risk to the 
subject, 2) decrease the benefit to the subject, or 3) significantly affect integrity of the 
research data. Any major problem/deviation will be summarized and reported to the IRB 
within five working days of awareness, including any event that: 1) increases the risk to 
the subject, or 2) significantly affects integrity of the research data.   
Stopping rules 
We will stop an individual study if a serious adverse event occurs. If four or more subjects 
experience a serious adverse event requiring termination of the study, the study will be 
stopped and the events will be discussed with the IRB to determine whether it is 
appropriate to continue and/or determine appropriate modifications to the protocol to avoid 
further adverse events. All unanticipated serious adverse events will be submitted for 
review according to current protocols. The medication will be discontinued at the discretion 
of the study safety officer. 
Definition of serious adverse event (SAE) 


Page 8 of 11 
A SAE is classified as any untoward medical occurrence that, at any dose, meets any of 
the following criteria (a – f): 
a. Results in death 
b. Is life-threatening 
The term ‘life-threatening’ in the definition refers to an event in which the subject was at 
risk of death at the time of the event, it does not refer to an event which hypothetically 
might have caused death if it were more severe. 
c. Requires inpatient hospitalization or prolongation of existing hospitalization 
A hospitalization or prolongation of hospitalization will not be regarded as a serious 
adverse event if 
at least one of the following exceptions is met: 
- 
The admission results in a hospital stay of less than 12 hours 
- 
The admission is pre-planned 
- 
The admission is not associated with an adverse event related to the 
study medication or study procedures as determined by the study safety 
officer and data safety monitoring board.  
d. Results in persistent or significant disability / incapacity 
Disability means a substantial disruption of a person’s ability to conduct normal life’s 
functions. 
e. Is a congenital anomaly / birth defect 
f. Is another serious or important medical event as judged by the investigator. 
Breach of confidentiality 
Subject confidentiality will be rigorously maintained. The data collected as part of this study 
will be for research only. It will be de-identified after collection. Confidentiality of data will 
be assured by coding of unique subject identities and that coding will be known only to the 
research team, including the use of secure files, locked in an office, and a unique subject 
coding system. The original study data will be kept in locked in an office (hard copy) or 
entered into a secure computer database password protected under a secure server space 
allocated for use by only the study team (electronic). Furthermore, data analysis will be 
appropriately blinded and any individual data presented in manuscripts will also be 
presented in an anonymous nature. No identifying information will be disclosed.  
Confirming with University of Missouri policy, all research records will be retained for a 
period of seven years following completion of the study. 
All protocols and techniques to be used will be approved by the Institutional Review Board 
(IRB) prior to initiation of any studies. Each subject will give written informed consent after 
all questions have been answered by a study team member. The consent form will also 
include a statement guaranteeing confidentiality. Adverse event reports and annual 


Page 9 of 11 
summaries will not include subject-identifiable material. No information will be given to 
anyone without permission from the subject. Electronic communication with study team 
members will involve only coded, unidentifiable information. Any unanticipated breach of 
confidentiality will be summarized and reported to the IRB within five working days of 
awareness. 
 
 
 
 
There may be no benefit to the subjects in this study. These data will aid in the 
understanding of the efficacy of neuraminidase inhibition as therapeutic strategy for 
restoring endothelial function in T2D patients as well as determining the efficacy of 
treating glycocalyx degradation as a means of improving endothelial function in T2D.   
 
 
 
 
We have completed multiple clinical studies 
involving human subjects with adherence 
rates of greater than 95% and subject 
retention rates of greater than 85%. We utilize 
a validated retention strategy published by 
Jeffrey et al (Am J Clin Nutr. 2003;78(4):684-
689) that has been successful. With respect to subject honoraria, subjects will be paid 
$50 after completion of the screening visit, $250 after the baseline visit, and $300 after 
the final visit. Thus, a total compensation of $600 will be provided as study events are 
completed.  
 
 
 
 
The subjects will not be charged for any procedures that are part of this research study.  
The costs of the study will be covered by a federal grant from the NIH. 
 
 
 
 
The data safety monitoring plan (DSMP) for this study is focused on the supervision 
performed by the PIs, the Co-Investigator, Dr. Manrique, and the safety officer, Dr. Guido 
Lastra. Monitoring will include enrollment, attrition, efficacy end-points, and adverse 
events.   
 
Plan for data management 
A password-protected database will be used to manage all study data. To ensure 
confidentiality only subject ID numbers will be entered into the database.  Signed informed 
IX. 
Anticipated Benefits 
X. 
Compensation 
XII. 
Data Safety Monitoring Plan 
XI. 
Costs 
Visit 
Compensation 
Screening 
$50 
Pre-assessment 
$ 250 
Post-assessment 
$ 300 


Page 10 of 11 
consent forms are kept in a locked office.  Participants will not be individually identified in 
any publication.  Participants’ right to privacy will be protected. 
 
Frequency of monitoring, including any plans for interim analysis and stopping 
rules  
Monitoring will include enrollment, attrition, efficacy endpoints, and adverse events. The 
safety officer will routinely review the safety information related to this project at three-
month intervals.  In addition to monitoring by the PIs, study physician, study coordinator, 
and safety officer, the DSMC conducts its reviews on a semiannual basis.  The frequency 
of the structured data review for this study can be summarized in the following table: 
 
 
Plan for adverse event reporting:  
Serious adverse events will be reported to the NIH.  Unanticipated events will be reported 
to the IRB, and both serious and non-serious adverse events will be reported to the MU 
School of Medicine DSMC. For reporting to the DSMC, adverse events will be categorized 
and classified according to the Common Terminology Criteria for Adverse Events Scale 
(CTCAE v3.0).  Safety reports will be sent to the safety officer.  The PIs will be responsible 
for assembling the data and producing these reports, as well as assuring that all parties 
obtain copies of these reports. 
 
Qualifications and responsibilities of the safety officer:  
Guido Lastra, MD, Associate Professor of Clinical Medicine, Division of Endocrinology, 
and board-certified endocrinologist will serve as the independent safety officer for this 
project.  Dr. Lastra is an experienced patient-oriented investigator, who is not part of the 
key personnel involved in this project but is familiar with all the proposed methodologies 
and their potential risks to human subjects. His expertise is in cardiovascular function and 
diabetes. As safety officer, Dr. Lastra will review eligibility criteria with the PIs and Dr. 
Manrique. He will review all reports sent by the PIs to determine whether there is any 
corrective action, trigger of an ad hoc review, or stopping rule violation that should be 
communicated to the University of Missouri IRB and the Data and Safety Monitoring 
Committee. In addition, the safety officer may comment on whether the study 
investigators need to report any specific out-of-range laboratory data. 
 
MU data and safety monitoring committee (DSMC) 
The MU School of Medicine DSMC was formed by the MU Institute for Clinical and 
Translational Science and activated as an advisory committee within the MU School of 
Data type 
Frequency of review 
Subject accrual (adherence to protocol regarding 
demographics, inclusion/exclusion) 
At the end of each 
recruitment 
Adverse event rates (injuries)  
semi-annually 
Compliance to supplementation 
semi-annually 
Stopping rules report regarding statistical power 
implications of dropouts and missing data 
semi-annually 
IRB review 
annually 
DSMC review  
semi-annually 


Page 11 of 11 
Medicine. Its structure and processes are consistent with NIH guidelines. The DSMC 
helps investigators, and MU research compliance oversight mechanisms protect human-
research participants and ensure the integrity and scientific validity of research data.  The 
DSMC provides education for investigators, research teams, and faculty regarding data 
and safety monitoring; reviews proposed Data and Safety Monitoring Plans; establishes 
Data and Safety Monitoring Boards; conducts independent, interim reviews of study 
safety and progress; and makes recommendations concerning the continuation of 
studies, including recommendations regarding the modification, suspension, or 
termination of a study.  
 
 
 
 
1. Hata K, Koseki K, Yamaguchi K, Moriya S, Suzuki Y, Yingsakmongkon S, Hirai 
G, Sodeoka M, von Itzstein M, Miyagi T. Limited inhibitory effects of oseltamivir 
and zanamivir on human sialidases. Antimicrob Agents Chemother. 
2008;52(10):3484-3491. 
2. Tarbell JM, Pahakis MY. Mechanotransduction and the glycocalyx. Journal of 
internal medicine. 2006;259(4):339-350. 
3. Yen W, Cai B, Yang J, Zhang L, Zeng M, Tarbell JM, Fu BM. Endothelial surface 
glycocalyx can regulate flow-induced nitric oxide production in microvessels in 
vivo. PLoS One. 2015;10(1):e0117133. 
4. Harris RA, Padilla J, Rink LD, Wallace JP. Variability of flow-mediated dilation 
measurements with repetitive reactive hyperemia. Vascular medicine (London, 
England). 2006;11(1):1-6. 
5. Jones B, Kenward MG. Design and Analysis of Cross-Over Trials. 3rd Edition ed: 
CRC Press, Boca Raton, FL; 2015. 
 
XIV. 
References/Appendices 

ICF_001.pdf: 
 
 
 
 
 
 
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CONSENT FORM AND HIPAA AUTHORIZATION FOR  
PARTICIPATION IN A RESEARCH STUDY  
 
INVESTIGATOR’S NAME: LUIS MARTINEZ-LEMUS, PHD, JAUME PADILLA, 
PHD, CAMILA MANRIQUE, MD 
 
 
 
PROJECT IRB #:  2038203 
 
STUDY TITLE: ROLE OF NEURAMINIDASE ACTIVITY ON ENDOTHELIAL DYSFUNCTION 
IN TYPE 2 DIABETES 
 
We invite you to take part in this research study. This consent form tells you why we are doing 
the study, what will happen if you join the study, and other important information about the 
study. 
 
Please take as much time as you need to read this consent form. You can discuss it with your 
family, friends, or personal doctor. If there is anything you do not understand, please ask us to 
explain. Then you can decide if you want to take part in the study or not.  
 
The Principal Investigator (also called the study doctor) is Dr. Luis Martinez-Lemus, PhD. The 
people working with Dr. Martinez-Lemus on this study are called the study team. 
National Institutes of Health (called the sponsor in this form) is paying for this study.  
 
WHAT SHOULD I KNOW BEFORE I DECIDE WHETHER TO TAKE PART IN THIS 
STUDY?  
• Research studies help us to learn new things and test new ideas about treating certain 
conditions/diseases.  
• Taking part in a research study is voluntary. You decide if you want to take part, and you 
can stop taking part at any time. Your regular medical care at the University of Missouri 
Hospitals and Clinics will not be affected now or in the future if you decide you do not 
want to be in this study. 
• We are doing this study because we want to learn more about whether the medicine 
zanamivir can benefit the cardiovascular health of people with type 2 diabetes. We hope 
to learn if zanamivir can help restore endothelial function in individuals with type 2 
diabetes. Zanamivir is a Food and Drug Administration (FDA) approved medication for 
the treatment of influenza virus. Zanamivir is being used in an off-label manner for this 
research study.   
• We invite you to take part in this study because you have the diagnosis of type 2 diabetes. 
• About 20 people will take part in this study at the University of Missouri. 
• If you take part in this study, you will come to the University of Missouri Clinical 
Research Center for three separate study visits. You will have blood tests, questionnaires, 
vascular ultrasound measurements, and a noninvasive Glycocheck test performed. We 
will explain these procedures in this form. 
• If you join this study, you will not have to stop your diabetes treatment for as long as you 
are in the study. 
• The total amount of time you could be in this study is about 1 month.  
IRB Approval Date: Nov 09, 2022; Written Consent with HIPAA Authorization ID #616724; Annual Update ID #384164


 
 
 
 
 
 
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• Taking part in this study may or may not make your health better. We hope that the 
information we learn from this study will help in the future treatment of people with type 
2 diabetes.   There is no guarantee that taking part in this research will result in any 
improvement in your condition. 
• As with any research study, there are risks that we know about and there may be some we 
do not know about. We will explain these risks in this form. 
• We will only include you in this study if you give us your permission first by signing this 
consent form. 
 
WHY ARE THE RESEARCHERS DOING THIS STUDY? 
In this study, we want to find out if a drug called zanamivir (also called the study drug in this 
form) improves endothelial function (blood vessel function) in patients with type 2 diabetes.   
 
WHAT WILL HAPPEN IF I TAKE PART IN THIS STUDY? 
Screening Tests 
If you decide to join this study, you will sign this form and then you will have some screening 
tests to see if you qualify to be in the study. These are the screening tests: 
• Medical Chart Review: The study doctors will review your medical chart. 
• Pregnancy Tests: The drug used in this study may affect unborn babies. For this reason, 
pregnant women cannot take part in this study. If you are a female who can become 
pregnant (you have had your first period and have not reached menopause), we will do a 
urine pregnancy test to make sure you are not pregnant. 
• Practice use of the Glycocheck study equipment  
 
If the results of these tests show that you can be in the study, you will start in the study within the 
next 3 weeks. If you do not qualify to be in the study, the study doctor will discuss other options 
with you and/or refer you back to your regular doctor. 
 
Research Study Treatment  
The treatment will include taking the study drug for five days. We will check with everyone via 
phone regularly after the initiation of treatment to ensure compliance and to inquiry about 
potential side effects. 
 
Study Tests and Procedures 
If you take part in this study, you will have the following tests and procedures: 
 
After signing the consent form, medical information will be obtained by the study team, 
including DOB, gender, ethnic/racial category, height, body weight (history of body weight gain 
or loss), waist circumference, vitals (including: heart rate, respirations, temperature, and blood 
pressure), and a medical history questionnaire.  
 
You will be asked to fast for eight or more hours and hold any medications that you take the 
morning of each of the assessment (pre and post) study visits. 
 
At each of the assessment visits, vitals and a fasting blood draw will be taken to test for 
biochemistries. You will also undergo measurements including Glycocheck and brachial artery 
flow-mediated dilation (FMD) at each of your assessment visits. You can find a description of 
these procedures in this form.  
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The information and/or samples we collect from you for this study will not be used or shared 
with other investigators for future research studies. This applies even if we remove all 
information that could identify you from the data and samples.  
 
Study Medication 
The study medication, zanamivir, is an oral inhalation medication that is dispensed from a disk 
inhaler. You will be instructed to take 10mg of the study medication via inhalation, twice daily 
for five consecutive days. The medication may have side effects that include allergic reactions, 
sinusitis, dizziness, fever and/or chills, and joint pain and/or inflammation. You should not take 
this medication if you have COPD or asthma. The study medication should not be used until two 
weeks following administration of live attenuated influenza vaccine if applicable, and you will 
be advised not to receive the live attenuated influenza vaccine until 48 hours following stopping 
treatment with zanamivir. The medication should not be administered to anyone with a history of 
allergic reaction to milk proteins. The study staff will inquire about your food and/or medication 
allergies prior to administering the medication. Zanamivir can also cause bronchospasm 
(irritation of your airways that results in wheezing and/or coughing), allergic reaction, and 
neuropsychiatric events (agitation, depression, sleeping problems, suicidal thoughts and actions, 
etc.). You will be monitored by the study physician and study safety officer while receiving 
treatment. The use of zanamivir in this study is off-label.  
 
Brachial artery FMD 
A blood pressure cuff will be inflated on your forearm for up to five minutes. During this time, 
your arm may get numb due to decreased blood flow. An ultrasound image/video of your upper 
arm will be taken before, during, and after the inflation of the blood pressure cuff. This is a 
measurement of vascular function. There are no risks associated with this procedure. When 
assessing FMD, the blood pressure cuff will squeeze your arm tightly; however, any discomfort 
will be alleviated as soon as the pressure in the cuff is released. We will complete this test twice 
per study visit.  
 
Glycocheck 
A small, light-emitting probe will be placed under your tongue. The probe allows researchers to 
assess the integrity of your blood vessels. This procedure can take up to 1 hour to perform and 
can cause discomfort. There are no risks associated with this test. 
 
Blood drawing/venipuncture 
We will take a blood sample from a vein in your arm using a needle at each of the four 
assessment visits that you complete. Each sample will be about 20mL or four teaspoons. We will 
take a total of about 40mL or two to three tablespoons of blood for the whole study (over the 
course of 1 month). Taking blood from you may cause some discomfort from the needle stick, 
dizziness, bruising, or very rarely, infection. 
 
We will tell you if we learn information from these procedures that may be important for you to 
know. It is possible that this will mean you need more testing or treatment for a new or existing 
medical condition.  You and/or your health plan/insurance will be responsible for the costs of 
this extra testing and/or treatment. 
 
HOW LONG WILL I BE IN THE STUDY? 
You will be in this study for about month. The study screening visit will take about 1 hour to 
complete. If you are eligible to participate in the study intervention, you will be scheduled within 
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3 weeks to participate in the pre-assessment. The pre-assessment visit will last about 3 hours. 
Following pre-assessment, you will take the study medication for 5 days. After your final dose of 
study medication, you will have a final, post-assessment visit that will last about 3 hours.  
 
CAN I STOP BEING IN THE STUDY? 
You can stop being in the study at any time without giving a reason. If you stop being in the 
study, your regular medical care will not change. Leaving the study will not affect your future 
medical care at the University of Missouri.  
 
There is no penalty to you if you do not join the study or if you leave it early. You will not 
lose any benefits you are entitled to if you leave the study. 
 
If you decide to stop participating in the study, you should discuss your decision with the study 
doctor. If you decide to stop participating in the study, just let us know. 
 
The study doctor may decide to take you off this study at any time, even if you want to stay in 
the study. The study doctor will tell you the reason why you need to stop being in the study. 
These reasons may be: 
• If it is in your best medical interest 
• You do not follow the study rules 
• The whole study is stopped 
• New information becomes available about the study drug 
If necessary, the study doctor will arrange for you to continue your medical care with your 
regular doctor. 
 
WHAT HEALTH RISKS OR PROBLEMS CAN I EXPECT FROM THE STUDY? 
There are risks to taking part in any research study. There may also be problems (also called side 
effects) we do not know about yet. If we learn about new important risks and side effects, we 
will tell you. We will tell you about any new information we learn that may affect your decision 
to continue taking part in the study. 
 
Drugs can affect people in different ways. Not everyone gets the same side effects. Side effects 
may be mild or very serious. Many go away soon after you stop taking the drug. Some side 
effects can last a long time or never go away.  
We will closely watch everyone in the study for side effects. You need to tell the study doctor 
immediately if you have any problems, side effects, or changes in your health.  Dr. Luis 
Martinez-Lemus’s telephone number is (573) 882-3244.  For more information about risks and 
side effects, ask the investigator or contact Dr. Camila Manrique at (573) 529-1141.   
WHAT OTHER RISKS ARE THERE? 
Other procedures and drugs that are part of this study might also involve some risks: 
 
Reproductive Risks 
• Risks to women who could become pregnant: 
The drug in this study might affect a baby, before or after it is born. We do not know if 
the drug can harm a baby, and so we do not want anyone who might be pregnant to be in 
the study. 
 
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You should not become pregnant or breastfeed a baby while taking part in this study and 
for four weeks after finishing treatment. You must use effective birth control while you 
are in the study. 
 
You must tell the study doctor right away if you think you are pregnant. We will ask you 
to take a pregnancy test to be sure you are not pregnant at the start of the study and again 
before starting the second arm of the study. 
 
ARE THERE BENEFITS TO TAKING PART IN THE STUDY? 
We do not know if this study will help you. Your condition may get better, but it could stay the 
same or even get worse. We hope that this study will help us to learn more about endothelial 
dysfunction in type 2 diabetics, and to develop new treatments for vascular disease in the future. 
 
WHAT OTHER CHOICES DO I HAVE? 
You do not have to take part in this study. You are free to say yes or no.  
 
WHAT ABOUT PRIVACY AND CONFIDENTIALITY? 
The study team needs to use some of your health/personal information. This information comes 
from questions we ask you, forms you fill out, and your medical record. One risk of taking part 
in a research study is that more people will handle your personal health information. We are  
committed to respecting your privacy and to keeping your personal information confidential. The 
study team will make every effort to protect your information and keep it confidential to the 
extent allowed by law. However, it is possible that an unauthorized person will see it.  
State and federal privacy laws (HIPAA) protect the use and release of your health information. If 
you decide to take part in this study, you also give us your permission to use your private health 
information, including the health information in your medical records and information that can 
identify you.  
 
You have the right to refuse to give us your permission for us to use your health information. 
However, doing so would mean that you could not take part in this study.  
 
The following identifiers will be obtained from your health records:  
Name 
 
 
 
 
 
Address 
Dates related to you 
 
 
 
Telephone number(s) 
Fax Number 
 
 
 
 
Email Address 
Social Security Number 
 
 
 
Medical Record Number 
Health Plan Beneficiary Number  
 
Account Numbers 
Certificate or License Numbers 
 
 
Any vehicle or device serial number 
Web Address (URL) 
 
 
 
Internet Protocol (IP) Address(es) 
Biometric Identifiers (finger/voice print)  
Photographic images 
Any other characteristic that could identify you 
 
The following is the type of protected health information that will be used in the study:  
Radiology Images  
 
 
 
Discharge Summaries 
Radiology Reports  
 
 
 
Health Care Billing or Financial Records 
EKG Recordings/Reports  
 
 
Consultations 
Progress Notes 
 
 
 
 
Medications 
History and Physical Exams 
 
 
Emergency Medicine Reports 
Operative Reports  
 
 
 
Dental Records 
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Pathology Reports  
 
 
 
Demographics (age, race, etc.) 
Laboratory Reports 
 
 
 
Questionnaires, Surveys, Diaries 
Photographs/Video Recordings 
 
 
Audio Recordings 
Social Security Number (This is only collected for billing/payment purposes and will not be 
shared with the study sponsor) 
 
We may share any of this information with the following:  
• Authorized members and staff of the University of Missouri Institutional Review Board 
(IRB).  
• Laboratories and other individuals and organizations that may need to see your health  
information in connection with this study. 
• Study monitors and auditors who make sure that the study is being done properly.  
• Government agencies and public health authorities, such as the Food and Drug  
Administration (FDA), the Department of Health and Human Services (DHHS), and the 
Office for Human Research Protections (OHRP) 
Any research information shared with outside entities will not contain your name, address, 
telephone or social security number, or any other personal identifier unless it is necessary for 
review or required by law. 
The people who get your health information may not be required by Federal privacy laws (such 
as the HIPAA Privacy Rule) to protect it. Some of those people may be able to share your 
information with others without your separate permission. 
 
Your permission for us to use and/or release your information will last until the end of the study 
unless you cancel your permission.  
 
You can cancel your permission at any time by writing to:  
Dr. Luis Martinez-Lemus, PhD 
University of Missouri 
Dalton Cardiovascular Research Center  
134 Research Park Dr 
Columbia, MO 65203 
 
The information we have already collected may still be used for this research study, but we will 
not collect anymore information after we receive your letter.  
 
You will not be allowed to access your protected health information that is obtained or created 
during this research project until the end of the study. 
 
If you have not already received a copy of the University of Missouri Healthcare Privacy Notice, 
you may request one. If you have any questions or concerns about your privacy rights, you may 
contact the Privacy Officer at 573-882-9054. 
 
We will scan a copy of this consent form into your medical record.  
 
Information that does not become part of your medical record will be stored in the investigator’s 
electronic/computer or paper files. Computer files are protected with a password and the 
computer is in a locked office that only study team members can open. Paper files are kept in a 
locked drawer in a locked office that only study team members can open. 
 
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Your records will be given a code number and will not contain your name or other information 
that could identify you.  The code number that connects your name to your information will be 
kept in a separate, secure location.  Information that may identify you may not be given to 
anyone who is not working on this study without your written consent, or if required by law.   
 
The people who may use and/or release your research information include: 
• Those working on the study team at the University of Missouri  
• The members of the University of Missouri Institutional Review Board (IRB) 
• Those who check on research activities to make sure it is being done correctly and safely  
• Other government or inspection agencies  
 
We may present the results of this study in public talks or written articles, but we will not use 
information that can identify you.   
 
This research is covered by a Certificate of Confidentiality from the National Institutes of 
Health. The researchers with this Certificate may not disclose or use information, documents, or 
biospecimens that may identify you in any federal, state, or local civil, criminal, administrative, 
legislative, or other action, suit, or proceeding, or be used as evidence, for example, if there is a 
court subpoena, unless you have consented for this use. Information, documents, or 
biospecimens protected by this Certificate cannot be disclosed to anyone else who is not 
connected with the research except, if there is a federal, state, or local law that requires 
disclosure (such as to report child abuse or communicable diseases but not for federal, state, or 
local civil, criminal, administrative, legislative, or other proceedings, see below); if you have 
consented to the disclosure, including for your medical treatment; or if it is used for other 
scientific research, as allowed by federal regulations protecting research subjects.  
 
The Certificate cannot be used to refuse a request for information from personnel of the United 
States federal or state government agency sponsoring the project that is needed for auditing or 
program evaluation by University of Missouri which is funding this project or for information 
that must be disclosed in order to meet the requirements of the federal Food and Drug 
Administration (FDA).  You should understand that a Certificate of Confidentiality does not 
prevent you from voluntarily releasing information about yourself or your involvement in this 
research. If you want your research information released to an insurer, medical care provider, or 
any other person not connected with the research, you must provide consent to allow the 
researchers to release it. 
 
ARE THERE ANY COSTS TO BEING IN THE STUDY? 
The study will pay for all research tests and procedures. You and/or your health plan/insurance 
will not be billed for tests and procedures that are done in this research study.  
 
There is no cost to you for taking part in this study. 
 
WILL I BE PAID FOR TAKING PART IN THIS STUDY? 
The total amount that you could receive is $600. You will be paid $50 after completion of 
screening, $250 after completion of the pre-assessment visit, and $350 after the post-assessment 
visit (after completion of the study).  Thus, a total compensation of $600 will be provided as 
study events are completed. 
If you decide to leave the study early, you will still receive a payment for each visit you 
completed. 
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We will need your social security number in order to pay you. Any payment may need to be 
reported as income on your tax return. If you are not a resident/citizen (non-resident alien) of the 
United States, you will need to work with the MU Nonresident Tax Specialist at 573-882-5509. 
 
WHAT HAPPENS IF I AM INJURED DURING THE STUDY?  
It is not the policy of the University of Missouri to compensate human subjects in the event the 
research results in injury.  The University of Missouri, in fulfilling its public responsibility, has 
provided medical, professional and general liability insurance coverage for any injury in the event 
such injury is caused by the negligence of the University of Missouri, its faculty and staff.   
The University of Missouri also will provide, within the limitations of the laws of the State of 
Missouri, facilities and medical attention to subjects who suffer injuries while participating in the 
research projects of the University of Missouri.   
 
In the event you have suffered injury as the result of participation in this research program, you are 
to contact the Risk Management Officer, telephone number (573) 882-1181, at the Health Sciences 
Center, who can review the matter and provide further information.   
This statement is not to be construed as an admission of liability. 
 
WHAT ARE MY RIGHTS AS A STUDY PARTICIPANT? 
Taking part in this study is voluntary.  You do not have to take part.  Your present or future 
medical care will not be affected if you decide not to take part.   
 
If you do decide to take part, you can change your mind and drop out of the study at any time. 
This will not affect your current or future care at the University of Missouri Hospitals and 
Clinics. There is no penalty for leaving the study and you will not lose any benefits that you are 
entitled to receive. 
 
If the study investigator decides to take you off the study, he will explain the reasons and help 
arrange for your continued care by your own doctor, if needed.   
 
We will tell you about any new information discovered during this study that might affect your 
health, welfare, or change your mind about taking part.  
A Data Safety and Monitoring Board, an independent group of experts, will review the data 
collected during this study. We will tell you about any new information discovered during this 
study that might affect your health, welfare, or change your mind about taking part.  
 
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WHERE CAN I GET MORE INFORMATION ABOUT THIS STUDY? 
A description of this clinical trial will be available on www.ClinicalTrials.gov, as required by 
U.S. law. This Web site will not include information that can identify you. At most, the Web site 
will include a summary of the results. You can search this Web site at any time. 
 
WHO CAN ANSWER MY QUESTIONS ABOUT THE STUDY? 
If you have more questions about this study at any time, you can call Dr. Luis Martinez-Lemus at 
(573) 882-3244. 
You may also contact the University of Missouri Institutional Review Board (IRB) if you: 
• Have any questions about your rights as a study participant; 
• Want to report any problems or complaints; or 
• Feel under any pressure to take part or stay in this study.  
 
The IRB is a group of people who review research studies to make sure the rights of participants 
are protected. Their phone number is 573-882-3181. There email is 
muresearchirb@missouri.edu. 
 
If you want to talk privately about your rights or any issues related to your participation in this 
study, you can contact University of Missouri Research Participant Advocacy by calling 888-
280-5002 (a free call), or emailing MUResearchRPA@missouri.edu. 
 
We will give you a copy of this consent form. Please keep it where you can find it easily. It will 
help you to remember what we discussed today. 
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SIGNATURE OF STUDY PARTICIPANT  
 
Consent to Participate in Research 
 
By signing my name below, I confirm the following: 
• I have read/had read to me this entire consent form. 
• All of my questions were answered to my satisfaction. 
• The study’s purpose, procedures, risks and possible benefits were explained to me. 
• I voluntarily agree to take part in this research study. I have been told that I can stop at 
any time. 
 
 
 
 
Subject’s Signature 
Date  
 
 
 
 
 
 
 
*A witness is required when a participant is competent to provide consent but is blind, or cannot 
read or write. 
 
SIGNATURE OF PERSON AUTHORIZED TO OBTAIN CONSENT*  
I have explained the purpose of the research, the study procedures (identifying those that are 
investigational), the possible risks and discomforts and potential benefits of the study, and have 
answered questions regarding the study to the best of my ability. 
 
 
 
 
 
*This signature is required for FDA regulated research and/or research that involves any 
medical procedure or surgical treatment. 
 
 
 
 
 
 
 
 
 
 
Consent version 6.0 
 
 
 
Signature of Witness (if applicable)* 
Date  
 
 
 
Signature of Person Authorized to Obtain Consent 
Date  
IRB Approval Date: Nov 09, 2022; Written Consent with HIPAA Authorization ID #616724; Annual Update ID #384164