WO2015106296A1

WO2015106296A1 - Enolse 1 (eno1) compositions and uses thereof

Info

Publication number: WO2015106296A1
Application number: PCT/US2015/011276
Authority: WO
Inventors: Niven Rajin Narain; Rangaprasad Sarangarajan; Vivek K. VISHNUDAS; Stephane Gesta; Enxuan Jing; Sylvia Daunert; Sapna K. DEO; Joaquin Juan JIMENEZ; Emre Dikici; Pirouz Mohammad Daftarian
Original assignee: Berg Llc; University Of Miami
Priority date: 2014-01-13
Filing date: 2015-01-13
Publication date: 2015-07-16
Also published as: KR20160106175A; US10188708B2; US11224641B2; JP6629234B2; EP3094379A2; CN106102835B; EP3094341A4; EP3094341A1; US20190307863A1; US10188707B2; CN106102835A; JP2017508000A; AU2015204452A1; WO2015106295A2; CA2936694A1; CN112336851A; WO2015106295A3; AU2015204451A1; IL246720A0; HK1231394A1

Abstract

The invention provides compositions comprising Enol for delivery to a muscle. Further, the invention provides a method for normalizing blood glucose in a subject with elevated blood glucose, comprising administering to the subject enolase 1 (Enol), thereby normalizing blood glucose in the subject. The invention also provides methods of treating one or more conditions including impaired glucose tolerance, insulin resistance, pre-diabetes, and diabetes, especially type 2 diabetes in a subject, comprising administering to the subject enolase 1 (Enol), thereby treating the condition in the subject. In certain methods of the invention, the Enol is delivered to muscle.

Description

ENOLASE 1 (ENOl) COMPOSITIONS AND USES THEREOF

RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent Application No.

61/926,913 filed on January 13, 2014, U.S. Provisional Patent Application No. 62/009,783 filed on June 9, 2014, and U.S. Provisional Patent Application No. 62/100,881 filed on January 7, 2015, the contents of each of which are incorporated herein in their entirety.

SUBMISSION OF SEQUENCE LISTING

The Sequence Listing associated with this application is filed in electronic format via EFS-Web and hereby incorporated by reference into the specification in its entirety. The name of the text file containing the Sequence Listing is 119992_10619_Sequence_Listing. The size of the text file is 33 KB, and the text file was created on January 13, 2015.

BACKGROUND

As the levels of blood glucose rise postprandially, insulin is secreted and stimulates cells of the peripheral tissues (skeletal muscles and fat) to actively take up glucose from the blood as a source of energy. Loss of glucose homeostasis as a result of dysregulated insulin secretion or action typically results in metabolic disorders such as diabetes, which may be co- triggered or further exacerbated by obesity. Because these conditions can reduce the quality of life or even be fatal, strategies to restore adequate glucose clearance from the bloodstream are required.

Although diabetes may arise secondary to any condition that causes extensive damage to the pancreas (e.g., pancreatitis, tumors, administration of certain drugs such as

corticosteroids or pentamidine, iron overload (i.e., hemochromatosis), acquired or genetic endocrinopathies, and surgical excision), the most common forms of diabetes typically arise from primary disorders of the insulin signaling system. There are two major types of diabetes, namely type 1 diabetes (also known as insulin dependent diabetes (IDDM)) and type 2 diabetes (also known as insulin independent or non-insulin dependent diabetes (NIDDM)), which share common long-term complications in spite of their different pathogenic mechanisms. Type 1 diabetes, which accounts for approximately 10% of all cases of primary diabetes, is an organ-specific autoimmune disease characterized by the extensive destruction of the insulin-producing beta cells of the pancreas. The consequent reduction in insulin production inevitably leads to the deregulation of glucose metabolism. While the

administration of insulin provides significant benefits to patients suffering from this condition, the short serum half-life of insulin is a major impediment to the maintenance of normoglycemia. An alternative treatment is islet transplantation, but this strategy has been associated with limited success.

Type 2 diabetes, which affects a larger proportion of the population, is characterized by a deregulation in the secretion of insulin and/or a decreased response of peripheral tissues to insulin, i.e., insulin resistance. While the pathogenesis of type 2 diabetes remains unclear, epidemiologic studies suggest that this form of diabetes results from a collection of multiple genetic defects or polymorphisms, each contributing its own predisposing risks and modified by environmental factors, including excess weight, diet, inactivity, drugs, and excess alcohol consumption. Although various therapeutic treatments are available for the management of type 2 diabetes, they are associated with various debilitating side effects. Accordingly, patients diagnosed with or at risk of having type 2 diabetes are often advised to adopt a healthier lifestyle, including loss of weight, change in diet, exercise, and moderate alcohol intake. Such lifestyle changes, however, are not sufficient to reverse the vascular and organ damages caused by diabetes.

SUMMARY OF THE INVENTION

In one aspect, the invention provides compositions comprising enolase 1 (Enol) or a fragment thereof for delivery to a muscle. In one aspect, the invention provides method for normalizing blood glucose in a subject with elevated blood glucose, comprising

administering to the subject a composition comprising Enol or a fragment thereof, thereby normalizing blood glucose in the subject. In one aspect, the invention provides methods of treating one or more conditions including impaired glucose tolerance, insulin resistance, prediabetes, and diabetes, especially type 2 diabetes, in a subject, comprising administering to the subject a composition comprising Enol or a fragment thereof, thereby treating the condition in the subject. In certain methods of the invention, the Enol is delivered to muscle. The invention provides pharmaceutical composition comprising Enol or a fragment thereof for delivery to a muscle cell.

In certain embodiments, the Enol comprises an Enol polypeptide, or a fragment thereof. In certain embodiments, the Enol comprises an Enol nucleic acid, or a fragment thereof. In certain embodiments, the Eno 1 comprises human Enol, e.g., a human Enol polypeptide or human Enol nucleic acid, or fragment thereof.

In certain embodiments, the composition further comprises a microparticle. In certain embodiments, the composition further comprises a nanoparticle. In certain embodiments, the Enol or the fragment thereof is biologically active. In certain

embodiments, the Enol or the fragment thereof has at least 90% of the activity of a purified endogenous human Enol polypeptide.

In certain embodiments, the composition further comprises an in situ forming composition. In certain embodiments, the composition further comprises a liposome. In certain embodiments, the composition comprises a dendrimer. In certain embodiments, the composition further comprises an expression vector, e.g., encoding the Enol or fragment thereof. In certain embodiments, the expression vector comprises a viral vector.

In certain embodiments, the composition comprises a complex comprising Enol or a fragment thereof, e.g., an Enol polypeptide, e.g., a human Enol polypeptide, and a muscle targeting moiety. In certain embodiments, the muscle targeting moiety comprises a skeletal and/or smooth muscle targeting peptide). In certain embodiments, the MTP comprises an amino acid sequence selected from the group consisting of: ASSLNIA; WDANGKT;

GETRAPL; CGHHPVYAC; and HAIYPRH. In certain embodiments, the complex comprises a linker, e.g., linking Enol and the SMTP. In certain embodiments, the linker is selected from the group consisting of a covalent linker, a non-covalent linkage, and a reversible linker. In certain embodiments, the complex comprises a pharmaceutically acceptable dendrimer. In certain embodiments, the dendrimer is a PAMAM dendrimer. In certain embodiments, the dendrimer is a G5 dendrimer. In certain embodiments, the dendrimer is an uncharged dendrimer. In certain embodiments, the dendrimer is an acylated dendrimer. In certain embodiments, the dendrimer is a PEGylated dendrimer or an acetylated dendrimer. In certain embodiments, the complex comprises a liposome. In certain embodiments, the complex comprises a microparticle or a nanoparticle. In certain embodiments, the composition comprises an in situ forming composition.

In certain embodiments, the Enol is released from the complex upon delivery to a muscle cell. In certain embodiments, the Enol or a fragment thereof and the targeting moiety are present in the complex at a ratio of about 1: 1 to about 1:30.

In certain embodiments, the composition is formulated for administration by injection or infusion. In certain embodiments, the composition is formulated for oral administration. In certain embodiments, the composition is formulated for parenteral administration. In certain embodiments, the composition is formulated for intramuscular administration, intravenous administration, or subcutaneous administration.

The invention provides methods of decreasing blood glucose in a subject with elevated blood glucose, the method comprising administering to the subject a pharmaceutical composition comprising of Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition comprises any of the pharmaceutical compositions provided herein.

The invention provides methods of increasing glucose tolerance in a subject with decreased glucose tolerance, the method comprising administering to the subject a pharmaceutical composition comprising of Enol. In certain embodiments, the

pharmaceutical composition comprises any of the pharmaceutical compositions provided herein.

The invention provides methods of improving insulin response in a subject with decreased insulin sensitivity and/or insulin resistance, the method comprising administering to the subject a pharmaceutical composition comprising of Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition comprises any of the pharmaceutical compositions provided herein.

The invention provides methods of treating diabetes in a subject, the method comprising administering to the subject a pharmaceutical composition comprising of Enol or a fragment thereof. In certain embodiments, the diabetes is type 2 diabetes. In certain embodiments, the diabetes is pre-diabetes. In certain embodiments, the diabetes is type 1 diabetes. In certain embodiments, the diabetes is gestational diabetes. In certain

embodiments, the pharmaceutical composition comprises any of the pharmaceutical compositions provided herein. The invention provides methods of decreasing an HbAlc level in a subject with an elevated HblAc level, the method comprising administering to the subject a pharmaceutical composition comprising of Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition comprises any of the pharmaceutical compositions provided herein. The invention provides methods of improving blood glucose level control in a subject with abnormal blood glucose level control, the method comprising administering to the subject a pharmaceutical composition comprising of Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition comprises any of the pharmaceutical compositions provided herein. In certain embodiments, the Enol or a fragment thereof is administered by injection or infusion. In certain embodiments, the Enol or a fragment thereof is administered parenterally. In certain embodiments the Enol or a fragment thereof is administered orally. In certain embodiments, the Enol or a fragment thereof is administered by a route selected from the group consisting of intramuscular, intravenous, and subcutaneous. The invention provides methods for diagnosing an elevate blood glucose level in a subject, comprising: (a) detecting the level of Enol in a biological sample of the subject, and (b) comparing the level of Enol in the biological sample with a predetermined threshold value, wherein the level Enol below the predetermined threshold value indicates the presence of elevated blood glucose in the subject. In certain embodiments, the methods further comprise detecting the level of one or more diagnostic indicators of elevated blood glucose. In certain embodiments, the one or more additional diagnostic indicators of elevated blood glucose is selected from the group consisting of HbAlc, fasting blood glucose, fed blood glucose, and glucose tolerance. In certain embodiments, the biological sample is blood or serum. In certain embodiments, the level of Enol is determined by immunoassay or ELISA. In certain embodiments, step (a) comprises (i) contacting the biological sample with a reagent that selectively binds to the Enol to form a biomarker complex, and (ii) detecting the biomarker complex. In certain embodiments, the reagent is an anti-Enol antibody that selectively binds to at least one epitope of Enol.

In certain embodiments, step (a) comprises determining the amount of Enol mRNA in the biological sample. In certain embodiments, an amplification reaction is used for determining the amount of Enol mRNA in the biological sample. In certain embodiments, the amplification reaction is (a) a polymerase chain reaction (PCR); (b) a nucleic acid sequence -based amplification assay (NASBA); (c) a transcription mediated amplification (TMA); (d) a ligase chain reaction (LCR); or (e) a strand displacement amplification (SDA). In certain embodiments, a hybridization assay is used for determining the amount of Enol mRNA in the biological sample. In certain embodiments, an oligonucleotide that is complementary to a portion of a Enol mRNA is used in the hybridization assay to detect the Enol mRNA.

In certain embodiments of the invention, diagnosis of elevated blood glucose is diagnostic of a disease or condition selected from the group consisting of type 2 diabetes, prediabetes, gestational diabetes, and type 1 diabetes.

The invention provides method for diagnosing the presence of elevated blood glucose in a subject, comprising:

(a) contacting a biological sample with a reagent that selectively binds to Enol;

(b) allowing a complex to form between the reagent and Enol;

(c) detecting the level of the complex, and

(d) comparing the level of the complex with a predetermined threshold value, wherein the level of the complex above the predetermined threshold value indicates the subject is suffering from elevated blood glucose. In certain embodiments, the reagent is an anti-Enol antibody. In certain embodiments, the antibody comprises a detectable label. In certain embodiments, the step of detecting the level of the complex further comprises contacting the complex with a detectable secondary antibody and measuring the level of the secondary antibody. In certain embodiments, the methods further comprise detecting the level of one or more additional indicators of elevated blood glucose. In certain embodiments, the one or more additional indicators of blood glucose is selected from the group consisting of HbAlc level, fasting glucose level, fed glucose level, and glucose tolerance. In certain embodiments, the biological sample is blood or serum.

In certain embodiments of the invention, the level of the complex is determined by immunoassay or ELISA. In certain embodiments, the elevated blood glucose is indicative of pre-diabetes, type 2 diabetes, type 1 diabetes, or gestational diabetes. In certain

embodiments, the method further comprises administering a therapeutic regimen where the diagnosis indicates the presence of elevated blood glucose in the subject, wherein the therapeutic regimen is selected from the group consisting of drug therapy and behavioral therapy, or a combination thereof. In certain embodiments, the drug therapy comprises treatment with an agent selected from the group consisting of (a) a meglitinide, (b) a sulfonylurea, (c) a dipeptidy peptidase-4 (DPP-4) inhibitor, (d) a biguanide, (e) a

thiazolidinediones, (f) an alpha-glucosidase inhibitor, (g) an amylin mimetic; (h) an incretin mimetics; (i) an isulin; and (j) any combination thereof.

In certain embodiments, any of the preceding methods further comprise selecting a subject suspected of having or being at risk of having elevated blood glucose.

In certain embodiments, any of the preceding methods further comprise obtaining a biological sample from a subject suspected of having or being at risk of having elevated blood glucose.

In certain embodiments, any of the preceding methods further comprise comparing the level of the one or more elevated blood glucose related indicators in the biological sample with the level of the one or more elevated blood glucose related indicators in a control sample selected from the group consisting of: a sample obtained from the same subject at an earlier time point than the biological sample, a sample from a subject with normal blood glucose, a sample from a subject with prediabetes, a sample from a subject with type 2 diabetes, a sample from a subject with gestational diabetes, and a sample from a subject with type 1 diabetes.

The invention provides methods for monitoring elevated blood glucose in a subject, the method comprising:

(1) determining a level of Enol in a first biological sample obtained at a first time from a subject having elevated blood glucose; (2) determining a level of Enol in a second biological sample obtained from the subject at a second time, wherein the second time is later than the first time; and

(3) comparing the level of Enol in the second sample with the level of Enol in the first sample, wherein a change in the level of Enol is indicative of a change in elevated blood glucose status in the subject.

In certain embodiments, the determining steps (1) and (2) further comprise determining the level of one or more additional indicators of blood glucose is selected from the group consisting of HbAlc level, fasting glucose level, fed glucose level, and glucose tolerance. In certain embodiments, the subject is treated with drugs for elevated blood glucose prior to obtaining the second sample. In certain embodiments, a decreased level of Enol in the second biological sample as compared to the first biological sample is indicative of elevation of blood glucose in the subject. In certain embodiments, an increased or equivalent level of Enol in the second biological sample as compared to the first biological sample is indicative of normalization of blood glucose in the subject. In certain embodiments, the method further comprises selecting and/or administering a different treatment regimen for the subject based on the blood glucose level in the subject. In certain embodiments, the treatment regimen is selected from the group consisting of drug therapy and behavioral modification therapy. In certain embodiments, the drug therapy comprises treatment with an agent selected from the group consisting of (a) a meglitinide, (b) a sulfonylurea, (c) a dipeptidy peptidase-4 (DPP-4) inhibitor, (d) a biguanide, (e) a thiazolidinediones, (f) an alpha- glucosidase inhibitor, (g) an amylin mimetic; (h) an incretin mimetics; (i) an isulin; and (j) any combination thereof.

The invention provides methods of treating elevated blood glucose in a subject, comprising: (a) obtaining a biological sample from a subject suspected of having elevated blood glucose, (b) submitting the biological sample to obtain diagnostic information as to the level of Enol, (c) administering a therapeutically effective amount of an anti-diabetic therapy if the level of Enol is above a threshold level.

The invention provides methods of treating elevated blood glucose in a subject, comprising: (a) obtaining diagnostic information as to the level of Enol in a biological sample, and (b) administering a therapeutically effective amount of an anti-diabetic therapy if the level of Enol is above a threshold level.

The invention provides methods of treating elevated blood glucose in a subject, comprising: (a) obtaining a biological sample from a subject suspected of having elevated blood glucose for use in identifying diagnostic information as to the level of Enol,

(b) measuring the level of Enol in the biological sample,

(c) recommending to a healthcare provider to administer a blood glucose lowering therapy if the level of Enol is below a threshold level. In certain embodiments, the method further comprises obtaining diagnostic information as to the level of one or more additional indicators of elevated blood glucose.

In certain embodiments, the method further comprises measuring the level of one or more additional indicators of elevated blood glucose.

In certain embodiments, the one or more additional indicators of elevated blood glucose is selected from the group consisting of HbAlc level, fasting glucose level, fed glucose level, and glucose tolerance.

In certain embodiments, step (c) further comprises administering a therapeutically effective amount of a glucose lowering therapy if the level of Enol is below and at least one of the additional indicator of elevated blood glucose is detected. In certain embodiments, step (c) further comprises recommending to a healthcare provider to administer a glucose lowering therapy if the level of Enol is below a threshold level and at least one of the additional indicator of elevated blood glucose is present.

In certain embodiments, the biological sample is blood or serum. In certain embodiments, the level of Enol is determined by immunoassay or ELISA. In certain embodiments, the level of Enol is determined by (i) contacting the biological sample with a reagent that selectively binds to the Enol to form a biomarker complex, and (ii) detecting the biomarker complex. In certain embodiments, the reagent is an anti-Enol antibody that selectively binds to at least one epitope of Enol. In certain embodiments, the level of Enol is determined by measuring the amount of Enol mRNA in the biological sample. In certain embodiments, an amplification reaction is used for measuring the amount of Enol mRNA in the biological sample. In certain embodiments, the amplification reaction is (a) a polymerase chain reaction (PCR); (b) a nucleic acid sequence-based amplification assay (NASBA); (c) a transcription mediated amplification (TMA); (d) a ligase chain reaction (LCR); or (e) a strand displacement amplification (SDA). In certain embodiments, a hybridization assay is used for measuring the amount of Enol mRNA in the biological sample. In certain embodiments, an

oligonucleotide that is complementary to a portion of a Enol mRNA is used in the hybridization assay to detect the Enol mRNA.

The invention provides kits for detecting Enol in a biological sample comprising at least one reagent for measuring the level of Enol in the biological sample, and a set of instructions for measuring the level of Enol. In certain embodiments, the reagent is an anti- Enol antibody. In certain embodiments, the kits further comprise a means to detect the anti- Enol antibody. In certain embodiments, the means to detect the anti-Enol antibody is a detectable secondary antibody. In certain embodiments, the reagent is an oligonucleotide that is complementary to a Enol mRNA. In certain embodiments, the instructions set forth an immunoassay or ELISA for detecting the Enol level in the biological sample. In certain embodiments, the instructions set forth an amplification reaction for assaying the level of Enol mRNA in the biological sample. In certain embodiments, an amplification reaction is used for determining the amount of Enol mRNA in the biological sample. In certain embodiments, the amplification reaction is (a) a polymerase chain reaction (PCR); (b) a nucleic acid sequence-based amplification assay (NASBA); (c) a transcription mediated amplification (TMA); (d) a ligase chain reaction (LCR); or (e) a strand displacement amplification (SDA). In certain embodiments, the instructions set forth a hybridization assay for determining the amount of Enol mRNA in the biological sample. In certain

embodiments, the kit further comprises at least one oligonucleotide that is complementary to a portion of a Enol mRNA. In certain embodiments, the kit further comprises at least one reagent for measuring a level of HbAlc and/or blood glucose in the biological sample. In certain embodiments, the kit further comprises instructions for measuring at least one level selected from the group consisting of HbAlc level, fed blood glucose level, fasting blood glucose level, and glucose tolerance in the subject from which the biological sample was obtained. The invention provides panels of reagents for use in a method of detecting elevated blood glucose, the panel comprising detection reagents for Enol and HbAlc.

The invention provides panels of reagents for use in a method of treating elevated blood glucose, the panel comprising detection reagents for Enol and HbAlc. The invention provides panels of reagents for use in a method of monitoring the treatment of elevated blood glucose, the panel comprising detection reagents for Enol and HbAlc.

The invention provides kits containing a the panel of reagents provided herein, and a set of instructions for obtaining diagnostic information as to level of one or more indicators of elevated blood glucose.

The invention provides for the use of a panel of reagents comprising a plurality of detection reagents specific for detecting markers of elevated blood glucose in a method for diagnosing and/or treating elevated blood glucose, wherein at least one detection reagent of the panel is specific for detecting Enol, and wherein the remaining one or more detection reagents are specific for detecting an indicator of elevated blood glucose marker selected from the group consisting of HbAlc and glucose.

In certain embodiments of the aforementioned methods, glucose flux in a skeletal muscle cell of the subject is increased.

In another aspect, the invention provides a method of increasing glucose flux in a subject, the method comprising administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the aforementioned pharmaceutical compositions. In another aspect, the invention provides a method of increasing glycolytic activity or capacity in a skeletal muscle cell of a subject, the method comprising

administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the aforementioned pharmaceutical compositions.

In another aspect, the invention provides a method of increasing mitochondrial free fatty acid oxidation in a skeletal muscle cell of a subject, the method comprising administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the aforementioned pharmaceutical compositions.

In certain embodiments, the subject has any one or more of elevated blood glucose, decreased glucose tolerance, decreased insulin sensitivity and/or insulin resistance, diabetes, elevated HblAc level, and abnormal blood glucose level control.

In certain embodiments of any of the aforementioned methods, the subject is human.

In certain aspects the invention relates to a pharmaceutical composition comprising a therapeutically effective amount of Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition is for delivery to a muscle cell. In certain aspects the invention relates to a pharmaceutical composition comprising Enol or a fragment thereof and a muscle targeting peptide. In certain embodiments, the composition is for delivery to a muscle cell. In certain embodiments, the Enol comprises an Enol polypeptide or a fragment thereof. In certain embodiments, the Enol comprises an Enol nucleic acid or a fragment thereof. In certain embodiments, the composition further comprises an expression vector encoding for the Enol or fragment thereof. In certain embodiments, the Enol or fragment thereof is biologically active. In certain embodiments, the Enol or fragment thereof has at least 90% of the activity of a purified endogenous human Enol polypeptide. In certain embodiments, the Enol is human Enol. In certain embodiments, the composition further comprises a microparticle. In certain embodiments, the composition further comprises a nanoparticle. In certain embodiments, the composition further comprises an in situ forming composition. In certain embodiments, the composition further comprises a liposome. In certain embodiments, the composition further comprises a dendrimer. In certain embodiments, the composition comprises a complex comprising the Enol polypeptide and the muscle targeting peptide. In certain embodiments, the Enol polypeptide is human Enol polypeptide. In certain embodiments, the muscle targeting peptide comprises an amino acid sequence selected from the group consisting of: ASSLNIA; WDANGKT; GETRAPL; CGHHPVYAC; and

HAIYPRH. In certain embodiments, the complex further comprises a linker. In certain embodiments, the linker is selected from the group consisting of a covalent linker, a non- covalent linkage, and a reversible linker. In certain embodiments, the complex further comprises a pharmaceutically acceptable dendrimer. In certain embodiments, the

pharmaceutically acceptable dendrimer is a PAMAM dendrimer. In certain embodiments, the pharmaceutically acceptable dendrimer is a G5 dendrimer. In certain embodiments, the pharmaceutically acceptable dendrimer is an uncharged dendrimer. In certain embodiments, the pharmaceutically acceptable dendrimer is an acylated dendrimer. In certain

embodiments, the pharmaceutically acceptable dendrimer is a PEGylated dendrimer or an acetylated dendrimer.

In certain embodiments of the aforementioned compositions, the complex further comprises a liposome. In certain embodiments, the complex further comprises a

microparticle. In certain embodiments, the complex further comprises an in situ forming composition. In certain embodiments, the Enol is released from the complex upon delivery to a muscle cell. In certain embodiments, the dendrimer and the ENOl are present in the complex at a ratio of about 1: 1 to about 10: 1. In certain embodiments, the dendrimer and the ENOl are present in the complex at a ratio of about 3: 1 to about 5: 1. In certain

embodiments, the muscle targeting moiety and the dendrimer are present in the complex at a ratio of about 0.1: 1 to about 10: 1. In certain embodiments, the muscle targeting moiety and the dendrimer are present in the complex at a ratio of about 1 : 1 to about 3: 1. In certain embodiments, the Enol and the muscle targeting moiety are present in the complex at a ratio of about 1: 1 to about 1:30.

In certain embodiments of the aforementioned compositions, the composition is formulated for parenteral administration. In certain embodiments, the composition is formulated for oral administration. In certain embodiments, the composition is formulated for intramuscular administration, intravenous administration, or subcutaneous administration.

In certain aspects the invention relates to a method of decreasing blood glucose in a subject with elevated blood glucose, the method comprising administering to the subject any of the compositions described above, thereby decreasing blood glucose in the subject. In certain aspects the invention relates to a method of increasing glucose tolerance in a subject with decreased glucose tolerance, the method comprising administering to the subject any of the compositions described above, thereby increasing glucose tolerance in the subject.

In certain aspects the invention relates to a method of improving insulin response in a subject with decreased insulin sensitivity and/or insulin resistance, the method comprising administering to the subject any of the compositions described above, thereby improving insulin response in the subject.

In certain aspects the invention relates to a method of treating diabetes in a subject, the method comprising administering to the subject any of the compositions described above, thereby treating diabetes in the subject. In certain embodiments, the diabetes is type 2 diabetes or type 1 diabetes. In certain embodiments, the diabetes is pre-diabetes.

In certain aspects the invention relates to a method of decreasing an HbAlc level in a subject with an elevated HblAc level, the method comprising administering to the subject any of the compositions described above, thereby decreasing the HbAlc level in the subject.

In certain aspects the invention relates to a method of improving blood glucose level control in a subject with abnormal blood glucose level control, the method comprising administering to the subject any of the compositions described above, thereby improving blood glucose level control in the subject. In certain embodiments of the aforementioned method, glucose flux in a skeletal muscle cell of the subject is increased.

In certain aspects the invention relates to a method of increasing glucose flux in a subject, the method comprising administering to the subject any of the compositions described above, thereby increasing glucose flux in the subject.

In certain aspects the invention relates to a method of increasing glycolytic activity or capacity in a skeletal muscle cell of a subject, the method comprising administering to the subject any of the compositions described above, thereby increasing glycolytic activity or capacity in a skeletal muscle cell of the subject.

In certain aspects the invention relates to a method of increasing mitochondrial free fatty acid oxidation in a skeletal muscle cell of a subject, the method comprising

administering to the subject any of the compositions described above, thereby increasing mitochondrial free fatty acid oxidation in a skeletal muscle cell of the subject.

In certain embodiments of the aforementioned methods, the Enol is administered parenterally. In certain embodiments of the aforementioned methods, the Enol is

administered orally. In certain embodiments, the Enol is administered by a route selected from the group consisting of intramuscular, intravenous, and subcutaneous. In certain embodiments of the aforementioned methods, the subject has any one or more of elevated blood glucose, decreased glucose tolerance, decreased insulin sensitivity and/or insulin resistance, diabetes, elevated HblAc level, and abnormal blood glucose level control.

In certain embodiments, the aforementioned methods further comprise selecting a subject having any one or more of elevated blood glucose, decreased glucose tolerance, decreased insulin sensitivity and/or insulin resistance, diabetes, elevated HblAc level, and abnormal blood glucose level control.

In certain embodiments of the aforementioned methods, the subject is human.

Other embodiments are provided infra.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1A is a graph showing glucose uptake in smooth muscle myoblasts treated with or without Enol and insulin. Figure IB shows glucose uptake in smooth muscle myoblasts treated with 0, 500, or 1000 ug/ml Enol without insulin treatment.

Figures 2A and 2B show Enol protein levels in human skeletal muscle myotubes treated with 0, 500 or 1000 μg/ml Enol. Figure 2C shows Enol activity in human skeletal muscle myotubes treated with 0, 500 or 1000 μg/ml Enol.

Figure 3 A shows Enol activity of native and heat inactivated Enol. Figure 3B shows induction of glucose uptake by active and heat inactivated Enol.

Figures 4A and 4B show (A) a time course and (B) the area under the curve (AUC) of glucose clearance in a glucose tolerance test in a mouse model of diet induced obesity (DIO) after treatment with or without Enol protein.

Figure 5 shows Coomassie Staining of a polyacrylamide gel containing various concentrations of Enol analyzed by SDS-PAGE. LI: Precision Plus Protein Standard Dual Color, L2: Enol (10.0 μg), L3: Enol (1.0 μg), L4: Enol (0.1 μg).

Figure 6 shows silver staining of a polyacrylamide gel containing various

concentrations of Enol analyzed by SDS-PAGE. LI: Precision Plus Protein Standard Dual Color, L2: Enol (10.0 μg), L3: Enol (1.0 μg), L4: Enol (0.1 μg). Figure 7 shows Western Blot analysis of Enol. LI: Precision Plus Protein Standard Dual Color, L2: Enol (10.0 μg), L3: Enol (1.0 μg), L4: Enol (0.1 μg).

Figure 8 shows Zeta ^-Potential measurement of Enol/G5-dendrimer/SMTP complexes made with a 2: 1 ratio of Enol to dendrimer SMTP. Figure 9 shows normalized activities of Enol alone (Enolase Alone) and Enol/G5- dendrimer/SMTP (Enolase/G5-SMC) solutions after storage at various temperatures.

Figures 10A and 10B are representative fluorescent images of the tissue distribution in mice of (A) a fluorescently-labeled Enol-G5-PAMAM dendrimer complex and (B) a fluorescently-labeled, muscle targeted Eno-l-G5-PAMAM dendrimer complex. Figure 11 is a graph of the body weights of lean mice or DIO mice treated with one of vehicle, G5-PAMAM dendrimer, G5-PAMAM dendrimer + SMTP, G5-PAMAM dendrimer + Enol, G5-PAMAM dendrimer + Enol + SMTP.

Figure 12 is a graph showing blood glucose levels in mice with diet induced obesity after injection of saline or G5-PAMAM dendrimer + Enol + SMTP (50ug/kg) at 1, 4, and 24 hours after injection.

Figure 13A shows the results of a glucose tolerance test in lean mice and a diet- induced obesity (DIO) mouse model of diabetes after 1 week of treatment with G5-PAMAM dendrimer +SMTP (DIO NP+SMTP) or G5-PAMAM dendrimer + Enol + SMTP (DIO Enolase- 1+NP+SMTP). Figure 13B shows the area under the curve (AUC) for each treatment group in Figure 13 A. Figures 13C and 13D show (C) a time course and (D) the area under the curve (AUC) of glucose clearance in a glucose tolerance test in lean mice or in DIO mice after two weeks treatment with one of vehicle, G5-PAMAM dendrimer (G5), G5- PAMAM dendrimer + SMTP, G5-PAMAM dendrimer + Enol, G5-PAMAM dendrimer + Enol + SMTP. Figures 14A and 14B show (A) a time course and (B) the area under the curve (AUC) of glucose clearance in a glucose tolerance test in lean mice or in DIO mice after four weeks treatment with one of vehicle, G5-PAMAM dendrimer, G5-PAMAM dendrimer + SMTP, G5-PAMAM dendrimer + Enol, G5-PAMAM dendrimer + Enol + SMTP. Figure 15 shows serum lactate levels in lean mice, diet induced obesity (DIO) mice, DIO mice treated with G5-dendrimer (DIO + NP), and DIO mice treated with Enol/G5- dendrimer/SMTP complex (DIO + Eno-1 + NP + SMTP) after 8 weeks of treatment.

Figures 16A and 16B show (A) a time course and (B) the area under the curve (AUC) of glucose clearance in an intraperitoneal glucose tolerance test in db/db mice (BKS.Cg- m +/+ Leprdb/J) after one week treatment with one of vehicle, G5-PAMAM dendrimer (G5) + SMTP, and G5-PAMAM dendrimer + Enol + SMTP at 25 ug/kg or 50 ug/kg.

Figures 17A and 17B show a time course of glucose levels in db/db mice (BKS.Cg- m +/+ Leprdb/J after two weeks of treatment with one of vehicle, G5-PAMAM dendrimer (G5) + SMTP, and G5-PAMAM dendrimer + Enol + SMTP at 25ug/kg or 50 ug/kg obtained in a time course initiated immediately after injection with the vehicle, G5-PAMAM dendrimer + SMTP, and G5-PAMAM dendrimer + Enol + SMTP at the indicated doses. Figure 17A shows the results from all four dosing regimens. Figure 17B shows results from the G5-PAMAM dendrimer + SMTP (G5+SMTP) and G5-PAMAM dendrimer + Enol + SMTP (Enol+G5+SMTP) 50 ug/kg to show the significant difference in glucose levels at the 30 minute time point.

Figure 18 shows the effect of once daily subcutaneous injection of 25 μg/kg body weight or 50 μg/kg body weight of Enol/G5-dendrimer/SMTP complex on fed blood glucose levels in a db/db diabetic mouse model after two weeks of treatment. Fed glucose was measured 24 hours after Enol injection without fasting. "NP" is the G5-dendrimer.

Figure 19 shows the effect of twice daily (morning and evening) subcutaneous injection of 100 μg/kg body weight or 200 μg/kg body weight of Enol/G5-dendrimer/SMTP complex on fed blood glucose levels in a db/db diabetic mouse model.

Figure 20 shows creatine kinase and caspase 3 activity detected after treatment with G5-PAMAM dendrimer (G5), G5-PAMAM dendrimer + SMTP (G5-SMC), and acylated G5- PAMAM dendrimer + SMTP (G5-SMC-Ac).

Figure 21 shows p-Akt protein levels in human skeletal muscle myo tubes with or without Enol and insulin treatment. Figure 22A shows Glutl, Glut4, HK2 and Myogenin mRNA levels in human skeletal muscle myotubes with or without treatment with purified Enol. Figure 22B shows Glutl protein levels in human skeletal muscle myotubes with or without treatment with purified Enol. Glut 1 protein levels are relative units normalized by the ribosomal proteins median.

Figure 23 shows glucose-6-phosphate (G6P) levels in glucose starved (top panel) and glucose stimulated (bottom panel) human skeletal muscle myotubes with or without treatment with purified Enol.

Figure 24 shows phosphoenol pyruvate (PEP) levels in glucose starved (top panel) and glucose stimulated (bottom panel) human skeletal muscle myotubes with or without treatment with purified Enol.

Figure 25 shows the oxygen consumption rate (OCR) in human skeletal muscle myotube (HSMM) cultures treated sequentially with palmitate, CCCP and etomoxir with or without treatment with purified Enol.

Figure 26 shows the extracellular acidification rate (ECAR) in human skeletal muscle myotube (HSMM) cultures treated sequentially with glucose, oligomycin and 2-DG with or without treatment with purified Enol.

Figure 27A shows mitochondrial content in human skeletal muscle myotubes treated with 500 μg/ml or 1000 μg/ml Enol relative to untreated control human skeletal muscle myotubes. Mitochondrial content was determined by adding Mito tracker Green, a green fluorescent mitochondrial stain, to the cells after 48 hours of Enol treatment.

Figure 27B shows mitochondrial reactive oxygen species (Mito-ROS) production in human skeletal muscle myotubes treated with 500 ug/ml or 1000 μg/ml Enol relative to untreated control human skeletal muscle myotubes (Eno 1 0 ug/ml). Mito-ROS was determined by treating cells with Dihydrorhodamin 123, an uncharged and nonfluorescent reactive oxygen species (ROS) indicator that can passively diffuse across membranes where it is oxidized to cationic rhodamine 123 which localizes in the mitochondria and exhibits green fluorescence. After dihydrorhodamin 123 treatment, myotubes were trypsinized, washed, and subjected to flow cytometry to determine Mito-ROS levels. Figure 28 A shows 5' AMP activated protein kinase (AMPK) and phosphorylated AMPK (pAMPK) levels in skeletal muscle myotubes treated with 0, 500, or 1000 μg/ml Enol. Lamin A/C was used as the loading control.

Figure 28B shows the ratio of pAMPK (p-AMPK) to AMPK in basal and serum starved skeletal muscle myotubes treated with 0, 500, or 1000 μg/ml Enol.

Figure 29 shows a schematic of a working model describing the potential role of Nampt in the mode of action for Enol.

Figure 30 shows Nampt activity in human skeletal muscle myotubes treated with 500 ug/ml or 1000 μg/ml Enol in differentiation medium for 48 hours after 4 days of

differentiation relative to untreated control human skeletal muscle myotubes (Eno 1 0 ug/ml).

Figure 31 shows 2-DG uptake in serum starved human skeletal muscle myotubes treated with recombinant extracellular Nampt (eNampt).

Figure 32 shows glucose uptake in human skeletal muscle myotube cultures treated with 0, 500 or 1000 μg/ml Enol in differentiation medium for 48 hours after 4 days of differentiation in the presence or absence of the Nampt inhibitor FK866. FK866 was added 24 hours after initiation of Enol treatment, and the myotubes were treated with FK866 for 24 hours. 2-DG uptake was measured after 3 hours serum starvation. Nampt inhibition by FK866 abolished Enol induced glucose uptake.

Figure 33 shows a schematic of the glycolysis pathway. Figures 34A and 34B show the (A) amino acid (SEQ ID NO: 2)and (B) nucleic acid coding sequence (SEQ ID NO: 1) of human Enol, variant 1 (NCBI Accession No.

NM_001428.3).

Figures 35A and 35B show the (A) amino acid (SEQ ID NO: 4) and (B) nucleic acid coding sequence (SEQ ID NO: 3) of human Enol, variant 2 (NCBI Accession No.

NM_001201483.1). The human Enol, variant 2 protein is also referred to as MBP-1.

Figure 36A shows the nucleic acid sequence of EN02 mRNA (SEQ ID NO: 5).

Figure 36B shows the amino acid sequence of Eno2 (SEQ ID NO: 6). Figures 37A and 37B show the nucleic acid sequences of variant 1 (SEQ ID NO: 7) and variant 2 (SEQ ID NO: 8), respectively, of EN03 mRNA. Figure 37C shows isoform 1 of the Eno3 protein (SEQ ID NO: 9), which is encoded by both variant 1 and variant 2.

Figure 37D shows the nucleic acid sequence of variant 3 of EN03 mRNA (SEQ ID NO: 10). Figure 37E shows the amino acid sequence of isoform 2 of Eno3 (SEQ ID NO: 11), which is encoded by variant 3. Variant 3 of the EN03 mRNA differs in the 5' UTR and lacks two exons in the 5' coding region compared to variant 1. Isoform 2 of the Eno3 protein is shorter than isoform 1, but has the same N- and C-termini.

DETAILED DESCRIPTION AND PREFERRED EMBODIMENTS

A discovery platform technology was used to delineate distinct molecular signatures that drive the pathophysiology of diabetes. Enol was identified through this discovery platform technology as a critical node that is significantly modulated in human primary in vitro models of diabetes. Subsequent in vitro and in vivo studies discussed herein confirmed a role for Enol in insulin dependent and independent glucose uptake, glucose tolerance, insulin sensitivity, and/or diabetes, e.g., type 1 diabetes, type 2 diabetes, pre-diabetes, and gestational diabetes. More specifically, treatment of human myotubes with Enol protein was demonstrated to increase both insulin independent and dependent glucose uptake in myotubes, indicating a role for Enol in the treatment of both type 1 and type 2 diabetes and in glucose uptake in both the presence and the absence of insulin and/or insulin response. Further, administration of Enol protein, either alone or in the context of a skeletal muscle targeted dendrimer, improved glucose tolerance in a diet induced obesity model in mice, and similar results are expected in genetic models of both type 1 and type 2 diabetes. These results demonstrate that Enol is effective in normalizing glucose and insulin response, and thus indicate that Enol is useful in improving glucose tolerance and increasing insulin sensitivity/decreasing insulin resistance, thereby treating diabetes.

I. DEFINITIONS

Enolase 1, (alpha), also known as ENOIL, alpha-enolase, enolase-alpha, tau- crystallin, non-neural enolase (NNE), alpha enolase like 1, phosphopyruvate hydratase (PPH), plasminogen-binding protein, MYC promoter-binding protein 1 (MPB1), and 2- phospho-D-glycerate hydro-lyase, is one of three enolase isoenzymes found in mammals. Protein and nucleic acid sequences of human Eno 1 isoforms are provided herein in Figures 34 and 35. The instant application provides human amino acid and nucleic acid sequences for the treatment of human disease. However, it is understood that the compositions and methods of the invention can be readily adapted for treatment of non-human animals by selection of an Enol of the species to be treated. Amino acid and nucleic acid sequences of Enol for non-human species are known in the art and can be found, for example, at ncbi.nlm.nih.gov/genbank/. In some embodiments, the Enol used in the compositions and methods of the invention is a mammalian Enol. In a preferred embodiment, the Enol is human Enol.

As used herein, "administration of Enol" unless otherwise indicated is understood as administration of either Enol protein or a nucleic acid construct for expression of Enol protein. In certain embodiments the Enol protein can include an Enol protein fragment or a nucleic acid for encoding an Enol protein fragment. In certain embodiments, administration of Enol is administration of Enol protein. In certain embodiments, administration of Enol is administration of Enol polynucleotide. Protein and nucleic acid sequences of human Enol are provided herein. In certain embodiments, administration of Enol comprises

administration of the first variant or the second variant of human Enol. In certain

embodiments, administration of Enol comprises administration of the first variant and the second variant of human Enol. In certain embodiments, administration of Enol comprises administration of the first variant of human Enol. In certain embodiments, administration of Enol comprises administration of the second variant of human Enol. In certain

embodiments, administration of Enol comprises administration of only the first variant of human Enol. In certain embodiments, administration of Enol comprises administration of only the second variant of human Eno 1.

As used herein, "biologically active" refers to an Enol molecule or fragment thereof that has at least one activity of an endogenous Enol protein. For example, in some embodiments, the biologically active Enol molecule or fragment thereof catalyzes the dehydration of 2-phospho-D-glycerate (PGA) to phosphoenolpyruvate (PEP). In some embodiments, the biologically active Enol molecule or fragment thereof catalyzes the hydration of PEP to PGA. In some embodiments, the biologically active Enol molecule or fragment thereof increases glucose uptake by a cell, for example a muscle cell, preferably a skeletal muscle cell. In some embodiments, the biologically active Enol molecule or fragment thereof reduces blood glucose levels, e.g. fed blood glucose levels or blood glucose levels in a glucose tolerance test. In some embodiments, the biologically active Enol molecule or fragment thereof binds to Nampt, for example, extracellular Nampt (eNampt). As used herein, "administration to a muscle", "delivery to a muscle", or "delivery to a muscle cell" including a skeletal muscle cell, smooth muscle cell, and the like are understood as a formulation, method, or combination thereof to provide an effective dose of Enol to a muscle e.g., a muscle cell, to provide a desired systemic effect, e.g., normalization of blood glucose in a subject with abnormal blood glucose, e.g., by increasing glucose tolerance and/or insulin sensitivity, or treating diabetes. In certain embodiments, the Enol is formulated for administration directly to, and preferably retention in, muscle. In certain embodiments, the formulation used for administration directly to the muscle (i.e., intramuscular administration) preferably a sustained release formulation of the Enol to permit a relatively low frequency of administration (e.g., once per week or less, every other week or less, once a month or less, once every other month or less, once every three months or less, once every four months or less, once every five months or less, once every six months or less). In certain embodiments, the Enol is linked to a targeting moiety to increase delivery of the Enol to muscle so that the Enol need not be delivered directly to muscle (e.g., is delivered subcutaneously or intravenously). It is understood that administration to muscle does not require that the entire dose of Enol be delivered to the muscle or into muscle cells. In certain embodiments, at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35% of the Enol is delivered to muscle, preferably skeletal muscle and/or smooth muscle. In certain embodiments, the amount of non-intramuscularly administered muscle-targeted Enol delivered to a muscle cell is about 1.5 or more times greater, 2 or more times greater, 3 or more times greater, 4 or more times greater, 5 or more times greater, or 6 or more times greater than the amount of non-targeted Enol delivered to muscle. In certain embodiments, the Enol is delivered to skeletal muscle. In certain embodiments, the Enol is delivered to smooth muscle. In certain embodiments, the Enol is delivered to skeletal muscle and smooth muscle. In certain embodiments, is delivered preferentially or in greater amount to skeletal muscle as compared to smooth muscle. In certain embodiments, at least 50%, 60%, 70%,

75%, 80%, 85%, 90%, 95% or greater of the Enol delivered to muscle is delivered to skeletal muscle. In certain embodiments, the Enol is not delivered to smooth muscle. Assays to determine the relative targeting of a payload by a targeting moiety are known in the art and provided, for example, in Samoylova et al., 1999, Muscle Nerve, 22:460-466, incorporated herein by reference.

As used herein, a "muscle targeting moiety" includes, at least, a muscle targeting peptide (MTP), for example a skeletal and/or smooth muscle targeting peptide (SMTP). In certain embodiments, the targeting moiety include ligands to bind integrins ανβ5 or ανβ3 integrins. In certain embodiments, the targeting moiety includes a CD-46 ligand. In certain embodiments, the targeting moiety includes an adenovirus peton protein optionally in combination with an adenovirus 35 fiber protein. In certain embodiments, at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35% of muscle- targeted Enol is delivered to muscle, in some embodiments preferably skeletal and/or smooth muscle, by a muscle-targeting moiety. In certain embodiments, the amount of non- intramuscularly administered muscle-targeted Enol delivered to a muscle cell is about 1.5 or more times greater, 2 or more times greater, 3 or more times greater, 4 or more times greater, 5 or more times greater, or 6 or more times greater than the amount of non-targeted Enol delivered to muscle.

As used herein, a "muscle targeting peptide" or "MTP" is understood as a peptide sequence that increases the delivery of its payload (e.g., Enol) to a muscle cell, preferably a skeletal and/or smooth muscle cell. MTPs are known in the art and are provided, for example, in US Patent No. 6329501; US Patent Publication No. 20110130346; and

Samoylova et al., 1999, Muscle and Nerve 22: 460-466, each of which is incorporated herein in its entirety. In certain embodiments the MTP is a skeletal muscle targeting peptide. A "skeletal muscle targeting peptide" is a peptide sequence that increases the delivery of its payload (e.g., Enol) to a skeletal muscle cell. In certain embodiments the MTP is a smooth muscle targeting peptide. A "smooth muscle targeting peptide" is a peptide sequence that increases the delivery of its payload (e.g., Enol) to a smooth muscle cell. In certain embodiments the MTP increases the delivery of its payload (e.g., Enol) to a skeletal cell and to a smooth muscle cell. In certain embodiments the MTP, e.g., skeletal muscle targeting peptide and/or smooth muscle targeting peptide, does not increase the delivery of its payload to cardiac muscle cell. MTP, e.g., skeletal muscle, targeting peptides include, but are not limited to peptides comprising the following sequences: ASSLNIA; WDANGKT;

GETRAPL; CGHHPVYAC; and HAIYPRH. In a preferred embodiment, the MTP comprises the amino acid sequence ASSLNIA. As used herein, "payload" is understood as a moiety for delivery to a target cell by a targeting moiety. In certain embodiments, the payload is a peptide, e.g., an Enol peptide. In certain embodiments, the payload is a nucleic acid, e.g., a nucleic acid encoding an Enol peptide. In certain embodiments, the payload further comprises additional components (e.g., dendrimers, liposomes, microparticles) or agents (e.g., therapeutic agents) for delivery with the Enol payload to the target cell.

As used herein, a "linker" is understood as a moiety that juxtaposes a targeting moiety and a payload in sufficiently close proximity such that the payload is delivered to the desired site by the targeting moiety. In certain embodiments, the linker is a covalent linker, e.g., a cross-linking agent including a reversible cross-linking agent; a peptide bond, e.g., wherein the payload is a protein co-translated with the targeting moiety. In certain embodiments, the linker is covalently joined to one of the payload or the targeting moiety and non-covalently linked to the other. In certain embodiments, the linker comprises a dendrimer. In certain embodiments, the dendrimer is covalently linked to the targeting moiety and non-covalently linked to the payload, e.g., Enol . In certain embodiments, the linker is a liposome or a microparticle, and the targeting moiety is exposed on the surface of the liposome and the payload, e.g., Enol is encapsulated in the liposome or microparticle. In certain embodiments, the linker and the Enol are present on the surface of the microparticle linker. In certain embodiments, the targeting moiety is present on the surface of a virus particle and the payload comprises a nucleic acid encoding Eno 1.

As used herein, "linked", "operably linked", "joined" and the like refer to a juxtaposition wherein the components described are present in a complex permitting them to function in their intended manner. The components can be linked covalently (e.g. , peptide bond, disulfide bond, non-natural chemical linkage), through hydrogen bonding (e.g. , knob- into-holes pairing of proteins, see, e.g. , US Patent 5,582,996; Watson-Crick nucleotide pairing), or ionic binding (e.g. , chelator and metal) either directly or through linkers (e.g., peptide sequences, typically short peptide sequences; nucleic acid sequences; or chemical linkers, including the use of linkers for attachment to higher order or larger structures including microparticles, beads, or dendrimers). As used herein, components of a complex can be linked to each other by packaging in and/or on a liposome and/or dendrimer wherein some of the components of the complex can be attached covalently and some non-covalently. Linkers can be used to provide separation between active molecules so that the activity of the molecules is not substantially inhibited (less than 10%, less than 20%, less than 30%, less than 40%, less than 50%) by linking the first molecule to the second molecule. Linkers can be used, for example, in joining Enol to a targeting moiety. As used herein, molecules that are linked, but no covalently joined, have a binding affinity (Kd) of less than 10^"3, 10^"4, 10^"5, 10^"6, 10^"7, 10^"8, 10^"9, 10^"10, 10^~u, or 10^"12, or any range bracketed by those values, for each other under conditions in which the reagents of the invention are used, i.e., typically physiological conditions.

In certain embodiments, the payload and the targeting moiety are present in a complex at about a 1: 1 molar ratio. In certain embodiments, the targeting moiety is present in a complex with a molar excess of the payload. In certain embodiments, the ratio of payload to targeting moiety is about 0.1: 1, about 0.2: 1, about 0.3: 1, about 0.4: 1, about 0.5: 1, about 0.6: 1, about 0.7: 1, about 0.8: 1, about 0.9: 1, about 1: 1, about 2: 1, about 3: 1, about 4: 1, about 5: 1, about 6: 1, about 7: 1, about 8: 1, about 9: 1, about 10: 1, about 11: 1, about 12: 1, about 13: 1, about 14: 1, about 15: 1, about 16: 1, about 17: 1, about 18: 1, about 19: 1, or about 20: 1. A "dendrimer" is a polymeric molecule composed of multiple branched monomers that eminate radially from a central core. Due to the structure and synthetic methods used to generate dendrimers, the products from dendrimer synthesis are theoretically monodisperse. When the core of a dendrimer is removed, a number of identical fragments called dendrons remain with the number of dendrons dependent on the multiplicity of the central core. The number of branch points encountered upon moving outward from the core to the periphery defines its generation, e.g., G-l, G-2, G-3, etc., with dendrimers of higher generations being larger, more branched, and having more end groups than dendrimers of lower generations. As used herein, a dendrimer is preferably a pharmaceutically acceptable dendrimer.

As used herein, a "subject with elevated blood glucose" or "increased blood glucose" is understood as a subject who has elevated blood glucose for a sufficient duration and frequency to be considered a pathological condition, i.e., a subject that does not produce enough insulin or is not sufficiently sensitive to insulin so that the glucose level of the subject remains elevated for an extended period after eating a meal, e.g. for more than two hours after eating a meal and/or who has an elevated fasting blood glucose. In certain

embodiments, a subject with elevated blood glucose is understood as a subject with one or both of fasting blood glucose of at least 100 mg/dl and 2-hour plasma glucose in a 75-g oral glucose tolerance test of at least 140 mg/dl. In certain embodiments, a subject with elevated blood glucose is understood as a subject with one or more of fasting blood glucose of at least 126 mg/dl; a 2-hour plasma glucose in a 75-g oral glucose tolerance test of at least 200 mg/dl; or a random plasma glucose of at least 200 mg/dl. In certain embodiments, a subject with elevated blood glucose is understood as a pregnant subject with one or more of fasting blood glucose of at least 92 mg/dl; a 1-hour plasma glucose in a 75-g oral glucose tolerance test of at least 180 mg/dl; and a 2-hour plasma glucose in a 75-g oral glucose tolerance test of at least 153 mg/dl. In certain embodiments as used herein, a subject with elevated blood glucose does not include subjects with type 1 diabetes or pancreatic disease that results in an absolute insulin deficiency. In certain embodiments as used herein, a subject with elevated blood glucose includes subjects with type 1 diabetes or pancreatic disease that results in an absolute insulin deficiency.

As used herein, a "subject with elevated HbAlc" or a "subject with elevated Ale" is understood as a subject with an HbAlc level of at least 5.7%. In certain embodiments, the subject has an HbAlc level of at least 6.5%. As used herein, "diabetes" is intended to refer to either type 1 diabetes or type 2 diabetes, or both type 1 and type 2 diabetes, optionally in combination with gestational diabetes. In certain embodiments, diabetes includes type 2 diabetes. In certain embodiments, diabetes does not include type 1 diabetes. In certain embodiments, diabetes includes gestational diabetes. In certain embodiments, diabetes does not include gestational diabetes. In certain embodiments, diabetes includes pre-diabetes. In certain embodiments, diabetes does not include pre-diabetes. In certain embodiments, diabetes includes pre-diabetes, type 1 diabetes, and type 2 diabetes. In certain embodiments, diabetes includes pre-diabetes and type 2 diabetes.

As used herein, "insulin resistance" and "insulin insensitivity" can be used

interchangeably and refers to conditions, especially pathological conditions, wherein the amount of insulin is less effective at lowering blood sugar than in a normal subject resulting in an increase in blood sugar above the normal range that is not due to the absence of insulin. Without being bound by mechanism, the conditions are typically associated with a decrease in signaling through the insulin receptor. Typically, insulin resistance in muscle and fat cells reduces glucose uptake and storage as glycogen and triglycerides, respectively. Insulin resistance in liver cells results in reduced glycogen synthesis and a failure to suppress glucose production and release into the blood. Insulin resistance is often present in the same subject together with "insulin insufficiency", which also results in an increase in blood sugar, especially a pathological increase in blood sugar, above the normal range that is not due to the absence of insulin. Insulin insufficiency is a condition related to a lack of insulin action in which insulin is present and produced by the body. It is distinct from type 1 diabetes in which insulin is not produced due to the lack of islet cells.

For the purposes of the methods of the instant invention, it is not necessary to distinguish if a subject suffers from insulin resistance/insensitivity, insulin insufficiency, or both. The term "impaired glucose tolerance" (IGT) or "pre-diabetes" is used to describe a person who, when given a glucose tolerance test, has a blood glucose level that falls between normal and hyperglycemic, i.e., has abnormal glucose tolerance, e.g., pathologically abnormal glucose tolerance. Such a person is at a higher risk of developing diabetes although they are not clinically characterized as having diabetes. For example, impaired glucose tolerance refers to a condition in which a patient has a fasting blood glucose concentration or fasting serum glucose concentration greater than 110 mg/dl and less than 126 mg/dl (7.00 mmol/L), or a 2 hour postprandial blood glucose or serum glucose concentration greater than 140 mg/dl (7.78 mmol/L) and less than 200 mg/dl (11.11 mmol/L). Prediabetes, also referred to as impaired glucose tolerance or impaired fasting glucose is a major risk factor for the development of type 2 diabetes mellitus, cardiovascular disease and mortality. Much focus has been given to developing therapeutic interventions that prevent the development of type 2 diabetes by effectively treating prediabetes (Pharmacotherapy, 24:362-71, 2004).

As used herein, a "pathological" condition reaches a clinically acceptable threshold of disease or condition. A pathological condition can result in significant adverse effects to the subject, particularly in the long term, if the condition is not resolved, e.g., blood glucose and/or HbAlc levels are not normalized. Pathological conditions can be reversed by therapeutic agents, surgery, and/or lifestyle changes. A pathological condition may or may not be chronic. A pathological condition may or may not be reversible. A pathological condition may or may not be terminal. "Hyperinsulinemia" is defined as the condition in which a subject with insulin resistance, with or without euglycemia, in which the fasting or postprandial serum or plasma insulin concentration is elevated above that of normal, lean individuals without insulin resistance (i.e., >100 mg/dl in a fasting plasma glucose test or > 140 mg/dl in an oral glucose tolerance test).

The condition of "hyperglycemia" (high blood sugar) is a condition in which the blood glucose level is too high. Typically, hyperglycemia occurs when the blood glucose level rises above 180 mg/dl. Symptoms of hyperglycemia include frequent urination, excessive thirst and, over a longer time span, weight loss.

The condition of "hypoglycemia" (low blood sugar) is a condition in which the blood glucose level is too low. Typically, hypoglycemia occurs when the blood glucose level falls below 70 mg/dl. Symptoms of hypoglycemia include moodiness, numbness of the extremities (especially in the hands and arms), confusion, shakiness or dizziness. Since this condition arises when there is an excess of insulin over the amount of available glucose it is sometimes referred to as an insulin reaction.

As used herein, an "HbAlc level" or "Ale level" is understood as a hemoglobin Ale (HbAlc) level determined from an HbAlc test, which assesses the average blood glucose levels during the previous two and three months. A person without diabetes typically has an HbAlc value that ranges between 4% and 6%. Prediabetes is characterized by a pathological HbAlc level of 5.7% to 6.5%, with an HblAc level greater than 6.5% being indicative of diabetes. Every 1 % increase in HbAlc reflects a blood glucose levels increases by approximately 30 mg/dL and increased risk of complications due to persistent elevated blood glucose. Preferably, the HbAlc value of a patient being treated according to the present invention is reduced to less than 9%, less than 7%, less than 6%, and most preferably to around 5%. Thus, the excess HbAlc level of the patient being treated (i.e., the HblAc level in excess of 5.7%) is preferably lowered by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or more relative to such levels prior to treatment (i.e., pre-treatment level - post- treatment level/pre-treatment level).

As used herein, the term "subject" refers to human and non-human animals, including veterinary subjects. The term "non-human animal" includes all vertebrates, e.g., mammals and non-mammals, such as non-human primates, mice, rabbits, sheep, dog, cat, horse, cow, chickens, amphibians, and reptiles. In a preferred embodiment, the subject is a human and may be referred to as a patient. As used herein, the terms "treat," "treating" or "treatment" refer, preferably, to an action to obtain a beneficial or desired clinical result including, but not limited to, alleviation or amelioration of one or more signs or symptoms of a disease or condition, diminishing the extent of disease, stability (i.e., not worsening) state of disease, amelioration or palliation of the disease state. As used herein, treatment can include one or more of reduction of insulin resistance, increasing insulin sensitivity, decreasing insulin deficiency, improving or normalizing HbAcl levels, improving or normalizing blood glucose levels (e.g., fed blood glucose levels, fasting blood glucose levels, glucose tolerance), and ameliorating at least one sign or symptom of diabetes. Therapeutic goals in the treatment of diabetes, including type 2 diabetes, include HbAcl levels < 6.5%; blood glucose 80-120 mg/dl before meals; and blood glucose < 140 mg/dl 2 hours after meals. Therapeutic goals in the treatment of pre-diabetes include reduction of HbAlc, blood glucose levels, and glucose response to normal levels. Treatment does not need to be curative or reach the ideal therapeutic goals of treatment. Treatment outcomes need not be determined quantitatively. However, in certain

embodiments, treatment outcomes can be quantitated by considering percent improvement towards a normal value at the end of a range. For example, metabolic syndrome is characterized by an excess of some measures (e.g., blood glucose levels, HbAlc levels) and a deficiency in other measures (e.g., insulin response). A subject with a fasting blood glucose level of 150 mg/dl would have excess fasting blood glucose of 50 mg/dl (150 mg/dl- lOOmg/dl, the maximum normal blood glucose level). Reduction of excess blood glucose by 20% would be an 10 mg/dl reduction in excess blood glucose. Similar calculations can be made for other values.

As used herein, "reducing glucose levels" means reducing excess of glucose by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, or more to achieve a normalized glucose level, i.e., a glucose level no greater than 150 mg/dl. Desirably, glucose levels prior to meals are reduced to normoglycemic levels, i.e., between 150 to 60 mg/dL, between 140 to 70 mg/dL, between 130 to 70 mg/dL, between 125 to 80 mg/dL, and preferably between 120 to 80 mg/dL. Such reduction in glucose levels may be obtained by increasing any one of the biological activities associated with the clearance of glucose from the blood. Accordingly, an agent having the ability to reduce glucose levels may increase insulin production, secretion, or action. Insulin action may be increased, for example, by increasing glucose uptake by peripheral tissues and/or by reducing hepatic glucose production. Alternatively, the agent may reduce the absorption of carbohydrates from the intestines, alter glucose transporter activity (e.g., by increasing GLUT4 expression, intrinsic activity, or translocation), increase the amount of insulin-sensitive tissue (e.g., by increasing muscle cell or adipocyte cell differentiation), or alter gene transcription in adipocytes or muscle cells (e.g., altered secretion of factors from adipocytes expression of metabolic pathway genes). Desirably, the agent increases more than one of the activities associated with the clearance of glucose.

By "alter insulin signaling pathway such that glucose levels are reduced" is meant to alter (by increasing or reducing) any one of the activities involved in insulin signaling such that the overall result is an increase in the clearance of glucose from plasma and normalizes blood glucose. For example, altering the insulin signaling pathway thereby causing an increase in insulin production, secretion, or action, an increasing glucose uptake by peripheral tissues, a reducing hepatic glucose production, or a reducing the absorption of carbohydrates from the intestines.

A "therapeutically effective amount" is that amount sufficient to treat a disease in a subject. A therapeutically effective amount can be administered in one or more

administrations.

A number of treatments for type 2 diabetes are known in the art including both drug and behavioral interventions. Drugs for treatment of type 2 diabetes include, but are not limited to meglitinides (repaglinide (Prandin) and nateglinide (Starlix); sulfonylureas

(glipizide (Glucotrol), glimepiride (Amaryl), and glyburide (DiaBeta, Glynase)); Dipeptidy peptidase-4 (DPP-4) inhibitors (saxagliptin (Onglyza), sitagliptin (Januvia), and linagliptin (Tradjenta)); biguanides (metformin (Fortamet, Glucophage)); thiazolidinediones

(rosiglitazone (Avandia) and pioglitazone (Actos)); and alpha-glucosidase inhibitors

(acarbose (Precose) and miglitol (Glyset)). Insulins are typically used only in treatment of later stage type 2 diabetes and include rapid-acting insulin (insulin aspart (NovoLog), insulin glulisine (Apidra), and insulin lispro (Humalog)); short-acting insulin (insulin regular (Humulin R, Novolin R)); intermediate- acting insulin (insulin NPH human (Humulin N, Novolin N)), and long-acting insulin (insulin glargine (Lantus) and insulin detemir

(Levemir)). Treatments for diabetes can also include behavior modification including exercise and weight loss which can be facilitated by the use of drugs or surgery. Treatments for elevated blood glucose and diabetes can be combined. For example, drug therapy can be combined with behavior modification therapy. By "diagnosing" and the like, as used herein, refers to a clinical or other assessment of the condition of a subject based on observation, testing, or circumstances for identifying a subject having a disease, disorder, or condition based on the presence of at least one indicator, such as a sign or symptom of the disease, disorder, or condition. Typically, diagnosing using the method of the invention includes the observation of the subject for multiple indicators of the disease, disorder, or condition in conjunction with the methods provided herein. Diagnostic methods provide an indicator that a disease is or is not present. A single diagnostic test typically does not provide a definitive conclusion regarding the disease state of the subject being tested. As used herein, "monitoring" is understood as assessing at least one sign or symptom of a disease in a subject at a first time point and at a later second time point, comparing the severity of the sign(s) or symptom(s) of the condition, and determining of the condition became more or less severe over time.

The terms "administer", "administering" or "administration" include any method of delivery of a pharmaceutical composition or agent into a subject's system or to a particular region in or on a subject. In certain embodiments, the agent is administered enterally or parenterally. In certain embodiments of the invention, an agent is administered

intravenously, intramuscularly, subcutaneously, intradermally, intranasally, orally, transcutaneously, or mucosally. In certain preferred embodiments, an agent is administered by injection or infusion, e.g., intravenously, intramuscularly, subcutaneously. In certain embodiments, administration includes the use of a pump. In certain embodiments, the agent is administered locally or systemically. Administering an agent can be performed by a number of people working in concert. Administering an agent includes, for example, prescribing an agent to be administered to a subject and/or providing instructions, directly or through another, to take a specific agent, either by self-delivery, e.g., as by oral delivery, subcutaneous delivery, intravenous delivery through a central line, etc.; or for delivery by a trained professional, e.g., intravenous delivery, intramuscular delivery, etc.

As used herein, the term "co-administering" refers to administration of Enol prior to, concurrently or substantially concurrently with, subsequently to, or intermittently with the administration of an agent for the treatment of diabetes, pre-diabetes, glucose intolerance, or insulin resistance. The Enol formulations provided herein, can be used in combination therapy with at least one other therapeutic agent for the treatment of diabetes, pre-diabetes, glucose intolerance, or insulin resistance. Enol and/or pharmaceutical formulations thereof and the other therapeutic agent can act additively or, more preferably, synergistically. In one embodiment, Enol and/or a formulation thereof is administered concurrently with the administration of another therapeutic agent for the treatment of diabetes, pre-diabetes, glucose intolerance, or insulin resistance. In another embodiment, Enol and/or a

pharmaceutical formulation thereof is administered prior or subsequent to administration of another therapeutic agent for the treatment of diabetes, pre-diabetes, glucose intolerance, or insulin resistance.

The term "sample" as used herein refers to a collection of similar fluids, cells, or tissues isolated from a subject. The term "sample" includes any body fluid (e.g., urine, serum, blood fluids, lymph, gynecological fluids, cystic fluid, ascetic fluid, ocular fluids, and fluids collected by bronchial lavage and/or peritoneal rinsing), ascites, tissue samples or a cell from a subject. Other subject samples include tear drops, serum, cerebrospinal fluid, feces, sputum, and cell extracts. In a particular embodiment, the sample is urine or serum. In certain embodiments, the sample comprises cells. In other embodiments, the sample does not comprise cells.

The term "control sample," as used herein, refers to any clinically relevant comparative sample, including, for example, a sample from a healthy subject not afflicted with any of impaired glucose tolerance, increased blood glucose, insulin resistance, diabetes, or prediabetes; or a sample from a subject from an earlier time point in the subject, e.g., prior to treatment, at an earlier stage of treatment. A control sample can be a purified sample, protein, and/or nucleic acid provided with a kit. Such control samples can be diluted, for example, in a dilution series to allow for quantitative measurement of analytes in test samples. A control sample may include a sample derived from one or more subjects. A control sample may also be a sample made at an earlier time point from the subject to be assessed. For example, the control sample can be a sample taken from the subject to be assessed before the onset abnormal blood glucose levels or Ale levels, at an earlier stage of disease, or before the administration of treatment or of a portion of treatment. The control sample may also be a sample from an animal model, or from a tissue or cell lines derived from the animal model of impaired glucose tolerance, increased blood glucose, insulin resistance, diabetes, or prediabetes. The level of Enol activity or expression in a control sample that consists of a group of measurements may be determined, e.g., based on any appropriate statistical measure, such as, for example, measures of central tendency including average, median, or modal values.

The term "control level" refers to an accepted or pre-determined level of a sign of a impaired glucose tolerance, increased blood glucose, insulin resistance, diabetes, or pre- diabetes in a subject or a subject sample. The following levels are considered to be normal levels:

— Fasting blood glucose less than or equal to 100 mg/dl.

— HbAlc less than or equal to 5.7%.

— Oral glucose tolerance test less than or equal to 140 mg/dl. Levels above these levels are understood to be pathological levels.

As used herein, a "predetermined threshold value" of a biomarker refers to the level of the biomarker (e.g., the expression level or quantity (e.g., ng/ml) in a biological sample) or other indicator of elevated blood glucose in a corresponding control/normal sample or group of control/normal samples obtained from normal or healthy subjects, e.g., subjects that do not have abnormal blood glucose. The predetermined threshold value may be determined prior to or concurrently with measurement of marker levels in a biological sample. The control sample may be from the same subject at a previous time or from different subjects.

As used herein, a sample obtained at an "earlier time point" is a sample that was obtained at a sufficient time in the past such that clinically relevant information could be obtained in the sample from the earlier time point as compared to the later time point. In certain embodiments, an earlier time point is at least four weeks earlier. In certain

embodiments, an earlier time point is at least six weeks earlier. In certain embodiments, an earlier time point is at least two months earlier. In certain embodiments, an earlier time point is at least three months earlier. In certain embodiments, an earlier time point is at least six months earlier. In certain embodiments, an earlier time point is at least nine months earlier. In certain embodiments, an earlier time point is at least one year earlier. Multiple subject samples (e.g., 3, 4, 5, 6, 7, or more) can be obtained at regular or irregular intervals over time and analyzed for trends in changes in marker levels. Appropriate intervals for testing for a particular subject can be determined by one of skill in the art based on ordinary

considerations. As used herein, the term "obtaining" is understood to refer to manufacturing, purchasing, or otherwise coming into possession of.

As used herein, "detecting", "detection" and the like are understood to refer to an assay performed for identification of a specific analyte in a sample, e.g., Enol expression or activity level in a sample. The amount of analyte or activity detected in the sample can be none or below the level of detection of the assay or method. Detecting or detection can also include measuring of glucose and/of Hb Ac 1 levels.

The terms "modulate" or "modulation" refer to upregulation (i.e., activation or stimulation), downregulation (i.e., inhibition or suppression) of a level, or the two in combination or apart. A "modulator" is a compound or molecule that modulates, and may be, e.g., an agonist, antagonist, activator, stimulator, suppressor, or inhibitor.

The term "expression" is used herein to mean the process by which a polypeptide is produced from DNA. The process involves the transcription of the gene into mRNA and the translation of this mRNA into a polypeptide. Depending on the context in which used, "expression" may refer to the production of RNA, or protein, or both.

The terms "level of expression of a gene" or "gene expression level" refer to the level of mRNA, as well as pre-mRNA nascent transcript(s), transcript processing intermediates, mature mRNA(s) and degradation products, or the level of protein, encoded by the gene in the cell. As used herein, the term "amplification" refers to any known in vitro procedure for obtaining multiple copies ("amplicons") of a target nucleic acid sequence or its complement or fragments thereof. In vitro amplification refers to production of an amplified nucleic acid that may contain less than the complete target region sequence or its complement. Known in vitro amplification methods include, e.g., transcription-mediated amplification, replicase- mediated amplification, polymerase chain reaction (PCR) amplification, ligase chain reaction (LCR) amplification and strand-displacement amplification (SDA including multiple strand- displacement amplification method (MSDA)). Replicase-mediated amplification uses self- replicating RNA molecules, and a replicase such as Q-P-replicase (e.g., Kramer et al., U.S. Pat. No. 4,786,600). PCR amplification is well known and uses DNA polymerase, primers and thermal cycling to synthesize multiple copies of the two complementary strands of DNA or cDNA (e.g., Mullis et al., U.S. Pat. Nos. 4,683, 195, 4,683,202, and 4,800,159). LCR amplification uses at least four separate oligonucleotides to amplify a target and its complementary strand by using multiple cycles of hybridization, ligation, and denaturation (e.g., EP Pat. App. Pub. No. 0 320 308). SDA is a method in which a primer contains a recognition site for a restriction endonuclease that permits the endonuclease to nick one strand of a hemimodified DNA duplex that includes the target sequence, followed by amplification in a series of primer extension and strand displacement steps (e.g., Walker et al., U.S. Pat. No. 5,422,252). Two other known strand-displacement amplification methods do not require endonuclease nicking (Dattagupta et al., U.S. Pat. No. 6,087,133 and U.S. Pat. No. 6,124,120 (MSDA)). Those skilled in the art will understand that the oligonucleotide primer sequences of the present invention may be readily used in any in vitro amplification method based on primer extension by a polymerase, (see generally Kwoh et al., 1990, Am. Biotechnol. Lab. 8: 14-25 and (Kwoh et al., 1989, Proc. Natl. Acad. Sci. USA 86, 1173-1177; Lizardi et al., 1988, BioTechnology 6: 1197-1202; Malek et al., 1994, Methods Mol. Biol., 28:253-260; and Sambrook et al., 2000, Molecular Cloning— A Laboratory Manual, Third Edition, CSH Laboratories). As commonly known in the art, the oligos are designed to bind to a complementary sequence under selected conditions.

As used herein, the term "antigen" refers to a molecule, e.g., a peptide, polypeptide, protein, fragment, or other biological moiety, which elicits an antibody response in a subject, or is recognized and bound by an antibody.

As used herein, the term "complementary" refers to the broad concept of sequence complementarity between regions of two nucleic acid strands or between two regions of the same nucleic acid strand. It is known that an adenine residue of a first nucleic acid region is capable of forming specific hydrogen bonds ("base pairing") with a residue of a second nucleic acid region which is antiparallel to the first region if the residue is thymine or uracil. Similarly, it is known that a cytosine residue of a first nucleic acid strand is capable of base pairing with a residue of a second nucleic acid strand which is antiparallel to the first strand if the residue is guanine. A first region of a nucleic acid is complementary to a second region of the same or a different nucleic acid if, when the two regions are arranged in an antiparallel fashion, at least one nucleotide residue of the first region is capable of base pairing with a residue of the second region. Preferably, the first region comprises a first portion and the second region comprises a second portion, whereby, when the first and second portions are arranged in an antiparallel fashion, at least about 50%, and preferably at least about 75%, at least about 90%, or at least about 95% of the nucleotide residues of the first portion are capable of base pairing with nucleotide residues in the second portion. More preferably, all nucleotide residues of the first portion are capable of base pairing with nucleotide residues in the second portion.

As use herein, the phrase "specific binding" or "specifically binding" when used in reference to the interaction of an antibody and a protein or peptide means that the interaction is dependent upon the presence of a particular structure (i.e., the antigenic determinant or epitope) on the protein; in other words the antibody is recognizing and binding to a specific protein structure rather than to proteins in general. For example, if an antibody is specific for epitope "A," the presence of a protein containing epitope A (or free, unlabeled A) in a reaction containing labeled "A" and the antibody will reduce the amount of labeled A bound to the antibody.

The phrase "specific identification" is understood as detection of a marker of interest with sufficiently low background of the assay and cross-reactivity of the reagents used such that the detection method is diagnostically useful. In certain embodiments, reagents for specific identification of a marker bind to only one isoform of the marker. In certain embodiments, reagents for specific identification of a marker bind to more than one isoform of the marker. In certain embodiments, reagents for specific identification of a marker bind to all known isoforms of the marker.

As used herein, the phrase "subject suspected of having elevated blood glucose" refers to a subject that presents one or more signs or symptoms indicative of or correlated with elevated blood glucose or is being screened for a elevated blood glucose (e.g., during a routine physical). A subject suspected of having elevated blood glucose may also have one or more risk factors. A subject suspected of having elevated blood glucose has generally not been tested for abnormal glucose levels, metabolism, or response. However, a "subject suspected of having elevated blood glucose" encompasses an individual who has received an initial diagnosis (e.g., a single incidence of elevated, but not confirmed, blood glucose) but for whom the degree of elevated glucose is not known. The term further includes people who once had elevated blood glucose (e.g., an individual treated for elevated blood glucose who maintained a normal blood glucose and/or HbAlc levels for an extended period, e.g., at least 3 months, at least 6 months, etc.). The articles "a", "an" and "the" are used herein to refer to one or to more than one (i.e. to at least one) of the grammatical object of the article unless otherwise clearly indicated by contrast. By way of example, "an element" means one element or more than one element.

The term "including" is used herein to mean, and is used interchangeably with, the phrase "including but not limited to".

The term "or" is used herein to mean, and is used interchangeably with, the term "and/or," unless context clearly indicates otherwise.

The term "such as" is used herein to mean, and is used interchangeably, with the phrase "such as but not limited to".

Unless specifically stated or obvious from context, as used herein, the term "about" is understood as within a range of normal tolerance in the art, for example within 2 standard deviations of the mean. About can be understood as within 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.1 %, 0.05%, or 0.01% of the stated value. Unless otherwise clear from context, all numerical values provided herein can be modified by the term about.

The recitation of a listing of chemical group(s) in any definition of a variable herein includes definitions of that variable as any single group or combination of listed groups. The recitation of an embodiment for a variable or aspect herein includes that embodiment as any single embodiment or in combination with any other embodiments or portions thereof.

Any compositions or methods provided herein can be combined with one or more of any of the other compositions and methods provided herein.

Ranges provided herein are understood to be shorthand for all of the values within the range. For example, a range of 1 to 50 is understood to include any number, combination of numbers, or sub-range from the group consisting 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, or 50.

Reference will now be made in detail to preferred embodiments of the invention. While the invention will be described in conjunction with the preferred embodiments, it will be understood that it is not intended to limit the invention to those preferred embodiments. To the contrary, it is intended to cover alternatives, modifications, and equivalents as may be included within the spirit and scope of the invention as defined by the appended claims. IIA. ENOLASE 1

Enolase 1, (alpha), also known as ENOIL, alpha-enolase, enolase-alpha, tau- crystallin, non-neural enolase (NNE), alpha enolase like 1, phosphopyruvate hydratase (PPH), plasminogen-binding protein, MYC promoter-binding protein 1 (MPB1), and 2- phospho-D-glycerate hydro-lyase, is one of three enolase isoenzymes found in mammals. Each isoenzyme is a homodimer composed of 2 alpha, 2 gamma, or 2 beta subunits, and functions as a glycolytic enzyme. Alpha-enolase in addition, functions as a structural lens protein (tau-crystallin) in the monomeric form. Alternative splicing of this gene results in a shorter isoform that has been shown to bind to the c-myc promoter and function as a tumor suppressor. Several pseudogenes have been identified, including one on the long arm of chromosome 1. Alpha-enolase has also been identified as an autoantigen in Hashimoto encephalopathy. Further information regarding human Enol can be found, for example, in the NCBI gene database under Gene ID No. 2023 (see, www.ncbi.nlm.nih.gov/gene/2023, incorporated herein by reference in the version available on the date of filing this

application).

Enol variants

Two isoforms of human Enol are known. Protein and mRNA sequences of Homo sapiens enolase 1, (alpha) (ENOl), transcript variant 1, mRNA can be found at GenBank Accession No. NM_001428 (see www.ncbi.nlm.nih.gov/nuccore/NM_001428.3, which is incorporated by reference in the version available on the date of filing the instant

application). This variant encodes the longer isoform, which is localized to the cytosol, and has alpha-enolase activity. It has been reported that the monomeric form of this isoform functions as a structural lens protein (tau-crystallin), and the dimeric form as an enolase. In a preferred embodiment of the invention, Enol is the transcript variant 1 of Enol.

Protein and mRNA sequences of the Homo sapiens enolase 1, (alpha) (ENOl), transcript variant 2, mRNA can be found at GenBank Accession No. NM_001201483 (see www.ncbi.nlm.nih.gov/nuccore/NM_001201483.1, which is incorporated by reference in the version available on the date of filing the instant application). This variant differs at the 5' end compared to variant 1, and initiates translation from an in-frame downstream start codon, resulting in a shorter isoform (MBP-1). This isoform is localized to the nucleus, and functions as a transcriptional repressor of c-myc protooncogene by binding to its promoter. In certain embodiments of the invention, Enol is the transcript variant 2 of Enol.

Several additional variants of the Enol protein have been described, for example, in the UniProtKB/Swiss-Prot database under Accession No. P06733. Examples of Enol protein variants are shown in Table 1 below.

Table 1. Enol variants.

AA modification 343 N6-acetyllysine

AA modification 406 N6-acetyllysine

AA modification 420 N6-acetyllysine; alternate

AA modification 420 N6-malonyllysine; alternate

AA modification 420 N6-succinyllysine; alternate

Natural variant 177 N→K.

Corresponds to variant rsl 1544513 [ dbSNP 1 Ensembl ] .

Natural variant 325 P→Q.

Corresponds to variant rsl 1544514 [ dbSNP 1 Ensembl ] .

Mutagenesis 94 M→ I: MBP1 protein production. No MBP1 protein production; when associated with 1-97.

Mutagenesis 97 M→ I: MBP1 protein production. No MBP1 protein production; when associated with 1-94.

Mutagenesis 159 Dramatically decreases activity levels

Mutagenesis 168 Dramatically decreases activity levels

Mutagenesis 211 Dramatically decreases activity levels

Mutagenesis 345 Dramatically decreases activity levels

Mutagenesis 384 L→ A: Loss of transcriptional repression and cell growth inhibition; when associated with A- 388.

Mutagenesis 388 L→ A: Loss of transcriptional repression and cell growth inhibition; when associated with A- 384.

Mutagenesis 396 Dramatically decreases activity levels

In certain embodiments of the invention, Enol is one of the variants listed in Table 1. Enol activity

Enol is a key glycolytic enzyme that catalyzes the dehydratation of 2-phospho-D- glycerate (PGA) to phosphoenolpyruvate (PEP) in the last steps of the catabolic glycolytic pathway. Diaz-Ramos et al., 2012, J Biomed Biotechnol. 2012: 156795 and Figure 33. Enolase enzymes catalyse the dehydration of PGA to PEP in the Emden Mayerhoff-Parnas glycolytic pathway (catabolic direction). In the anabolic pathway (reverse reaction) during gluconeogenesis, Enol catalyses hydration of PEP to PGA. Accordingly Enol is also known as phosphopyruvate hydratase. Metal ions are cofactors impairing the increase of enolase activity; hence Enol is also called metal-activated metalloenzyme. Magnesium is a natural cofactor causing the highest activity and is required for the enzyme to be catalytically active. The relative activation strength profile of additional metal ions involved in the enzyme activity appears in the following order Mg²⁺ > Zn²⁺ > Mn²⁺ > Fe(II)²⁺ > Cd²⁺ > Co²⁺, Ni²⁺, Sm³⁺, Tb³⁺ and most other divalent metal ions. In reactions catalyzed by enolases, the alpha- proton from a carbon adjacent to a carboxylate group of PGA, is abstracted, and PGA is conversed to enolate anion intermediate. This intermediate is further processed in a variety of chemical reactions, including racemization, cycloisomerization and beta-elimination of either water or ammonia. See Atlas of Genetics and Cytogenetics in Oncology and

Haematology database, atlasgeneticsoncology.org/Genes/GC_EN01.html.

Enzymatically active enolase exists in a dimeric (homo- or heterodimers) form and is composed of two subunits facing each other in an antiparallel fashion. The crystal structure of enolase from yeast and human has been determined and catalytic mechanisms have been proposed. Diaz-Ramos et al., cited above. The five residues that participate in catalytic activity of this enzyme are highly conserved throughout evolution. Studies in vitro revealed that mutant enolase enzymes that differ at positions Glul68, Glu211, Lys345, Lys396 or Hisl59, demonstrate dramatically decreased activity levels. An integral and conserved part of enolases are two Mg2+ ions that participate in conformational changes of the active site of enolase and enable binding of a substrate or its analogues. Atlas of Genetics and

Cytogenetics in Oncology database, cited above. In certain embodiments, the compositions of the invention comprise a metal ion cofactor. The metal ion cofactor can provide increased stability of the Enol in the composition and/or increased activity of the Enol in vivo. In one embodiment, the metal ion cofactor is divalent. In one embodiment, the divalent metal ion cofactor is Mg²⁺, Zn²⁺, Mn²⁺, Fe(II)²⁺, Cd²⁺, Co²⁺, or Ni²⁺. In one embodiment, the metal ion cofactor is trivalent, e.g. Sm³⁺ or Tb3⁺.

Enol activity may be determined, for example, using the pyruvate kinase (PK)/lactate dehydrogenase (LDH) assay. The reaction for this enolase assay is shown below.

2-Phospho- ADP ATP NADH NAD+

D-glycerate (DPG) The rate of reaction of NADH to NAD⁺ conversion may be determined by measuring the decrease of fluorescence of NADH, for example by using a PTI Quantamaster 40 spectrophotometer from Photon Technology International, Inc. (pti-nj.com). Kits for measuring Enol activity by a colorimetric pyruvate kinase/lactate dehydrogenase assay are also commercially available, for example, from ABCAM (Cambridge, MA; Cat. No.

abl 17994). The ABCAM Enol activity assay is further described in Example 5 below.

Enol activity may also be determined by measuring the effect of Enol on glucose uptake in human skeletal muscle myotubes (HSMM) as described in Example 2. In certain embodiments, the Enol or the fragment thereof has at least 10%, 20%,

30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 110%, 120%, 130%, 140%, 150%, 160%, 170%, 180%, 190%, 200%, 300%, 400% or 500% of the activity of a purified endogenous human Enol polypeptide. In certain embodiments, the activity of the Enol, the fragment thereof, and the purified endogenous human Enol polypeptide are determined by the pyruvate kinase/lactate dehydrogenase assay or the HSMM glucose uptake assay described above.

In certain embodiments, the Enol polypeptide in complex with a dendrimer as described herein has at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 110%, 120%, 130%, 140%, 150%, 160%, 170%, 180%, 190%, 200%, 300%, 400% or 500% of the activity of a purified endogenous Enol polypeptide that is not in complex with a dendrimer. In certain embodiments, the activity of the Enol polypeptide in complex with a dendrimer and the activity of the purified endogenous Enol polypeptide that is not in complex with a dendrimer are determined by the pyruvate kinase/lactate dehydrogenase assay or the HSMM glucose uptake assay described above. In certain embodiments the Enol polypeptide in complex with a dendrimer and a targeting peptide as described herein has at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 110%, 120%, 130%, 140%, 150%, 160%, 170%, 180%, 190%, 200%, 300%, 400% or 500% of the activity of a purified endogenous ENOl polypeptide that is not in complex with a dendrimer or a targeting peptide. In certain embodiments the activity of the Enol polypeptide in complex with a dendrimer and a targeting peptide and the activity of the purified endogenous ENOl polypeptide that is not in complex with a dendrimer or a targeting peptide are determined by the pyruvate kinase/lactate dehydrogenase assay or the HSMM glucose uptake assay described above.

In one embodiment, the Enol or the fragment thereof in the composition of the invention, wherein the composition comprises a metal ion cofactor (e.g., a divalent metal ion cofactor, e.g., Mg²⁺, Zn²⁺, Mn²⁺, Fe(II)²⁺, Cd²⁺, Co²⁺, or Ni²⁺, or a trivalent metal ion cofactor, e.g. Sm³⁺ or Tb3⁺⁾ has at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 110%, 120%, 130%, 140%, 150%, 160%, 170%, 180%, 190%, 200%, 300%, 400% or 500% of the activity of a purified endogenous human Enol polypeptide. In certain embodiments, the activity of the Enol or the fragment thereof in the composition comprising a metal ion cofactor as described above and the activity of the purified endogenous human Enol polypeptide are determined by the pyruvate kinase/lactate dehydrogenase assay or the HSMM glucose uptake assay described above.

Glucose flux The regulation of muscle glucose uptake involves a three-step process consisting of:

(1) delivery of glucose to muscle, (2) transport of glucose into the muscle by the glucose transporter GLUT4 and (3) phosphorylation of glucose within the muscle by a hexokinase (HK). The physiological regulation of muscle glucose uptake requires that glucose travels from the blood to the interstitium to the intracellular space and is then phosphorylated to G6P. Blood glucose concentration, muscle blood flow and recruitment of capillaries to muscle determine glucose movement from the blood to the interstitium. Plasma membrane GLUT4 content controls glucose transport into the cell. Muscle hexokinase (HK) activity, cellular HK compartmentalization and the concentration of the HK inhibitor, G6P, determine the capacity to phosphorylate glucose. These three steps - delivery, transport and

phosphorylation of glucose -comprise glucose flux, and all three steps are important for glucose flux control. However steps downstream of glucose phosphorylation may also affect glucose uptake. For example, acceleration of glycolysis or glycogen synthesis could reduce G6P, increase HK activity, increase the capacity for glucose phosphorylation and potentially stimulate muscle glucose uptake. Wasserman et al., 2010, J Experimental Biology, Vol. 214, pp. 254-262. The present invention is based, at least in part, on the discovery that Enol affects several components of the glucose flux pathway, including increasing expression of the glucose transporters GLUT1 and GLUT4 and the hexokinase HK2, and increasing levels of the glycolysis pathway intermediates G6P and PEP, thus indicating that Enol treatment acts to increase glucose flux.

The present invention is also based, at least in part, on the discovery that Enol is differentially regulated in muscle cells from normal subjects and muscle cells from subjects with type 2 diabetes. The invention is further based on the surprising discovery that treatment of muscle cells with Enol increases glucose uptake into the cells and

administration of Enol to mice with diet induced obesity normalizes glucose tolerance and insulin response.

Accordingly, the invention provides methods for treatment of elevated blood glucose typically related to diabetes including at least type 1 diabetes, pre-diabetes, type 2 diabetes, and gestational diabetes by administration of Enol to the subject. Further, the invention provides methods for diagnosing and/or monitoring (e.g., monitoring of disease progression or treatment) and/or prognosing an elevated blood glucose state, e.g., diabetes, in a mammal. The invention also provides methods for treating or for adjusting treatment regimens based on diagnostic information relating to the levels of Enol in the blood or serum of a subject with elevated blood glucose. The invention further provides panels and kits for practicing the methods of the invention.

The invention also provides methods for increasing glucose flux in a subject comprising administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the pharmaceutical compositions described herein. The invention also provides a method of increasing glucose flux in a skeletal muscle cell of a subject, the method comprising administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the pharmaceutical compositions described herein.

The invention also provides a method of increasing glycolytic activity in a skeletal muscle cell of a subject, the method comprising administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the pharmaceutical compositions described herein.

The invention also provides a method of increasing mitochondrial free fatty acid oxidation in a skeletal muscle cell of a subject, the method comprising administering to the subject a pharmaceutical composition comprising Enol or a fragment thereof. In certain embodiments, the pharmaceutical composition administered to the subject is any of the pharmaceutical compositions described herein.

"Increasing glucose flux" as used herein is understood as increasing at least one or more of (1) delivery of glucose to muscle, (2) transport of glucose into the muscle, and (3) phosphorylation of glucose within the muscle. In particular embodiments, increasing gluocse flux includes increasing glycolytic activity or mitochondrial free fatty acid oxidation in a muscle cell.

IIA. ENOLASE 2 and ENOLASE 3

Enolase 2 (Eno2) is also known as gamma enolase, neuronal enolase, neuron- specific enolase (NSE), or HEL-S-279 and is encoded by the EN02 gene. Eno2 is a phosphopyruvate phosphatase, a glycolytic enzyme. Eno2 is a homodimer and is found in mature neurons of the central nervous system (CNS) and cells of neuronal origin. Neurons under stress of various types release Eno2 into the systemic circulation. Yee, et al., 2012, Invest.

Ophthalmol. Vis. Sci. Vol. 53, No. 10, pp. 6389-6392. The nucleic acid sequence of the ENO2 mRNA and the amino acid sequence of Eno2 are shown in Figures 36A and 36B, respectively.

Enolase 3 (Eno3) is also known as beta enolase, muscle enolase, muscle- specific enolase (MSE), or GSD13 and is encoded by the ENO3 gene. Eno3 catalyzes the

interconversion of 2-phosphoglycerate and phosphoenolpyruvate. Eno3 is found in adult skeletal muscle cells where it may play a role in muscle development and regeneration. In adult human muscle, over 90% of enolase activity is accounted for by Eno3. Mutations in the gene encoding Eno3 have been associated with glycogen storage disease. Comi et al., 2001, Ann Neurol. Vol. 50, No. 2, pp. 202-207. Three variants of ENO3 mRNA have been identified, variants 1, 2 and 3. Variants 1 and 2 encode isoform 1 of the Eno3 protein, and variant 3 encodes isoform 2 of the Eno3 protein. Variant 3 of the ENO3 mRNA differs in the 5' UTR and lacks two exons in the 5' coding region compared to variant 1. Isoform 2 of the Eno3 protein is shorter than isoform 1, but has the same N- and C-termini. The nucleic acid sequences of variants 1, 2 and 3 and amino acid sequences of isoforms 1 and 2 of Eno3 are shown in Figures 37A-37E.

Eno2 and/or Eno3 may alternatively also be used in the methods, pharmaceutical compositions, panels, and kits described herein for Enol. For example, Eno2 and/or Eno3 may be used in methods for treatment of elevated blood glucose typically related to diabetes including at least type 1 diabetes, pre-diabetes, type 2 diabetes, and gestational diabetes by administration of a pharmaceutical composition comprising Eno2 and/or Eno3 to the subject. Further, Eno2 and/or Eno3 may be used in methods for diagnosing and/or monitoring (e.g., monitoring of disease progression or treatment) and/or prognosing an elevated blood glucose state, e.g., diabetes, in a mammal. Eno2 and/or Eno3 may also be used in methods for treating or for adjusting treatment regimens based on diagnostic information relating to the levels of Eno2 or Eno3 in the blood or serum of a subject with elevated blood glucose, and for panels and kits for practicing the methods of the invention. The invention also relates to pharmaceutical compositions comprising Eno2 and/or Eno3, e.g. for delivery to a muscle cell.

III. DIABETES DIAGNOSIS AND CLASSIFICATION

Diabetes mellitus (DM), often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (increased hunger).

Type 2 diabetes results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. The defective responsiveness of body tissues to insulin is believed, at least in part, to involve the insulin receptor. However, the specific defects are not known.

In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin sensitivity. At this stage, hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver.

Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes. Type 2 diabetes is due to insufficient insulin production from beta cells in the setting of insulin resistance. Insulin resistance, which is the inability of cells to respond adequately to normal levels of insulin, occurs primarily within the muscles, liver, and fat tissue. In the liver, insulin normally suppresses glucose release. However in the setting of insulin resistance, the liver inappropriately releases glucose into the blood. The proportion of insulin resistance verses beta cell dysfunction differs among individuals with some having primarily insulin resistance and only a minor defect in insulin secretion and others with slight insulin resistance and primarily a lack of insulin secretion.

Other potentially important mechanisms associated with type 2 diabetes and insulin resistance include: increased breakdown of lipids within fat cells, resistance to and lack of incretin, high glucagon levels in the blood, increased retention of salt and water by the kidneys, and inappropriate regulation of metabolism by the central nervous system. However not all people with insulin resistance develop diabetes, since an impairment of insulin secretion by pancreatic beta cells is also required. Type 1 diabetes results from the body's failure to produce insulin, and presently requires treatment with injectable insulin. Type 1 diabetes is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas, leading to insulin deficiency. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. However, particularly in late stages, insulin resistance can occur, including insulin resistance due to immune system clearance of administered insulin.

A. Diagnostic Criteria

Criteria for diagnosis and classification of diabetes mellitus were published by the American Diabetes Association in Diabetes Care, 36:S67-74, 2013, incorporated herein by reference, which provides a more detailed definition of the various types of diabetes.

Diagnostic criteria for diabetes are discussed further below. The reference classifies type 1 diabetes or type 2 diabetes as follows:

I. Type 1 diabetes (β-cell destruction, usually leading to absolute insulin deficiency)

A. Immune mediated B. Idiopathic II. Type 2 diabetes (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance)

III. Other specific types

IV. Gestational diabetes mellitus Methods for performing diagnostic or assessment methods are provided therein. The diagnostic criteria for diabetes provided therein are as follows:

Criteria for the Diagnosis of Diabetes

HbAlc >_6.5%. The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program (NGSP) certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay.*

OR

Fasting plasma glucose (FPG) >126 mg/dl (7.0 mmol/1). Fasting is defined as no caloric intake for at least 8 h.*

OR

2-h plasma glucose >200 mg/dl (l l. lmmol/1) during an oral glucose tolerance test (OGTT). The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*

OR

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose >200 mg/dl (11.1 mmol/1).

*In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing.

The diagnostic criteria for increased risk of diabetes/ pre-diabetes provided therein are as follows:

Criteria for Increased Risk of Diabetes (Pre-Diabetes)*

Fasting Plasma Glucose (FPG) 100 mg/dl (5.6mmol/l) to 125mg/dl (6.9 mmol/1) [Impaired Fasting Glucose - IFG]

2-h Plasma Glucose (PG) in the 75-g oral glucose tolerance test (OGTT) 140 mg/dl (7.8 mmol/1) to 199 mg/dl (11.0 mmol/1) [Impaired Glucose Tolerance - IGT]

AIC 5.7-6.4% *For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range.

The diagnostic criteria for gestational diabetes provided therein are as follows: Screening for and diagnosis of Gestational Diabetes Mellitus (GDM)

The blood glucose measurements for the diagnosis and/or monitoring of elevated blood glucose or diabetes can be cumbersome due to the specific timing requirements relative to eating, e.g., a fasting blood glucose or the amount of time required to perform the test, e.g., as with an oral glucose tolerance test. Moreover, the diagnostic criteria explicitly require that in absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing. The use of an HbAlc level as a diagnostic indicator can be advantageous as it provides an indication of blood glucose levels over time, i.e., for about the prior 1-2 months, and does not require special scheduling to perform the test. Similarly, an Enol level can be determined without particular scheduling requirements or food consumption limitations or requirements. Accordingly, in some aspects the invention relates to a method for diagnosing the presence of elevated blood glucose in a subject, comprising: (a) contacting a biological sample with a reagent that selectively binds to Enol; (b) allowing a complex to form between the reagent and Enol; (c) detecting the level of the complex, and (d) comparing the level of the complex with a predetermined threshold value, wherein a level of the complex in the sample below the predetermined threshold value indicates the subject is suffering from elevated blood glucose. In certain embodiments, the reagent that selectively binds to Eno 1 is an anti-Enol antibody. In certain embodiments, the antibody comprises a detectable label. In some embodiments of the method described above, the step of detecting the level of the complex further comprises contacting the complex with a detectable secondary antibody and measuring the level of the secondary antibody. The method may also further comprise detecting the level of one or more additional indicators of elevated blood glucose. The one or more additional indicators of blood glucose may be selected from the group consisting of HbAlc level, fasting glucose level, fed glucose level, and glucose tolerance.

In some embodiments of the aforementioned method, the biological sample is blood or serum. In some embodiments, the level of the complex is detected by immunoassay or ELISA. In some embodiments, the presence of elevated blood glucose in the subject is indicative of a disease or condition selected from the group consisting of pre-diabetes, type 2 diabetes, type 1 diabetes, and gestational diabetes.

B. Secondary Pathologies of Diabetes, Insulin Resistance, and Insulin

Insufficiency

Abnormal glucose regulation resulting from diabetes, both type 1 and type 2, insulin resistance, and insulin insufficiency are associated with secondary pathologies, many of which result from poor circulation. Such secondary pathologies include macular

degeneration, peripheral neuropathies, ulcers and decrease wound healing, and decreased kidney function. It has been suggested that maintaining glucose levels and/ or HbAcl levels within normal ranges decreases the occurrence of these secondary pathologies. It is understood that normalization of blood glucose, insulin, and HbAcl levels will reduce the development of secondary pathologies by limiting the primary pathology, e.g., impaired glucose tolerance, increased blood glucose. In certain embodiments, Enol is not used for the treatment of secondary pathologies associated with impaired glucose tolerance, increased blood glucose, insulin resistance, insulin insufficiency, diabetes, or pre-diabetes. In certain embodiments, Enol is used for the treatment of secondary pathologies associated with impaired glucose tolerance, increased blood glucose, insulin resistance, insulin insufficiency, diabetes, or pre-diabetes.

IV. Dosages and Modes of Administration

Techniques and dosages for administration vary depending on the type of compound (e.g., protein and/or nucleic acid, alone or complexed with a microparticle, liposome, or dendrimer) and are well known to those skilled in the art or are readily determined. Therapeutic compounds of the present invention may be administered with a pharmaceutically acceptable diluent, carrier, or excipient, in unit dosage form. Administration may be parenteral, intravenous, subcutaneous, oral, topical, or local. In certain embodiments, administration is not oral. In certain embodiments, administration is not topical. In certain preferred embodiments, administration is systemic. Administering an agent can be performed by a number of people working in concert. Administering an agent includes, for example, prescribing an agent to be administered to a subject and/or providing instructions, directly or through another, to take a specific agent, either by self-delivery, e.g., as by oral delivery, subcutaneous delivery, intravenous delivery through a central line, etc.; or for delivery by a trained professional, e.g., intravenous delivery, intramuscular delivery, subcutaneous delivery, etc.

The composition can be in the form of a pill, tablet, capsule, liquid, or sustained release tablet for oral administration; or a liquid for intravenous, subcutaneous, or parenteral administration; or a polymer or other sustained release vehicle for systemic administration. Methods well known in the art for making formulations are found, for example, in

"Remington: The Science and Practice of Pharmacy" (20th ed., ed. A. R. Gennaro, 2000, Lippincott Williams & Wilkins, Philadelphia, Pa.). Formulations for parenteral

administration may, for example, contain excipients, sterile water, saline, polyalkylene glycols such as polyethylene glycol, oils of vegetable origin, or hydrogenated napthalenes. Biocompatible, biodegradable lactide polymer, lactide/glycolide copolymer, or

polyoxyethylene-polyoxypropylene copolymers may be used to control the release of the compounds. Nanoparticulate formulations (e.g., biodegradable nanoparticles, solid lipid nanoparticles, liposomes) may be used to control the biodistribution of the compounds. Other potentially useful parenteral delivery systems include ethylene-vinyl acetate copolymer particles, osmotic pumps, implantable infusion systems, and liposomes. The concentration of the compound in the formulation varies depending upon a number of factors, including the dosage of the drug to be administered, and the route of administration.

The compound may be optionally administered as a pharmaceutically acceptable salt, such as non-toxic acid addition salts or metal complexes that are commonly used in the pharmaceutical industry. Examples of acid addition salts include organic acids such as acetic, lactic, pamoic, maleic, citric, malic, ascorbic, succinic, benzoic, palmitic, suberic, salicylic, tartaric, methanesulfonic, toluenesulfonic, or trifluoroacetic acids and the like; polymeric acids such as tannic acid, carboxymethyl cellulose, and the like; and inorganic acid such as hydrochloric acid, hydrobromic acid, sulfuric acid phosphoric acid, and the like. Metal complexes include zinc, iron, and the like.

Formulations for oral use include tablets containing the active ingredient(s) in a mixture with non-toxic pharmaceutically acceptable excipients. These excipients may be, for example, inert diluents or fillers (e.g., sucrose and sorbitol), lubricating agents, glidants, and anti-adhesives (e.g., magnesium stearate, zinc stearate, stearic acid, silicas, hydrogenated vegetable oils, or talc). Formulations for oral use may also be provided as chewable tablets, or as hard gelatin capsules wherein the active ingredient is mixed with an inert solid diluent, or as soft gelatin capsules wherein the active ingredient is mixed with water or an oil medium.

The dosage and the timing of administering the compound depend on various clinical factors including the overall health of the subject and the severity of the symptoms of disease, e.g., diabetes, pre-diabetes. A. Formulations for Long Acting Injectable Drugs

Biologies and other agents subject to high rates of first pass clearance may not be amenable to oral administration and require administration by parenteral routes. However, compliance with treatment regimens for injectable drugs can be low as subjects are often adverse to self-administering agents by injection, e.g., subcutaneous injection, particularly when the disease does not make the subject feel sick. Other routes of administration by injection, e.g., intravenous, intramuscular, typically require administration by a trained professional, making frequent administration of the agent inconvenient and often painful.

Formulations have been created to provide sustained delivery of injectable agents including, but not limited to, oil-based injections, injectable drug suspensions, injectable microspheres, and injectable in situ systems. Long-acting injectable formulations offer many advantages when compared with conventional formulations of the same compounds. These advantages include, at least, the following: a predictable drug-release profile during a defined period of time following each injection; better patient compliance; ease of application;

improved systemic availability by avoidance of first-pass metabolism; reduced dosing frequency (i.e., fewer injections) without compromising the effectiveness of the treatment; decreased incidence of side effects; and overall cost reduction of medical care. 1. Oil-based injectable solutions and injectable drug suspensions.

Conventional long-acting injections consist either of lipophilic drugs in aqueous solvents as suspensions or of lipophilic drugs dissolved in vegetable oils. Commercially available oil based injectable drugs for intramuscular administration include, but are not limited to, haloperidol deconate, fluphenazine deconate, testosterone enanthate, and estradiol valerate. Administration frequency for these long-acting formulations is every few weeks or so. In the suspension formulations, the rate-limiting step of drug absorption is the dissolution of drug particles in the formulation or in the tissue fluid surrounding the drug formulation. Poorly water-soluble salt formations can be used to control the dissolution rate of drug particles to prolong the absorption. However, several other factors such as injection site, injection volume, the extent of spreading of the depot at the injection site, and the absorption and distribution of the oil vehicle per se can affect the overall pharmacokinetic profile of the drug. Modulation of these factors to provide the desired drug release profile is within the ability of those of skill in the art. 2. Polymer-based microspheres and in-situ formings.

The development of polymer-based long-acting injectables is one of the most suitable strategies for macromolecules such as peptide and protein drugs. Commercially available microsphere preparations include, but are not limited to, leuprolide acetate, triptorelin pamoate, octreotide acetate, lanreotide acetate, risperidone, and naltrexone. Commercially available in situ forming implants include leuprolide acetate, and in situ forming implants containing paclitaxel and bupivacaine are in clinical trials. These formulations are for intramuscular administration. Advantages of polymer-based formulations for

macromolecules include: in vitro and in vivo stabilization of macromolecules, improvement of systemic availability, extension of biological half life, enhancement of patient convenience and compliance, and reduction of dosing frequency.

The most crucial factor in the design of injectable microspheres and in situ formings is the choice of an appropriate biodegradable polymer. The release of the drug molecule from biodegradable microspheres is controlled by diffusion through the polymer matrix and polymer degradation. The nature of the polymer, such as composition of copolymer ratios, polymer crystallinities, glass-transition temperature, and hydrophilicities plays a critical role in the release process. Although the structure, intrinsic polymer properties, core solubility, polymer hydrophilicity, and polymer molecular weight influence the drug-release kinetics, the possible mechanisms of drug release from microsphere are as follows: initial release from the surface, release through the pores, diffusion through the intact polymer barrier, diffusion through a water-swollen barrier, polymer erosion, and bulk degradation. All these

mechanisms together play a part in the release process. Polymers for use in microsphere and in situ formings include, but are not limited to a variety of biodegradable polymers for controlled drug delivery intensively studied over the past several decades include polylactides (PLA), polyglycolides (PGA), poly(lactide-co-glycolide) (PLGA), poly(8-caprolactone) (PCL), polyglyconate, polyanhydrides, polyorthoesters, poly(dioxanone), and

polyalkylcyanoacrylates. Thermally induced gelling systems used in in situ formings show thermo-reversible sol/gel transitions and are characterized by a lower critical solution temperature. They are liquid at room temperature and produce a gel at and above the lower critical solution temperature. In situ solidifying organogels are composed of water-insoluble amphiphilic lipids, which swell in water and form various types of lyotropic liquid crystals.

B. Targeted Drug Delivery

Delivery of drugs to their site of action can increase the therapeutic index by reducing the amount of drug required to provide the desired systemic effect. Drugs can be delivered to the site of action by administration of the drug to the target tissue using a method or formulation that will limit systemic exposure, e.g., intramuscular injection, intrasinovial injection, intrathecal injection, intraocular injection. A number of the sustained delivery formulations discussed above are for intramuscular administration and provide local delivery to muscle tissue. Alternatively, targeting moieties can be associated with or linked to therapeutic payloads for administration to the target site. Targeting moieties can include any of a number of moieties that bind to specific cell types. 1. Targeting Moieties

Certain embodiments of the invention include the use of targeting moieties include relatively small peptides (e.g., 25 amino acids or less, 20 amino acids or less, 15 amino acids or less, 10 amino acids or less), muscle targeting peptides (MTP) including smooth muscle and/or skeletal muscle targeting peptides, ανβ3 integrin ligands (e.g., RGD peptides and peptide analogs), ανβ5 integrin ligands, or CD46 ligands as discussed above. It is understood that such peptides can include one or more chemical modifications to permit formation of a complex with Enol, to modify pharmacokinetic and/or pharmacodynamic properties of the peptides. In certain embodiments, the targeting moiety can be a small molecule, e.g., RGD peptide mimetics. In certain embodiments, the targeting moiety can include a protein and optionally a fiber protein from an adenovirus 35. In certain embodiments, the viral proteins are present on a virus particle. In certain embodiments, the viral proteins are not present on a viral particle. In certain embodiments, the targeting moiety can be an antibody, antibody fragment, antibody mimetic, or T-cell receptor.

2. Targeted Complexes

Targeted Enol complexes can be administered by a route other than intramuscular injection (e.g., subcutaneous injection, intravenous injection) while providing delivery of the Enol to muscle. Targeted complexes can include one or more targeting moieties attached either directly or indirectly to Enol. Formation of the targeted complex does not

substantially or irreversibly inhibit the activity of Enol and its effect on normalizing blood glucose levels and insulin response. In certain embodiments, use of a targeted complex can reduce the total amount of Enol required to provide an effective dose. Some exemplary, non-limiting, embodiments of targeted complexes are discussed below.

In certain embodiments, the payload and the targeting moiety are present in a complex at about a 1: 1 molar ratio. In certain embodiments, the targeting moiety is present in a complex with a molar excess of the payload (e.g., 2: 1, 3: 1, 4: 1, 5: 1, 6: 1, 7: 1; 8: 1, 9: 1,10: 1, 11: 1, 12: 1, 13: 1, 14: 1, 15: 1, 16: 1, 17: 1; 18: 1, 19: 1,20: 1, 21: 1, 22: 1, 23: 1, 24: 1, 25: 1, 26: 1, 27: 1; 28: 1, 29: 1, 30: 1, or more; or any range bracketed by any two values). In certain embodiments, the payload to targeting moiety is about 1:5-1: 15; about 1:7-1: 13, about 1:8- 1: 12.

It is understood that the compositions and methods of the invention include the administration of more than one, i.e., a population of, targeting moiety-payload complexes. Therefore, it is understood that the number of targeting moieties per payload can represent an average number of targeting moieties per payload in a population of complexes. In certain embodiments, at least 70% of the complexes have the selected molar ratio of targeting moieties to payload. In certain embodiments, at least 75% of the complexes have the selected molar ratio of targeting moieties to payload. In certain embodiments, at least 80% of the complexes have the selected molar ratio of targeting moieties to payload. In certain embodiments, at least 85% of the complexes have the selected molar ratio of targeting moieties to payload. In certain embodiments, at least 90% of the complexes have the selected molar ratio of targeting moieties to payload. a. Linkers

A number of chemical linkers are known in the art and available from commercial sources (e.g., Pierce Thermo Fisher Scientific Inc., see, e.g.,

www.piercenet.com/cat/crosslinking-reagents). Such agents can be used to chemically link, reversibly or irreversibly, one or more targeting moieties to Enol. Linkers can also be used to attach targeting moieties and Enol to a structure, e.g., microparticle, dendrimer, rather than attaching the targeting moiety directly to Enol. In certain embodiments, the linker attaching Enol to the targeted complex is reversible so that the Enol is released from the complex after administration, preferably substantially at the muscle. b. Peptide bonds

As used herein, targeted complexes can include the translation of Enol with a peptide targeting moiety. Methods to generate expression constructs including an amino acid sequence for targeting Enol is well within the ability of those of skill in the art. c. Liposomes

Liposomal delivery systems are known in the art including formulations to limit systemic exposure, thereby reducing systemic exposure and off target effects. For example, Doxil® is a composition in which doxorubicin encapsulated in long-circulating pegylated liposomes that further comprise cholesterol for treatment of certain types of cancer. Various liposomal formulations of amphotericin B including Ambisome®, Abelcet®, and

Amphotec® are formulated for intravenous administration in liposomes or a lipid complex containing various phospholipids, cholesterol, and cholesteryl sulfate. Visudine® is verteporfin formulated as a liposome in egg phosphotidyl glycerol and DMPC for intravenous administration. Liposomal formulations are also known for intramuscular injection. Epaxal® is an inactivated hepatitis A virus and Inflexal V® is an inactivated hemaglutinine of influenza virus strains A and B. Both viral preparations are formulated in combinations of DOPC and DOPE. Such liposomes, or other physiologically acceptable liposomes, can be used for the packaging of Enol and subsequent surface decoration with targeting moieties to delivery Enol to the muscle. Additional moieties to modulate intracellular trafficking of the liposome can also be included. Upon uptake of the liposome into the cell, the liposome releases the Enol thereby allowing it to have its therapeutic effect. d. Dendrimers

Dendrimers can be used as a scaffold for the attachment of multiple targeting moieties with one or more molecules of Enol. In certain embodiments, the dendrimer is decorated with targeting moieties prior to coupling with Eno 1. e. Microparticles

Microparticles can be used as a scaffold for the attachment of multiple targeting moieties with one or more molecules of Enol either attached to or encapsulated in the microparticle. In certain embodiments, the microparticle is decorated with targeting moieties prior to coupling with Enol. f. Viral Vectors

Viral tropisms have long been studied and are used to direct viruses to the cell type of interest. Parker et al., 2013 (Gene Therapy, 20: 1158-64) have developed an adenovirus serotype 5 capsite with the fiber and peton of serotype 35 to enhance delivery to skeletal and/or smooth muscle cells. Such viral vectors and other viral vectors can be used for the delivery of Enol expression constructs to muscle cells.

C. Dendrimers

Dendrimers can be used in the context of the invention as the backbone for targeted complexes for the delivery of non-intramuscularly administered Enol to muscle.

Alternatively, dendrimers can be used to modulate the pharmacokinetic and

pharmacodynamic properties of intramuscularly administered Enol. In the compositions and methods of the invention, dendrimers are understood to be pharmaceutically acceptable dendrimers. Dendrimer-based platforms have achieved attention for use in pharmaceutical applications. Similar to other polymeric carriers, dendrimers can be synthesized to avoid structural toxicity and immunogenicity. The dendrimer' s ability to mimic the size, solubility, and shape of human proteins makes the technology an ideal choice for many therapeutic and diagnostic applications. Being 1-10 nanometers in size enables dendrimers to efficiently diffuse across the vascular endothelium, internalize into cells, and be rapid cleared by the kidneys. This helps to avoid long-term toxicities and reduces the need for a rapidly degradable platform. The availability of multiple reactive surface groups enables the dendrimer to carry a higher payload of functional molecules, enhancing targeted delivery to the site of action, thereby increasing efficacy. Dendrimers have been produced or are under commercial development for several biomedical applications. A topical, polylysine dendrimer-based microbicide, VivaGel™, has been developed by Starpharma. SuperFect® is a dendrimer-based material used for gene transfection. Dendrimer based diagnostic tools include Gadomer-17, a magnetic resonance imaging (MRI) contrast agent containing a polylysine dendrimer functionalized with gadolinium chelates, and Stratus® CS, a biosensor for cardiac markers to rapidly diagnosis heart attacks.

Dendrimers are defined by their core-shell structure, where the dendrimer approximately doubles in size and number of functional surface groups with each additional shell (or generation) added to the core. Shells are synthesized by alternating monomer reactions by means well known in the art. Specialized dendrimer backbones can be synthesized by varying the monomer units. The biological properties of the dendrimer are largely influenced by the chemical backbone and surface termination. For a dendrimer to be an appropriate vehicle for drug delivery in vivo, they must be non-toxic, non-immunogenic, and be capable of targeting and reaching specific locations by crossing the appropriate barriers while being stable enough to remain in circulation. The vast majority of the dendrimers synthesized and published in literature are insoluble in physiological conditions or are incapable of remaining soluble after the addition of functional molecules and are inappropriate for biological applications. However, several classes of dendrimers have been shown to be useful scaffolds for biomedical applications; examples include polyesters, polylysine, and polypropyleneimine (PPI or DAB) dendrimers.

The most widely used dendrimers in biomedical applications are poly(amidoamine) (PAMAM) dendrimers. The polyamide backbone synthesized from repeating reactions of methyl acrylate and ethylene-diamine helps the macromolecule maintain water solubility and minimizes immunogenicity. PAMAM dendrimers of different generation also are able to mimic the size and properties of globular proteins readily found in the body. The amine- terminated surface of full generation PAMAM dendrimers allows for easy surface modification, enabling the platform to carry and solubilize hydrophobic therapeutic molecules, such as methotrexate, in physiological conditions. PAMAM dendrimers exhibit little non-specific toxicity if the surface amines have been neutralized or appropriately modified (e.g., acylated).

Active targeting uses a molecule, such as targeting moiety, to mediate delivery of its payload (drug or otherwise) to cells by binding to cell-specific molecules. Targeting moieties, such as those provided herein, frequently bind through receptors highly expressed on target cells. The interactions between the targeting ligand and cell-surface receptor allow the therapeutic agent or payload to selectively reach muscle cells and even be ushered inside via receptor-mediated processes. The multivalent effect associated with the display of multiple binding ligands on the dendrimer surface enhances the uptake of the dendritic scaffold compared to single ligands. Multivalent interactions, caused by the simultaneous binding of multiple ligands, allow for the dendrimers to increase the binding avidities of the platform, even when individual ligands have low affinities for the targeted receptor. The PAMAM platform has been successfully used as a scaffold for the attachment of multivalent targeting molecules including antibodies, peptides, T-antigens, and folic acid. The targeting ligands anchor the dendrimers to locations where specific receptors are expressed on cell surfaces. Targeted dendrimer-drug conjugates to deliver a higher dose specifically to targeted cells while avoiding normal cells, thus avoiding the potential systemic toxicity. Neutralizing the surface amines of PAMAM dendrimers with acetyl groups minimizes toxicity and non-specific dendrimer uptake. The acetyl capping of the dendrimer also allows for increased clearance from the body, minimizing effects from long-term treatment.

PEGylation of amino-terminated PAMAM dendrimers reduces immunogenicity and increases solubility. PEG terminated dendrimers have an increased half-life the blood stream as compared to the cationic parent material. Hydroxyl and methyoxyl terminated polyester dendrimers have been shown to be nontoxic in vivo up at concentrations up to 40 mg/kg. The differences in toxicities between cationic and anionic dendrimers have also been confirmed in vivo. Using a zebrafish embryo model, carboxyl terminated dendrimer was significantly less toxic than G4 amine-terminated dendrimer. In the same study, surface modification with RGD also reduced toxicity.

It will be understood that all of the dendrimers described above and herein may be used in the Enol compositions of the invention and their methods of use. In certain embodiments, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is between about 1: 1 and about 10: 1, e.g., about 1: 1, about 2: 1, about 3: 1, about 4: 1, about 5: 1, about 6: 1, about 7: 1, about 8: 1, about 9: 1, or about 10: 1. In one embodiment, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is between about 3: 1 and 7: 1, e.g., 3: 1, 4: 1, 5: 1, 6: 1, or 7: 1. In one embodiment, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is between 4: 1 and 6: 1, e.g., 3: 1, 4: 1, or 5: 1. In one embodiment, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is between 3: 1 and 5: 1, e.g., 3: 1, 4: 1, or 5: 1. In yet another embodiment, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is between 4: 1 and 5: 1. In another embodiment, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is between 3: 1 and 4: 1. In a further preferred embodiment, the ratio of the number of dendrimer molecules to the number of Enol molecules in the complex comprising dendrimer and Enol is about 5: 1.

Optimal ratios of dendrimer to Enol in the complex may be tested and selected by assaying the Enol activity of the dendrimer/Enol complexes (e.g., as compared to uncomplexed Enol) by using any routine methods known in the art, such as, for example, the pyruvate kinase (PK)/lactate dehydrogenase (LDH) assay or any other assays described herein. Optimal ratios of dendrimer to Enol may also be tested and selected by assessing the effect of the dendrimer/Enol complexes on glucose uptake in an in vitro assay, for example, by measuring glucose uptake in human skeletal muscle myotubes (HSMM) as described herein in Example 2 or any similar assays known in the art. Optimal ratios of dendrimer to Enol may also be tested and selected by measuring the effect of the dendrimer/Enol complexes on blood glucose levels in vivo, for example, by measuring the effect of the dendrimer/Enol complex on blood glucose in diabetic mouse models, as described herein in Examples 7 and 8, or any similar models or assays known in the art. Optimal ratios of dendrimer to Enol in the complex will preferably retain Enol activity in vitro and/or in vivo, and/or provide delivery of Enol to cells..

It is understood that the compositions and methods of the invention include the administration of more than one, i.e., a population of dendrimer-Enol -targeting peptide complexes. Therefore, it is understood that the number of dendrimer per Enol molecules can represent an average number of dendrimer per Enol in a population of complexes. In certain embodiments, at least 70% of the complexes have the selected molar ratio of dendrimer to Enol. In certain embodiments, at least 75% of the complexes have the selected molar ratio of dendrimer to Enol. In certain embodiments, at least 80% of the complexes have the selected molar ratio of dendrimer to Enol. In certain embodiments, at least 85% of the complexes have the selected molar ratio of dendrimer to Enol. In certain embodiments, at least 90% of the complexes have the selected molar ratio of dendrimer to Enol.

In certain embodiments, the ratio of the number of dendrimer molecules to the number of targeting peptides in the dendrimer/Enol /targeting peptide complex is between 1:0.1 and 1: 10, between 1: 1 and 1: 10, between 1: 1 and 1:5, or between 1: 1 and 1:3. In certain embodiements the ratio of the number of dendrimer molecules to the number of targeting peptides is about 1: 1, 1:2, 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9 or 1: 10. In a preferred embodiment, the ratio of the number of dendrimer molecules to the number of targeting peptides in the dendrimer/Enol /targeting peptide complex is about 1: 1. In a preferred embodiment, the ratio of the number of dendrimer molecules to the number of targeting peptides in the dendrimer/Enol /targeting peptide complex is about 1:2. In a preferred embodiment, the ratio of the number of dendrimer molecules to the number of targeting peptides in the dendrimer/Enol /targeting peptide complex is about 1:3. In certain embodiments, the ratio of the number of targeting peptides to the number of dendrimer molecules in the dendrimer/Enol /targe ting peptide complex is at least 1: 1, at least 2: 1, at least 3: 1, at least 4: 1, at least 5: 1, at least 6: 1, at least 7: 1, at least 8: 1, at least 9: 1 or at least 10: 1. In one embodiment, the ratio of the number of targeting peptides to the number of dendrimer molecules in the dendrimer/Enol /targe ting peptide complex is at least 3: 1. It is understood that the compositions and methods of the invention include the administration of more than one, i.e., a population of targeting peptide-Enol -dendrimer complexes. Therefore, it is understood that the number of targeting peptides per dendrimer can represent an average number of targeting peptides per dendrimer in a population of complexes. In certain embodiments, at least 70% of the complexes have the selected molar ratio of targeting peptides to dendrimer. In certain embodiments, at least 75% of the complexes have the selected molar ratio of targeting peptides to dendrimer. In certain embodiments, at least 80% of the complexes have the selected molar ratio of targeting peptide to dendrimer. In certain embodiments, at least 85% of the complexes have the selected molar ratio of targeting peptide to dendrimer. In certain embodiments, at least 90% of the complexes have the selected molar ratio of targeting peptide to dendrimer.

Optimal ratios of dendrimer to targeting peptide may be selected by measuring the targeting of the dendrimer/Enol /targeting peptide complex to specific tissues in vivo, for example, by measuring the targeting of a detectably labeled dendrimer/Enol /targeting peptide complex in vivo, as described herein in Example 6.

V. DETECTION AND MEASUREMENT OF INDICATORS OF BLOOD

GLUCOSE LEVELS AND CONTROL

Methods for detection and measurement of indicators of elevated blood glucose and blood glucose control vary depending on the nature of the indicator to be measured. Elevated blood glucose, and thereby loss of blood glucose level control and severity of diabetes can be measured directly, e.g., by determining the amount of glucose in the blood, or indirectly, e.g., by detecting the amount of glycated hemoglobin (HbAlc), a reaction product of hemoglobin and glucose. The invention further provides methods for detecting blood glucose control using Enol.

The present invention contemplates any suitable means, techniques, and/or procedures for detecting and/or measuring the blood glucose level indicators of the invention. The skilled artisan will appreciate that the methodologies employed to measure the indicators of the invention will depend at least on the type of indicator being detected or measured (e.g., glucose, ketones, mRNA, or polypeptide including a glycated polypeptide) and the biological sample (e.g., whole blood, serum). Certain biological sample may also require certain specialized treatments prior to measuring the biomarkers of the invention, e.g., the preparation of mRNA in the case where an mRNA biomarker, e.g., Enol mRNA, is being measured.

A. Direct and Indirect Measurement of Blood Glucose and Blood Glucose Control using Established Indicators

Blood glucose monitoring is a way of testing the concentration of glucose in the blood (glycemia) directly at a single point in time. Particularly important in the care of diabetes mellitus, a blood glucose test is performed by piercing the skin (typically, on the finger) to draw blood, then applying the blood to a chemically active disposable 'test-strip'. Different manufacturers use different technology, but most systems measure an electrical characteristic, and use this to determine the glucose level in the blood. The test is usually referred to as capillary blood glucose. Commercially available blood glucose monitors for periodic or continuous use are known in the art. Glucose monitors for periodic detection of blood glucose levels include, but are not limited to, TRUEResult Blood Glucose Meter (TRUE), ACCU-CHEK Glucose Meter (ACCU-CHEK), OneTouch Glucose Meter (ONETOUCH), and FreeStyle Lite Blood Glucose (FREESTYLE LITE). It is understood that a directly measured normal blood glucose level will vary depending on the amount of time since food was last consumed with a normal fasting blood glucose level being lower than a normal fed blood glucose level. Direct blood glucose monitoring is also used in glucose tolerance tests to monitor response to consumption of a high dose of glucose and the rate of glucose clearance from the blood. Glycated hemoglobin (hemoglobin Ale, HbAlc, AIC, Hblc, HbAlc) is a form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time, i.e., an indirect measurement of blood glucose. HbAlc is formed in a non-enzymatic glycation pathway by hemoglobin's exposure to plasma glucose. When normal levels of glucose are present, a normal amount of glycated hemoglobin, measured as a percent of total hemoglobin, or a specific blood concentration, is produced. When blood glucose levels are high, elevated levels of glycated hemoglobin are produced. Glycation is an irreversible reaction. Therefore, the amount of glycated hemoglobin within the red cell reflects the average level of glucose to which the cell has been exposed.

Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long- term serum glucose regulation rather than a snapshot image as provided by glucose monitoring. The HbAlc level is proportional to average blood glucose concentration over the previous four weeks to three months. HbAlc levels can be measured, for example, using high-performance liquid chromatography (HPLC) or immunoassay. Methods for detection and measurement of protein analytes are discussed in detail below. B. Detection of Nucleic Acid Indicators

In certain embodiments, the invention involves the detection of nucleic acid biomarkers, e.g., Enol mRNA biomarkers, optionally in combination with other indicators of blood glucose, to monitor diabetes and/or glucose control in a subject e.g., direct

measurement of blood glucose, ketones, and/or HbAlc.

In various embodiments, the diagnostic/prognostic methods of the present invention generally involve the determination of expression levels of Enol in a blood sample.

Determination of gene expression levels in the practice of the inventive methods may be performed by any suitable method. For example, determination of gene expression levels may be performed by detecting the expression of mRNA expressed from a gene of interest and/or by detecting the expression of a polypeptide encoded by the gene.

For detecting nucleic acids encoding Enol, any suitable method can be used, including, but not limited to, Southern blot analysis, northern blot analysis, polymerase chain reaction (PCR) (see, for example, U.S. Pat. Nos. 4,683,195; 4,683,202, and 6,040,166; "PCR Protocols: A Guide to Methods and Applications", Innis et al. (Eds), 1990, Academic Press: New York), reverse transcriptase PCR (RT-PCR), anchored PCR, competitive PCR (see, for example, U.S. Pat. No. 5,747,251), rapid amplification of cDNA ends (RACE) (see, for example, "Gene Cloning and Analysis: Current Innovations, 1997, pp. 99-115); ligase chain reaction (LCR) (see, for example, EP 01 320 308), one-sided PCR (Ohara et al., Proc. Natl. Acad. Sci., 1989, 86: 5673-5677), in situ hybridization, Taqman-based assays (Holland et al., Proc. Natl. Acad. Sci., 1991, 88: 7276-7280), differential display (see, for example, Liang et al., Nucl. Acid. Res., 1993, 21: 3269-3275) and other RNA fingerprinting techniques, nucleic acid sequence based amplification (NASBA) and other transcription based amplification systems (see, for example, U.S. Pat. Nos. 5,409,818 and 5,554,527), Qbeta Replicase, Strand Displacement Amplification (SDA), Repair Chain Reaction (RCR), nuclease protection assays, subtraction-based methods, Rapid-Scan®, etc.

In other embodiments, gene expression levels of Enol may be determined by amplifying complementary DNA (cDNA) or complementary RNA (cRNA) produced from mRNA and analyzing it using a microarray. A number of different array configurations and methods of their production are known to those skilled in the art (see, for example, U.S. Pat. Nos. 5,445,934; 5,532,128; 5,556,752; 5,242,974; 5,384,261; 5,405,783; 5,412,087; 5,424,186; 5,429,807; 5,436,327; 5,472,672; 5,527,681; 5,529,756; 5,545,531; 5,554,501; 5,561,071; 5,571,639; 5,593,839; 5,599,695; 5,624,711; 5,658,734; and 5,700,637).

Microarray technology allows for the measurement of the steady- state mRNA level of a large number of genes simultaneously. Microarrays currently in wide use include cDNA arrays and oligonucleotide arrays. Analyses using microarrays are generally based on measurements of the intensity of the signal received from a labeled probe used to detect a cDNA sequence from the sample that hybridizes to a nucleic acid probe immobilized at a known location on the microarray (see, for example, U.S. Pat. Nos. 6,004,755; 6,218,114; 6,218,122; and 6,271,002). Array-based gene expression methods are known in the art and have been described in numerous scientific publications as well as in patents (see, for example, M. Schena et al., Science, 1995, 270: 467-470; M. Schena et al., Proc. Natl. Acad. Sci. USA 1996, 93: 10614-10619; J. J. Chen et al., Genomics, 1998, 51: 313-324; U.S. Pat. Nos.

5,143,854; 5,445,934; 5,807,522; 5,837,832; 6,040,138; 6,045,996; 6,284,460; and

6,607,885). In one particular embodiment, the invention comprises a method for identification of a subject suffering from abnormal blood glucose by amplifying and detecting nucleic acids corresponding to Enol, optionally in combination with one or more additional indicators of elevated blood glucose.

Nucleic acid used as a template for amplification can be isolated from cells contained in the biological sample, according to standard methodologies (Sambrook et al., 1989). The nucleic acid may be genomic DNA or fractionated or whole cell RNA. Where RNA is used, it may be desired to convert the RNA to a complementary cDNA. In one embodiment, the RNA is whole cell RNA and is used directly as the template for amplification.

Pairs of primers that selectively hybridize to nucleic acids corresponding to any of the Enol nucleotide sequences identified herein are contacted with the isolated nucleic acid under conditions that permit selective hybridization. Once hybridized, the nucleic acid:primer complex is contacted with one or more enzymes that facilitate template-dependent nucleic acid synthesis. Multiple rounds of amplification, also referred to as "cycles," are conducted until a sufficient amount of amplification product is produced. Next, the amplification product is detected. In certain applications, the detection may be performed by visual means. Alternatively, the detection may involve indirect identification of the product via

chemiluminescence, radioactive scintigraphy of incorporated radiolabel or fluorescent label or even via a system using electrical or thermal impulse signals (AFFYMAX technology; Bellus, 1994). Following detection, one may compare the results seen in a given patient with a statistically significant reference group of normal patients and patients with elevated blood glucose, e.g., patients with pre-diabetes, type 2 diabetes, gestational diabetes, or type 1 diabetes. In this way, it is possible to correlate the amount of nucleic acid detected with various clinical states.

The term primer, as defined herein, is meant to encompass any nucleic acid that is capable of priming the synthesis of a nascent nucleic acid in a template-dependent process. Typically, primers are oligonucleotides from ten to twenty, preferably fifteen to twenty nucleotides in length, but longer sequences may be employed. Primers may be provided in double- stranded or single-stranded form, although the single- stranded form is preferred.

A number of template dependent processes are available to amplify the nucleic acid sequences present in a given template sample. One of the best known amplification methods is the polymerase chain reaction (referred to as PCR) which is described in detail in U.S. Pat. Nos. 4,683,195, 4,683,202 and 4,800,159, and in Innis et al., 1990, each of which is incorporated herein by reference in its entirety.

In PCR, two primer sequences are prepared which are complementary to regions on opposite complementary strands of the target nucleic acid sequence. An excess of

deoxynucleoside triphosphates are added to a reaction mixture along with a DNA

polymerase, e.g., Taq polymerase. If the target nucleic acid sequence is present in a sample, the primers will bind to the target nucleic acid and the polymerase will cause the primers to be extended along the target nucleic acid sequence by adding on nucleotides. By raising and lowering the temperature of the reaction mixture, the extended primers will dissociate from the target nucleic acid to form reaction products, excess primers will bind to the target nucleic acid and to the reaction products and the process is repeated.

A reverse transcriptase PCR amplification procedure may be performed in order to quantify the amount of mRNA amplified. Methods of reverse transcribing RNA into cDNA are well known and described in Sambrook et al., 1989. Alternative methods for reverse transcription utilize thermostable DNA polymerases. These methods are described in WO 90/07641 filed Dec. 21, 1990. Polymerase chain reaction methodologies are well known in the art. Another method for amplification is the ligase chain reaction ("LCR"), disclosed in European Application No. 320 308, incorporated herein by reference in its entirely. In LCR, two complementary probe pairs are prepared, and in the presence of the target sequence, each pair will bind to opposite complementary strands of the target such that they abut. In the presence of a ligase, the two probe pairs will link to form a single unit. By temperature cycling, as in PCR, bound ligated units dissociate from the target and then serve as "target sequences" for ligation of excess probe pairs. U.S. Pat. No. 4,883,750 describes a method similar to LCR for binding probe pairs to a target sequence.

Qbeta Replicase, described in PCT Application No. PCT/US87/00880, also may be used as still another amplification method in the present invention. In this method, a replicative sequence of RNA which has a region complementary to that of a target is added to a sample in the presence of an RNA polymerase. The polymerase will copy the replicative sequence which may then be detected.

An isothermal amplification method, in which restriction endonucleases and ligases are used to achieve the amplification of target molecules that contain nucleotide 5'-[a-thio]- triphosphates in one strand of a restriction site also may be useful in the amplification of nucleic acids in the present invention. Walker et al. (1992), incorporated herein by reference in its entirety.

Strand Displacement Amplification (SDA) is another method of carrying out isothermal amplification of nucleic acids which involves multiple rounds of strand displacement and synthesis, i.e., nick translation. A similar method, called Repair Chain Reaction (RCR), involves annealing several probes throughout a region targeted for amplification, followed by a repair reaction in which only two of the four bases are present. The other two bases may be added as biotinylated derivatives for easy detection. A similar approach is used in SDA. Target specific sequences also may be detected using a cyclic probe reaction (CPR). In CPR, a probe having 3' and 5' sequences of non-specific DNA and a middle sequence of specific RNA is hybridized to DNA which is present in a sample. Upon hybridization, the reaction is treated with RNase H, and the products of the probe identified as distinctive products which are released after digestion. The original template is annealed to another cycling probe and the reaction is repeated. Still other amplification methods described in GB Application No. 2 202 328, and in PCT Application No. PCT/US89/01025, each of which is incorporated herein by reference in its entirety, may be used in accordance with the present invention. In the former application, "modified" primers are used in a PCR like, template and enzyme dependent synthesis. The primers may be modified by labeling with a capture moiety (e.g., biotin) and/or a detector moiety (e.g., enzyme). In the latter application, an excess of labeled probes are added to a sample. In the presence of the target sequence, the probe binds and is cleaved catalytically. After cleavage, the target sequence is released intact to be bound by excess probe. Cleavage of the labeled probe signals the presence of the target sequence. Other contemplated nucleic acid amplification procedures include transcription-based amplification systems (TAS), including nucleic acid sequence based amplification (NASBA) and 3SR. Kwoh et al. (1989); Gingeras et al., PCT Application WO 88/10315, incorporated herein by reference in their entirety. In NASBA, the nucleic acids may be prepared for amplification by standard phenol/chloroform extraction, heat denaturation of a clinical sample, treatment with lysis buffer and minispin columns for isolation of DNA and RNA or guanidinium chloride extraction of RNA. These amplification techniques involve annealing a primer which has target specific sequences. Following polymerization, DNA/RNA hybrids are digested with RNase H while double stranded DNA molecules are heat denatured again. In either case the single stranded DNA is made fully double stranded by addition of second target specific primer, followed by polymerization. The double- stranded DNA molecules are then multiply transcribed by a polymerase such as T7 or SP6. In an isothermal cyclic reaction, the RNA's are reverse transcribed into double stranded DNA, and transcribed once against with a polymerase such as T7 or SP6. The resulting products, whether truncated or complete, indicate target specific sequences. Davey et al., European Application No. 329 822 (incorporated herein by reference in its entirely) disclose a nucleic acid amplification process involving cyclically synthesizing single- stranded RNA ("ssRNA"), ssDNA, and double- stranded DNA (dsDNA), which may be used in accordance with the present invention. The ssRNA is a first template for a first primer oligonucleotide, which is elongated by reverse transcriptase (RNA-dependent DNA polymerase). The RNA is then removed from the resulting DNA:RNA duplex by the action of ribonuclease H(RNase H, an RNase specific for RNA in duplex with either DNA or RNA). The resultant ssDNA is a second template for a second primer, which also includes the sequences of an RNA polymerase promoter (exemplified by T7 RNA polymerase) 5' to its homology to the template. This primer is then extended by DNA polymerase (exemplified by the large "Klenow" fragment of E. coli DNA polymerase 1), resulting in a double- stranded DNA ("dsDNA") molecule, having a sequence identical to that of the original RNA between the primers and having additionally, at one end, a promoter sequence. This promoter sequence may be used by the appropriate RNA polymerase to make many RNA copies of the DNA. These copies may then re-enter the cycle leading to very swift amplification. With proper choice of enzymes, this amplification may be done isothermally without addition of enzymes at each cycle. Because of the cyclical nature of this process, the starting sequence may be chosen to be in the form of either DNA or RNA.

Miller et al., PCT Application WO 89/06700 (incorporated herein by reference in its entirety) disclose a nucleic acid sequence amplification scheme based on the hybridization of a promoter/primer sequence to a target single- stranded DNA ("ssDNA") followed by transcription of many RNA copies of the sequence. This scheme is not cyclic, i.e., new templates are not produced from the resultant RNA transcripts. Other amplification methods include "race" and "one-sided PCR.TM.." Frohman (1990) and Ohara et al. (1989), each herein incorporated by reference in their entirety.

Methods based on ligation of two (or more) oligonucleotides in the presence of nucleic acid having the sequence of the resulting "di-oligonucleotide", thereby amplifying the di-oligonucleotide, also may be used in the amplification step of the present invention. Wu et al. (1989), incorporated herein by reference in its entirety.

Oligonucleotide probes or primers of the present invention may be of any suitable length, depending on the particular assay format and the particular needs and targeted sequences employed. In a preferred embodiment, the oligonucleotide probes or primers are at least 10 nucleotides in length (preferably, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 . . . ), preferably at least 15 nucleotides in length (15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 . . . ) and they may be adapted to be especially suited for a chosen nucleic acid amplification system and/or hybridization system used. Longer probes and primers are also within the scope of the present invention as well known in the art. Primers having more than 30, more than 40, more than 50 nucleotides and probes having more than 100, more than 200, more than 300, more than 500 more than 800 and more than 1000 nucleotides in length are also covered by the present invention. Of course, longer primers have the disadvantage of being more expensive and thus, primers having between 15 and 30 nucleotides in length are usually designed and used in the art. As well known in the art, probes ranging from 10 to more than 2000 nucleotides in length can be used in the methods of the present invention. As for the % of identity described above, non- specifically described sizes of probes and primers (e.g., 16, 17, 31, 24, 39, 350, 450, 550, 900, 1240 nucleotides, . . . ) are also within the scope of the present invention. In one embodiment, the oligonucleotide probes or primers of the present invention specifically hybridize with an Enol RNA (or its complementary sequence) or an Enol mRNA. More preferably, the Enol primers and probes are chosen to detect an Enol RNA which is associated with elevated blood glucose or abnormal blood glucose regulation related to, e.g., pre-diabetes, type 2 diabetes, type 1 diabetes, or gestational diabetes.

In other embodiments, the detection means can utilize a hybridization technique, e.g., where a specific primer or probe is selected to anneal to a target biomarker of interest, e.g., Enol, and thereafter detection of selective hybridization is made. As commonly known in the art, the oligonucleotide probes and primers can be designed by taking into consideration the melting point of hybridization thereof with its targeted sequence (see below and in Sambrook et al., 1989, Molecular Cloning— A Laboratory Manual, 2nd Edition, CSH Laboratories; Ausubel et al., 1994, in Current Protocols in Molecular Biology, John Wiley & Sons Inc., N.Y.). To enable hybridization to occur under the assay conditions of the present invention, oligonucleotide primers and probes should comprise an oligonucleotide sequence that has at least 70% (at least 71%, 72%, 73%, 74% or more), preferably at least 75% (75%, 76%, 77%, 78%, 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89% or more) and more preferably at least 90% (90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, 100%) identity to a portion of an Enol polynucleotide. Probes and primers of the present invention are those that hybridize under stringent hybridization conditions and those that hybridize to Enol homologs under at least moderately stringent conditions. In certain embodiments probes and primers of the present invention have complete sequence identity to Enol gene sequences (e.g., cDNA or mRNA). It should be understood that other probes and primers could be easily designed and used in the present invention based on the Enol sequences disclosed herein by using methods of computer alignment and sequence analysis known in the art (cf. Molecular Cloning: A Laboratory Manual, Third Edition, edited by Cold Spring Harbor Laboratory, 2000).

C. Detection of Polypeptide Indicators of Blood Glucose of Blood Glucose Control The present invention contemplates any suitable method for detecting polypeptide indicators of blood glucose including Enol and HbAlc. In certain embodiments, the detection method is an immunodetection method involving an antibody that specifically binds to one or more of Enol and hemoglobin, especially specifically to glycated hemoglobin. The steps of various useful immunodetection methods have been described in the scientific literature, such as, e.g., Nakamura et al. (1987), which is incorporated herein by reference.

In general, the immunobinding methods include obtaining a sample suspected of containing a protein or peptide indicator of elevated blood glucose, and contacting the sample with an antibody in accordance with the present invention, as the case may be, under conditions effective to allow the formation of immunocomplexes. The immunobinding methods include methods for detecting or quantifying the amount of a reactive component in a sample, which methods require the detection or quantitation of any immune complexes formed during the binding process. Here, one would obtain a sample suspected of containing a protein or peptide indicator of elevated blood glucose, and contact the sample with an antibody, and then detect or quantify the amount of immune complexes formed under the specific conditions.

In terms of detection of an indicator of blood glucose, the biological sample analyzed may be any sample that is suspected of containing a protein or peptide indicator of blood glucose, such as, Enol or HbAlc. The biological sample may be, for example, blood, in the case of HbAlc, or blood or serum in the case of Enol. Contacting the chosen biological sample with the antibody (e.g., as a detection reagent that binds Enol, HbAlc, or hemoglobin in a biological sample) under conditions effective and for a period of time sufficient to allow the formation of immune complexes (primary immune complexes). Generally, complex formation is a matter of simply adding the composition to the biological sample and incubating the mixture for a period of time long enough for the antibodies to form immune complexes with, i.e., to bind to, any antigens present. After this time, the sample-antibody composition, such as a tissue section, ELISA plate, dot blot or western blot, is generally washed to remove any non-specifically bound antibody species, allowing only those antibodies specifically bound within the primary immune complexes to be detected. In general, the detection of immunocomplex formation is well known in the art and may be achieved through the application of numerous approaches. These methods are generally based upon the detection of a label or marker, such as any radioactive, fluorescent, biological or enzymatic tags or labels of standard use in the art. U.S. patents concerning the use of such labels include U.S. Pat. Nos. 3,817,837; 3,850,752; 3,939,350; 3,996,345;

4,277,437; 4,275,149 and 4,366,241, each incorporated herein by reference. Of course, one may find additional advantages through the use of a secondary binding ligand such as a second antibody or a biotin/avidin ligand binding arrangement, as is known in the art.

The antibody (e.g., anti-Enol antibody, anti-hemoglobin or anti-glycated hemoglobin antibody) employed in the detection may itself be linked to a detectable label, wherein one would then simply detect this label, thereby allowing the amount of the primary immune complexes in the composition to be determined.

Alternatively, the first added component that becomes bound within the primary immune complexes may be detected by means of a second binding ligand that has binding affinity for the bound antibody. In these cases, the second binding ligand may be linked to a detectable label. The second binding ligand is itself often an antibody, which may thus be termed a "secondary" antibody. The primary immune complexes are contacted with the labeled, secondary binding ligand, or antibody, under conditions effective and for a period of time sufficient to allow the formation of secondary immune complexes. The secondary immune complexes are then generally washed to remove any non-specifically bound labeled secondary antibodies or ligands, and the remaining label in the secondary immune complexes is then detected.

Further methods include the detection of primary immune complexes by a two step approach. A second binding ligand, such as an antibody, that has binding affinity for the encoded protein, peptide or corresponding antibody is used to form secondary immune complexes, as described above. After washing, the secondary immune complexes are contacted with a third binding ligand or antibody that has binding affinity for the second antibody, again under conditions effective and for a period of time sufficient to allow the formation of immune complexes (tertiary immune complexes). The third ligand or antibody is linked to a detectable label, allowing detection of the tertiary immune complexes thus formed. This system may provide for signal amplification if this is desired. The immunodetection methods of the present invention have evident utility in the diagnosis of conditions such as elevated blood glucose, loss of blood glucose control, and diabetes. Here, a biological or clinical sample suspected of containing either the encoded protein or glycated peptide is used. However, these embodiments also have applications to non-clinical samples, such as in the tittering of antigen or antibody samples, in the selection of hybridomas, and the like.

The present invention, in particular, contemplates the use of ELISAs as a type of immunodetection assay. It is contemplated that the biomarker proteins or peptides of the invention will find utility as immunogens in ELISA assays in diagnosis and prognostic monitoring abnormal blood glucose and diabetes. Immunoassays, in their most simple and direct sense, are binding assays. Certain preferred immunoassays are the various types of enzyme linked immunosorbent assays (ELISAs) and radioimmunoassays (RIA) known in the art. Immunohistochemical detection using tissue sections can be useful. However, it will be readily appreciated that detection is not limited to such techniques, and western blotting, dot blotting, and the like also may be used. In one exemplary ELISA, antibodies binding to the protein indicators of the invention are immobilized onto a selected surface exhibiting protein affinity, such as a well in a polystyrene microtiter plate. Then, a test composition suspected of containing an indicator of blood glucose levels, such as a blood or serum sample, is added to the wells. After binding and washing to remove non- specifically bound immunecomplexes, the bound antigen may be detected. Detection is generally achieved by the addition of a second antibody specific for the indicator protein, that is linked to a detectable label. This type of ELISA is a simple

"sandwich ELISA." Detection also may be achieved by the addition of a second antibody, followed by the addition of a third antibody that has binding affinity for the second antibody, with the third antibody being linked to a detectable label. In another exemplary ELISA, the samples suspected of containing the blood glucose indicator proteins are immobilized onto the well surface and then contacted with specific antibodies for binding the indicators. After binding and washing to remove non- specifically bound immunecomplexes, the bound antigen is detected. Where the initial antibodies are linked to a detectable label, the immunecomplexes may be detected directly. Again, the immunocomplexes may be detected using a second antibody that has binding affinity for the first antibody, with the second antibody being linked to a detectable label.

Irrespective of the format employed, ELISAs have certain features in common, such as coating, incubating or binding, washing to remove non- specifically bound species, and detecting the bound immunecomplexes. These are described as follows.

In coating a plate with either antigen or antibody, one will generally incubate the wells of the plate with a solution of the antigen or antibody, either overnight or for a specified period of hours. The wells of the plate will then be washed to remove incompletely adsorbed material. Any remaining available surfaces of the wells are then "coated" with a nonspecific protein that is antigenically neutral with regard to the test antisera. These include bovine serum albumin (BSA), casein, and solutions of milk powder. The coating allows for blocking of nonspecific adsorption sites on the immobilizing surface and thus reduces the background caused by nonspecific binding of antisera onto the surface.

In ELISAs, it is customary to use a secondary or tertiary detection means rather than a direct procedure. Thus, after binding of a protein or antibody to the well, coating with a non- reactive material to reduce background, and washing to remove unbound material, the immobilizing surface is contacted with the control biological sample, e.g., blood or serum from a subject with normal blood glucose and/or sufficient blood glucose control to be tested under conditions effective to allow immunecomplex (antigen/antibody) formation. Detection of the immunocomplex then requires a labeled secondary binding ligand or antibody, or a secondary binding ligand or antibody in conjunction with a labeled tertiary antibody or third binding ligand.

The phrase "under conditions effective to allow immunecomplex (antigen/antibody) formation" means that the conditions preferably include diluting the antigens and antibodies with solutions such as BSA, bovine gamma globulin (BGG) and phosphate buffered saline (PBS)/Tween. These added agents also tend to assist in the reduction of nonspecific background. The "suitable" conditions also mean that the incubation is at a temperature and for a period of time sufficient to allow effective binding. Incubation steps are typically from about 1 to about 4 hours, at temperatures preferably on the order of 25 to 27°C, or may be overnight at about 4°C or so.

Following all incubation steps in an ELISA, the contacted surface is washed so as to remove non-complexed material. A preferred washing procedure includes washing with a solution such as PBS/Tween or borate buffer. Following the formation of specific

immunecomplexes between the test sample and the originally bound material, and subsequent washing, the occurrence of even minute amounts of immunecomplexes may be determined.

To provide a detecting means, the second or third antibody has an associated label to allow detection. Preferably, the label is an enzyme that generates color development upon incubating with an appropriate chromogenic substrate. Thus, for example, the first or second immunecomplex is contacted and incubated with a urease, glucose oxidase, alkaline phosphatase or hydrogen peroxidase-conjugated antibody for a period of time and under conditions that favor the development of further immunecomplex formation (e.g., incubation for 2 h at room temperature in a PBS-containing solution such as PBS-Tween).

After incubation with the labeled antibody, and subsequent to washing to remove unbound material, the amount of label is quantified, e.g., by incubation with a chromogenic substrate such as urea and bromocresol purple. Quantitation is then achieved by measuring the degree of color generation, e.g., using a visible spectra spectrophotometer.

The protein biomarkers/indicators of the invention (e.g., Enol, HbAlc) can also be measured, quantitated, detected, and otherwise analyzed using protein mass spectrometry methods and instrumentation. Protein mass spectrometry refers to the application of mass spectrometry to the study of proteins. Although not intending to be limiting, two approaches are typically used for characterizing proteins using mass spectrometry. In the first, intact proteins are ionized and then introduced to a mass analyzer. This approach is referred to as "top-down" strategy of protein analysis. The two primary methods for ionization of whole proteins are electrospray ionization (ESI) and matrix-assisted laser desorption/ionization (MALDI). In the second approach, proteins are enzymatically digested into smaller peptides using a protease such as trypsin. Subsequently these peptides are introduced into the mass spectrometer and identified by peptide mass fingerprinting or tandem mass spectrometry. Hence, this latter approach (also called "bottom-up" proteomics) uses identification at the peptide level to infer the existence of proteins.

Whole protein mass analysis of the biomarkers of the invention can be conducted using time-of-flight (TOF) MS, or Fourier transform ion cyclotron resonance (FT-ICR). These two types of instruments are useful because of their wide mass range, and in the case of FT-ICR, its high mass accuracy. The most widely used instruments for peptide mass analysis are the MALDI time-of-flight instruments as they permit the acquisition of peptide mass fingerprints (PMFs) at high pace (1 PMF can be analyzed in approx. 10 sec). Multiple stage quadrupole-time-of-flight and the quadrupole ion trap also find use in this application. Protein indicators can also be measured in complex mixtures of proteins and molecules that co-exist in a biological medium or sample, however, fractionation of the sample may be required and is contemplated herein. It will be appreciated that ionization of complex mixtures of proteins can result in situation where the more abundant proteins have a tendency to "drown" or suppress signals from less abundant proteins in the same sample. In addition, the mass spectrum from a complex mixture can be difficult to interpret because of the overwhelming number of mixture components. Fractionation can be used to first separate any complex mixture of proteins prior to mass spectrometry analysis. Two methods are widely used to fractionate proteins, or their peptide products from an enzymatic digestion. The first method fractionates whole proteins and is called two-dimensional gel

electrophoresis. The second method, high performance liquid chromatography (LC or HPLC) is used to fractionate peptides after enzymatic digestion. In some situations, it may be desirable to combine both of these techniques. Any other suitable methods known in the art for fractionating protein mixtures are also contemplated herein.

Gel spots identified on a 2D Gel are usually attributable to one protein. If the identity of the protein is desired, usually the method of in-gel digestion is applied, where the protein spot of interest is excised, and digested proteolytically. The peptide masses resulting from the digestion can be determined by mass spectrometry using peptide mass fingerprinting. If this information does not allow unequivocal identification of the protein, its peptides can be subject to tandem mass spectrometry for de novo sequencing. Characterization of protein mixtures using HPLC/MS may also be referred to in the art as "shotgun proteomics" and MuDPIT (Multi-Dimensional Protein Identification Technology). A peptide mixture that results from digestion of a protein mixture is fractionated by one or two steps of liquid chromatography (LC). The eluent from the chromatography stage can be either directly introduced to the mass spectrometer through electrospray ionization, or laid down on a series of small spots for later mass analysis using MALDI.

Protein indicators (e.g., Enol or HblAc) can be identified using MS using a variety of techniques, all of which are contemplated herein. Peptide mass fingerprinting uses the masses of proteolytic peptides as input to a search of a database of predicted masses that would arise from digestion of a list of known proteins. If a protein sequence in the reference list gives rise to a significant number of predicted masses that match the experimental values, there is some evidence that this protein was present in the original sample. It will be further appreciated that the development of methods and instrumentation for automated, data- dependent electrospray ionization (ESI) tandem mass spectrometry (MS/MS) in conjunction with microcapillary liquid chromatography (LC) and database searching has significantly increased the sensitivity and speed of the identification of gel-separated proteins.

Microcapillary LC-MS/MS has been used successfully for the large-scale identification of individual proteins directly from mixtures without gel electrophoretic separation (Link et al., 1999; Opitek et al., 1997).

Several recent methods allow for the quantitation of proteins by mass spectrometry. For example, stable (e.g., non-radioactive) heavier isotopes of carbon (13C) or nitrogen (15N) can be incorporated into one sample while the other one can be labeled with corresponding light isotopes (e.g. 12C and 14N). The two samples are mixed before the analysis. Peptides derived from the different samples can be distinguished due to their mass difference. The ratio of their peak intensities corresponds to the relative abundance ratio of the peptides (and proteins). The most popular methods for isotope labeling are SILAC (stable isotope labeling by amino acids in cell culture), trypsin-catalyzed 180 labeling, ICAT (isotope coded affinity tagging), iTRAQ (isobaric tags for relative and absolute quantitation). "Semi-quantitative" mass spectrometry can be performed without labeling of samples.

Typically, this is done with MALDI analysis (in linear mode). The peak intensity, or the peak area, from individual molecules (typically proteins) is here correlated to the amount of protein in the sample. However, the individual signal depends on the primary structure of the protein, on the complexity of the sample, and on the settings of the instrument. Other types of "label-free" quantitative mass spectrometry, uses the spectral counts (or peptide counts) of digested proteins as a means for determining relative protein amounts.

In one embodiment, any one or more of the protein indicators (e.g., Enol, HbAlc) can be identified and quantified from a complex biological sample using mass spectroscopy in accordance with the following exemplary method, which is not intended to limit the invention or the use of other mass spectrometry-based methods.

In the first step of this embodiment, (A) a biological sample, e.g., a biological sample suspected of having increased blood glucose, which comprises a complex mixture of protein (including at least one indicator of interest) is fragmented and labeled with a stable isotope X. (B) Next, a known amount of an internal standard is added to the biological sample, wherein the internal standard is prepared by fragmenting a standard protein that is identical to the at least one target biomarker of interest, and labeled with a stable isotope Y. (C) This sample obtained is then introduced in an LC-MS/MS device, and multiple reaction monitoring (MRM) analysis is performed using MRM transitions selected for the internal standard to obtain an MRM chromatogram. (D) The MRM chromatogram is then viewed to identify a target peptide biomarker derived from the biological sample that shows the same retention time as a peptide derived from the internal standard (an internal standard peptide), and quantifying the target protein indicator in the test sample by comparing the peak area of the internal standard peptide with the peak area of the target peptide indicator. Any suitable biological sample may be used as a starting point for LC-MS/MS/MRM analysis, including biological samples derived blood, urine, saliva, hair, cells, cell tissues, biopsy materials, and treated products thereof; and protein-containing samples prepared by gene recombination techniques. Preferred embodiments of the invention include the use of blood or serum samples. Each of the above steps (A) to (D) is described further below.

Step (A) (Fragmentation and Labeling). In step (A), the target protein indicator is fragmented to a collection of peptides, which is subsequently labeled with a stable isotope X. To fragment the target protein, for example, methods of digesting the target protein with a proteolytic enzyme (protease) such as trypsin, and chemical cleavage methods, such as a method using cyanogen bromide, can be used. Digestion by protease is preferable. It is known that a given mole quantity of protein produces the same mole quantity for each tryptic peptide cleavage product if the proteolytic digest is allowed to proceed to completion. Thus, determining the mole quantity of tryptic peptide to a given protein allows determination of the mole quantity of the original protein in the sample. Absolute quantification of the target protein can be accomplished by determining the absolute amount of the target protein-derived peptides contained in the protease digestion (collection of peptides). Accordingly, in order to allow the proteolytic digest to proceed to completion, reduction and alkylation treatments are preferably performed before protease digestion with trypsin to reduce and alkylate the disulfide bonds contained in the target protein.

Subsequently, the obtained digest (collection of peptides, comprising peptides of the target biomarker in the biological sample) is subjected to labeling with a stable isotope X. Examples of stable isotopes X include 1H and 2H for hydrogen atoms, 12C and 13C for carbon atoms, and 14N and 15N for nitrogen atoms. Any isotope can be suitably selected therefrom. Labeling by a stable isotope X can be performed by reacting the digest (collection of peptides) with a reagent containing the stable isotope. Preferable examples of such reagents that are commercially available include mTRAQ® (produced by Applied

Biosystems), which is an amine- specific stable isotope reagent kit. mTRAQ® is composed of 2 or 3 types of reagents (mTRAQ®-light and mTRAQ®-heavy; or mTRAQ®-D0, mTRAQ®-D4, and mTRAQ®-D8) that have a constant mass difference there between as a result of isotope-labeling, and that are bound to the N-terminus of a peptide or the primary amine of a lysine residue.

Step (B) (Addition of the Internal Standard). In step (B), a known amount of an internal standard is added to the sample obtained in step (A). The internal standard used herein is a digest (collection of peptides) obtained by fragmenting a protein (standard protein) consisting of the same amino acid sequence as the target protein (target biomarker) to be measured, and labeling the obtained digest (collection of peptides) with a stable isotope Y. The fragmentation treatment can be performed in the same manner as above for the target protein. Labeling with a stable isotope Y can also be performed in the same manner as above for the target protein. However, the stable isotope Y used herein must be an isotope that has a mass different from that of the stable isotope X used for labeling the target protein digest. For example, in the case of using the aforementioned mTRAQ (registered trademark) (produced by Applied Biosystems), when mTRAQ-light is used to label a target protein digest, mTRAQ-heavy should be used to label a standard protein digest. Step (C) (LC-MS/MS and MRM Analysis). In step (C), the sample obtained in step (B) is first placed in an LC-MS/MS device, and then multiple reaction monitoring (MRM) analysis is performed using MRM transitions selected for the internal standard. By LC (liquid chromatography) using the LC-MS/MS device, the sample (collection of peptides labeled with a stable isotope) obtained in step (B) is separated first by one-dimensional or multi-dimensional high-performance liquid chromatography. Specific examples of such liquid chromatography include cation exchange chromatography, in which separation is conducted by utilizing electric charge difference between peptides; and reversed-phase chromatography, in which separation is conducted by utilizing hydrophobicity difference between peptides. Both of these methods may be used in combination.

Subsequently, each of the separated peptides is subjected to tandem mass

spectrometry by using a tandem mass spectrometer (MS/MS spectrometer) comprising two mass spectrometers connected in series. The use of such a mass spectrometer enables the detection of several fmol levels of a target protein. Furthermore, MS/MS analysis enables the analysis of internal sequence information on peptides, thus enabling identification without false positives. Other types of MS analyzers may also be used, including magnetic sector mass spectrometers (Sector MS), quadrupole mass spectrometers (QMS), time-of-flight mass spectrometers (TOFMS), and Fourier transform ion cyclotron resonance mass spectrometers (FT-ICRMS), and combinations of these analyzers. Subsequently, the obtained data are put through a search engine to perform a spectral assignment and to list the peptides experimentally detected for each protein. The detected peptides are preferably grouped for each protein, and preferably at least three fragments having an m/z value larger than that of the precursor ion and at least three fragments with an m/z value of, preferably, 500 or more are selected from each MS/MS spectrum in descending order of signal strength on the spectrum. From these, two or more fragments are selected in descending order of strength, and the average of the strength is defined as the expected sensitivity of the MRR transitions. When a plurality of peptides is detected from one protein, at least two peptides with the highest sensitivity are selected as standard peptides using the expected sensitivity as an index. Step (D) (Quantification of the Target Protein in the Test Sample). Step (D) comprises identifying, in the MRM chromatogram detected in step (C), a peptide derived from the target protein (a target biomarker of interest) that shows the same retention time as a peptide derived from the internal standard (an internal standard peptide), and quantifying the target protein in the test sample by comparing the peak area of the internal standard peptide with the peak area of the target peptide. The target protein can be quantified by utilizing a calibration curve of the standard protein prepared beforehand. The calibration curve can be prepared by the following method. First, a recombinant protein consisting of an amino acid sequence that is identical to that of the target biomarker protein is digested with a protease such as trypsin, as described above. Subsequently, precursor-fragment transition selection standards (PFTS) of a known concentration are individually labeled with two different types of stable isotopes (i.e., one is labeled with a stable isomer used to label an internal standard peptide (labeled with IS), whereas the other is labeled with a stable isomer used to label a target peptide (labeled with T). A plurality of samples are produced by blending a certain amount of the IS-labeled PTFS with various concentrations of the T-labeled PTFS. These samples are placed in the aforementioned LC- MS/MS device to perform MRM analysis. The area ratio of the T-labeled PTFS to the IS- labeled PTFS (T-labeled PTFS/IS-labeled PTFS) on the obtained MRM chromatogram is plotted against the amount of the T-labeled PTFS to prepare a calibration curve. The absolute amount of the target protein contained in the test sample can be calculated by reference to the calibration curve.

D. Antibodies and Labels (e.g., fluorescent moieties and dyes) In some embodiments, the invention provides methods and compositions that include labels for the highly sensitive detection and quantitation of the biomolecules of the invention, e.g., Enol alone or in combination with at least one other indicator of blood glucose and blood glucose control, e.g., HbAlc, ketones, or direct measurement of blood glucose. One skilled in the art will recognize that many strategies can be used for labeling target molecules to enable their detection or discrimination in a mixture of particles (e.g., labeled anti-Enol antibody or labeled secondary antibody, or labeled oligonucleotide probe that specifically hybridizes to Enol mRNA). The labels may be attached by any known means, including methods that utilize non-specific or specific interactions of label and target. Labels may provide a detectable signal or affect the mobility of the particle in an electric field. In addition, labeling can be accomplished directly or through binding partners. In some embodiments, the label comprises a binding partner that binds to the indicator of interest, where the binding partner is attached to a fluorescent moiety. The compositions and methods of the invention may utilize highly fluorescent moieties, e.g., a moiety capable of emitting at least about 200 photons when simulated by a laser emitting light at the excitation wavelength of the moiety, wherein the laser is focused on a spot not less than about 5 microns in diameter that contains the moiety, and wherein the total energy directed at the spot by the laser is no more than about 3 microJoules. Moieties suitable for the compositions and methods of the invention are described in more detail below.

In some embodiments, the invention provides a label for detecting a biological molecule comprising a binding partner for the biological molecule that is attached to a fluorescent moiety, wherein the fluorescent moiety is capable of emitting at least about 200 photons when simulated by a laser emitting light at the excitation wavelength of the moiety, wherein the laser is focused on a spot not less than about 5 microns in diameter that contains the moiety, and wherein the total energy directed at the spot by the laser is no more than about 3 microJoules. In some embodiments, the moiety comprises a plurality of fluorescent entities, e.g., about 2 to 4, 2 to 5, 2 to 6, 2 to 7, 2 to 8, 2 to 9, 2 to 10, or about 3 to 5, 3 to 6, 3 to 7, 3 to 8, 3 to 9, or 3 to 10 fluorescent entities. In some embodiments, the moiety comprises about 2 to 4 fluorescent entities. In some embodiments, the biological molecule is a protein or a small molecule. In some embodiments, the biological molecule is a protein. The fluorescent entities can be fluorescent dye molecules. In some embodiments, the fluorescent dye molecules comprise at least one substituted indolium ring system in which the substituent on the 3-carbon of the indolium ring contains a chemically reactive group or a conjugated substance. In some embodiments, the dye molecules are Alexa Fluor molecules selected from the group consisting of Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 647, Alexa Fluor 680 or Alexa Fluor 700. In some embodiments, the dye molecules are Alexa Fluor molecules selected from the group consisting of Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 680 or Alexa Fluor 700. In some embodiments, the dye molecules are Alexa Fluor 647 dye molecules. In some embodiments, the dye molecules comprise a first type and a second type of dye molecules, e.g., two different Alexa Fluor molecules, e.g., where the first type and second type of dye molecules have different emission spectra. The ratio of the number of first type to second type of dye molecule can be, e.g., 4 to 1, 3 to 1, 2 to 1, 1 to 1, 1 to 2, 1 to 3 or 1 to 4. The binding partner can be, e.g., an antibody. In some embodiments, the invention provides a label for the detection of a biological indicators of the invention, wherein the label comprises a binding partner for the indicator and a fluorescent moiety, wherein the fluorescent moiety is capable of emitting at least about 200 photons when simulated by a laser emitting light at the excitation wavelength of the moiety, wherein the laser is focused on a spot not less than about 5 microns in diameter that contains the moiety, and wherein the total energy directed at the spot by the laser is no more than about 3 microJoules. In some embodiments, the fluorescent moiety comprises a fluorescent molecule. In some embodiments, the fluorescent moiety comprises a plurality of fluorescent molecules, e.g., about 2 to 10, 2 to 8, 2 to 6, 2 to 4, 3 to 10, 3 to 8, or 3 to 6 fluorescent molecules. In some embodiments, the label comprises about 2 to 4 fluorescent molecules. In some embodiments, the fluorescent dye molecules comprise at least one substituted indolium ring system in which the substituent on the 3-carbon of the indolium ring contains a chemically reactive group or a conjugated substance. In some embodiments, the fluorescent molecules are selected from the group consisting of Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 647, Alexa Fluor 680 or Alexa Fluor 700. In some embodiments, the fluorescent molecules are selected from the group consisting of Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 680 or Alexa Fluor 700. In some embodiments, the fluorescent molecules are Alexa Fluor 647 molecules. In some embodiments, the binding partner comprises an antibody. In some embodiments, the antibody is a monoclonal antibody. In other

embodiments, the antibody is a polyclonal antibody.

In various embodiments, the binding partner for detecting an indicator of interest, e.g., Enol or HbAlc, is an antibody or antigen -binding fragment thereof. The term "antibody," as used herein, is a broad term and is used in its ordinary sense, including, without limitation, to refer to naturally occurring antibodies as well as non-naturally occurring antibodies, including, for example, single chain antibodies, chimeric, bifunctional and humanized antibodies, as well as antigen-binding fragments thereof. An "antigen-binding fragment" of an antibody refers to the part of the antibody that participates in antigen binding. The antigen binding site is formed by amino acid residues of the N-terminal variable ("V") regions of the heavy ("H") and light ("L") chains. It will be appreciated that the choice of epitope or region of the molecule to which the antibody is raised will determine its specificity, e.g., for various forms of the molecule, if present, or for total (e.g., all, or substantially all of the molecule). Methods for producing antibodies are well-established. One skilled in the art will recognize that many procedures are available for the production of antibodies, for example, as described in Antibodies, A Laboratory Manual, Ed Harlow and David Lane, Cold Spring Harbor Laboratory (1988), Cold Spring Harbor, N.Y. One skilled in the art will also appreciate that binding fragments or Fab fragments which mimic antibodies can also be prepared from genetic information by various procedures (Antibody Engineering: A Practical Approach (Borrebaeck, C, ed.), 1995, Oxford University Press, Oxford; J. Immunol. 149, 3914-3920 (1992)). Monoclonal and polyclonal antibodies to molecules, e.g., proteins, and markers also commercially available (R and D Systems, Minneapolis, Minn.; HyTest, HyTest Ltd., Turku Finland; Abeam Inc., Cambridge, Mass., USA, Life Diagnostics, Inc., West Chester, Pa., USA; Fitzgerald Industries International, Inc., Concord, Mass. 01742-3049 USA; BiosPacific, Emeryville, Calif.).

In some embodiments, the antibody is a polyclonal antibody. In other embodiments, the antibody is a monoclonal antibody. Antibodies may be prepared by any of a variety of techniques known to those of ordinary skill in the art (see, for example, Harlow and Lane, Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory, 1988). In general, antibodies can be produced by cell culture techniques, including the generation of monoclonal antibodies as described herein, or via transfection of antibody genes into suitable bacterial or mammalian cell hosts, in order to allow for the production of recombinant antibodies.

Monoclonal antibodies may be prepared using hybridoma methods, such as the technique of Kohler and Milstein (Eur. J. Immunol. 6:511-519, 1976), and improvements thereto. These methods involve the preparation of immortal cell lines capable of producing antibodies having the desired specificity. Monoclonal antibodies may also be made by recombinant DNA methods, such as those described in U.S. Pat. No. 4,816,567. DNA encoding antibodies employed in the disclosed methods may be isolated and sequenced using conventional procedures. Recombinant antibodies, antibody fragments, and/or fusions thereof, can be expressed in vitro or in prokaryotic cells (e.g. bacteria) or eukaryotic cells (e.g. yeast, insect or mammalian cells) and further purified as necessary using well known methods. More particularly, monoclonal antibodies (MAbs) may be readily prepared through use of well-known techniques, such as those exemplified in U.S. Pat. No. 4,196,265, incorporated herein by reference. Typically, this technique involves immunizing a suitable animal with a selected immunogen composition, e.g., a purified or partially purified expressed protein, polypeptide or peptide. The immunizing composition is administered in a manner effective to stimulate antibody producing cells. The methods for generating monoclonal antibodies (MAbs) generally begin along the same lines as those for preparing polyclonal antibodies. Rodents such as mice and rats are preferred animals, however, the use of rabbit, sheep or frog cells is also possible. The use of rats may provide certain advantages (Goding, 1986, pp. 60-61), but mice are preferred, with the BALB/c mouse being most preferred as this is most routinely used and generally gives a higher percentage of stable fusions.

The animals are injected with antigen as described above. The antigen may be coupled to carrier molecules such as keyhole limpet hemocyanin if necessary. The antigen would typically be mixed with adjuvant, such as Freund's complete or incomplete adjuvant. Booster injections with the same antigen would occur at approximately two-week intervals. Following immunization, somatic cells with the potential for producing antibodies, specifically B lymphocytes (B cells), are selected for use in the MAb generating protocol. These cells may be obtained from biopsied spleens, tonsils or lymph nodes, or from a peripheral blood sample. Spleen cells and peripheral blood cells are preferred, the former because they are a rich source of antibody-producing cells that are in the dividing plasma blast stage, and the latter because peripheral blood is easily accessible. Often, a panel of animals will have been immunized and the spleen of the animal with the highest antibody titer will be removed and the spleen lymphocytes obtained by homogenizing the spleen with a syringe.

The antibody-producing B lymphocytes from the immunized animal are then fused with cells of an immortal myeloma cell, generally one of the same species as the animal that was immunized. Myeloma cell lines suited for use in hybridoma-producing fusion procedures preferably are non-antibody-producing, have high fusion efficiency, and enzyme deficiencies that render then incapable of growing in certain selective media which support the growth of only the desired fused cells (hybridomas). The selected hybridomas are then serially diluted and cloned into individual antibody- producing cell lines, which clones may then be propagated indefinitely to provide MAbs. The cell lines may be exploited for MAb production in two basic ways. A sample of the hybridoma may be injected (often into the peritoneal cavity) into a histocompatible animal of the type that was used to provide the somatic and myeloma cells for the original fusion. The injected animal develops tumors secreting the specific monoclonal antibody produced by the fused cell hybrid. The body fluids of the animal, such as serum or ascites fluid, can then be tapped to provide MAbs in high concentration. The individual cell lines also can be cultured in vitro, where the MAbs are naturally secreted into the culture medium from which they can be readily obtained in high concentrations. MAbs produced by either means can be further purified, if desired, using filtration, centrifugation and various chromatographic methods such as HPLC or affinity chromatography.

Large amounts of the monoclonal antibodies of the present invention also can be obtained by multiplying hybridoma cells in vivo. Cell clones are injected into mammals which are histocompatible with the parent cells, e.g., syngeneic mice, to cause growth of antibody-producing tumors. Optionally, the animals are primed with a hydrocarbon, especially oils such as pristane (tetramethylpentadecane) prior to injection.

In accordance with the present invention, fragments of the monoclonal antibody of the invention may be obtained from the monoclonal antibody produced as described above, by methods which include digestion with enzymes such as pepsin or papain and/or cleavage of disulfide bonds by chemical reduction. Alternatively, monoclonal antibody fragments encompassed by the present invention may be synthesized using an automated peptide synthesizer.

Antibodies can also be derived from a recombinant antibody library that is based on amino acid sequences that have been designed in silico and encoded by polynucleotides that are synthetically generated. Methods for designing and obtaining in silico-created sequences are known in the art (Knappik et al., J. Mol. Biol. 296:254:57-86, 2000; Krebs et al., J.

Immunol. Methods 254:67-84, 2001; U.S. Pat. No. 6,300,064).

Digestion of antibodies to produce antigen-binding fragments thereof can be performed using techniques well known in the art. For example, the proteolytic enzyme papain preferentially cleaves IgG molecules to yield several fragments, two of which (the "F(ab)" fragments) each comprise a covalent heterodimer that includes an intact antigen- binding site. The enzyme pepsin is able to cleave IgG molecules to provide several fragments, including the "F(ab')₂" fragment, which comprises both antigen-binding sites. "Fv" fragments can be produced by preferential proteolytic cleavage of an IgM, IgG or IgA immunoglobulin molecule, but are more commonly derived using recombinant techniques known in the art. The Fv fragment includes a non-covalent V_H-V_L heterodimer including an antigen-binding site which retains much of the antigen recognition and binding capabilities of the native antibody molecule (Inbar et al., Proc. Natl. Acad. Sci. USA 69:2659-2662 (1972); Hochman et al., Biochem. 15:2706-2710 (1976); and Ehrlich et al., Biochem. 19:4091-4096 (1980)).

Antibody fragments that specifically bind to the polypeptide indicators disclosed herein can also be isolated from a library of scFvs using known techniques, such as those described in U.S. Pat. No. 5,885,793.

A wide variety of expression systems are available in the art for the production of antibody fragments, including Fab fragments, scFv, VL and VHs. For example, expression systems of both prokaryotic and eukaryotic origin may be used for the large-scale production of antibody fragments. Particularly advantageous are expression systems that permit the secretion of large amounts of antibody fragments into the culture medium. Eukaryotic expression systems for large-scale production of antibody fragments and antibody fusion proteins have been described that are based on mammalian cells, insect cells, plants, transgenic animals, and lower eukaryotes. For example, the cost-effective, large-scale production of antibody fragments can be achieved in yeast fermentation systems. Large-scale fermentation of these organisms is well known in the art and is currently used for bulk production of several recombinant proteins.

Antibodies that bind to the polypeptide biomarkers employed in the present methods are well known to those of skill in the art and in some cases are available commercially or can be obtained without undue experimentation.

In still other embodiments, particularly where oligonucleotides are used as binding partners to detect and hybridize to mRNA biomarkers or other nucleic acid based biomarkers, the binding partners (e.g., oligonucleotides) can comprise a label, e.g., a fluorescent moiety or dye. In addition, any binding partner of the invention, e.g., an antibody, can also be labeled with a fluorescent moiety. A "fluorescent moiety," as that term is used herein, includes one or more fluorescent entities whose total fluorescence is such that the moiety may be detected in the single molecule detectors described herein. Thus, a fluorescent moiety may comprise a single entity (e.g., a Quantum Dot or fluorescent molecule) or a plurality of entities (e.g., a plurality of fluorescent molecules). It will be appreciated that when "moiety," as that term is used herein, refers to a group of fluorescent entities, e.g., a plurality of fluorescent dye molecules, each individual entity may be attached to the binding partner separately or the entities may be attached together, as long as the entities as a group provide sufficient fluorescence to be detected. Typically, the fluorescence of the moiety involves a combination of quantum efficiency and lack of photobleaching sufficient that the moiety is detectable above background levels in a single molecule detector, with the consistency necessary for the desired limit of detection, accuracy, and precision of the assay. For example, in some embodiments, the fluorescence of the fluorescent moiety is such that it allows detection and/or quantitation of a molecule, e.g., a marker, at a limit of detection of less than about 10, 5, 4, 3, 2, 1, 0.1, 0.01, 0.001, 0.00001, or 0.000001 pg/ml and with a coefficient of variation of less than about 20, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1% or less, e.g., about 10% or less, in the instruments described herein. In some embodiments, the fluorescence of the fluorescent moiety is such that it allows detection and/or quantitation of a molecule, e.g., a marker, at a limit of detection of less than about 5, 1, 0.5, 0.1, 0.05, 0.01, 0.005, 0.001 pg/ml and with a coefficient of variation of less than about 10%, in the instruments described herein. "Limit of detection," or LoD, as those terms are used herein, includes the lowest concentration at which one can identify a sample as containing a molecule of the substance of interest, e.g., the first non-zero value. It can be defined by the variability of zeros and the slope of the standard curve. For example, the limit of detection of an assay may be determined by running a standard curve, determining the standard curve zero value, and adding 2 standard deviations to that value. A concentration of the substance of interest that produces a signal equal to this value is the "lower limit of detection" concentration.

Furthermore, the moiety has properties that are consistent with its use in the assay of choice. In some embodiments, the assay is an immunoassay, where the fluorescent moiety is attached to an antibody; the moiety must have properties such that it does not aggregate with other antibodies or proteins, or experiences no more aggregation than is consistent with the required accuracy and precision of the assay. In some embodiments, fluorescent moieties that are preferred are fluorescent moieties, e.g., dye molecules that have a combination of 1) high absorption coefficient; 2) high quantum yield; 3) high photo stability (low photobleaching); and 4) compatibility with labeling the molecule of interest (e.g., protein) so that it may be analyzed using the analyzers and systems of the invention (e.g., does not cause precipitation of the protein of interest, or precipitation of a protein to which the moiety has been attached).

Any suitable fluorescent moiety may be used. Examples include, but are not limited to, Alexa Fluor dyes (Molecular Probes, Eugene, Oreg.). The Alexa Fluor dyes are disclosed in U.S. Pat. Nos. 6,977,305; 6,974,874; 6,130,101; and 6,974,305 which are herein incorporated by reference in their entirety. Some embodiments of the invention utilize a dye chosen from the group consisting of Alexa Fluor 647, Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 555, Alexa Fluor 610, Alexa Fluor 680, Alexa Fluor 700, and Alexa Fluor 750. Some embodiments of the invention utilize a dye chosen from the group consisting of Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 647, Alexa Fluor 700 and Alexa Fluor 750. Some embodiments of the invention utilize a dye chosen from the group consisting of Alexa Fluor 488, Alexa Fluor 532, Alexa Fluor 555, Alexa Fluor 610, Alexa Fluor 680, Alexa Fluor 700, and Alexa Fluor 750. Some embodiments of the invention utilize the Alexa Fluor 647 molecule, which has an absorption maximum between about 650 and 660 nm and an emission maximum between about 660 and 670 nm. The Alexa Fluor 647 dye is used alone or in combination with other Alexa Fluor dyes.

In some embodiments, the fluorescent label moiety that is used to detect an indicator in a sample using the analyzer systems of the invention is a quantum dot. Quantum dots (QDs), also known as semiconductor nanocrystals or artificial atoms, are semiconductor crystals that contain anywhere between 100 to 1,000 electrons and range from 2-10 nm. Some QDs can be between 10-20 nm in diameter. QDs have high quantum yields, which makes them particularly useful for optical applications. QDs are fluorophores that fluoresce by forming excitons, which are similar to the excited state of traditional fluorophores, but have much longer lifetimes of up to 200 nanoseconds. This property provides QDs with low photobleaching. The energy level of QDs can be controlled by changing the size and shape of the QD, and the depth of the QDs' potential. One optical feature of small excitonic QDs is coloration, which is determined by the size of the dot. The larger the dot, the redder, or more towards the red end of the spectrum the fluorescence. The smaller the dot, the bluer or more towards the blue end it is. The bandgap energy that determines the energy and hence the color of the fluoresced light is inversely proportional to the square of the size of the QD. Larger QDs have more energy levels which are more closely spaced, thus allowing the QD to absorb photons containing less energy, i.e., those closer to the red end of the spectrum. Because the emission frequency of a dot is dependent on the bandgap, it is possible to control the output wavelength of a dot with extreme precision. In some embodiments the protein that is detected with the single molecule analyzer system is labeled with a QD. In some embodiments, the single molecule analyzer is used to detect a protein labeled with one QD and using a filter to allow for the detection of different proteins at different wavelengths. E. Isolated Macromolecular Indicators of Blood Glucose

1. Isolated Polypeptide Indicators

One aspect of the invention pertains to isolated indicator proteins and biologically active portions thereof, as well as polypeptide fragments suitable for use as immunogens to raise antibodies directed against an indicator protein or a fragment thereof. In one

embodiment, the native indicator protein can be isolated from cells or tissue sources by an appropriate purification scheme using standard protein purification techniques. In another embodiment, a protein or peptide comprising the whole or a segment of the indicator protein is produced by recombinant DNA techniques. Alternative to recombinant expression, such protein or peptide can be synthesized chemically using standard peptide synthesis techniques. Recombinant proteins can be modified, e.g. glycated, to provide appropriate antigens for detection of HbAlc. Simlarly, non-glycated fragments of hemoglobin can be used to raise antibodies that bind either non-glycated hemoglobin alone or total hemoglobin.

An "isolated" or "purified" protein or biologically active portion thereof is

substantially free of cellular material or other contaminating proteins from the cell or tissue source from which the protein is derived, or substantially free of chemical precursors or other chemicals when chemically synthesized. The language "substantially free of cellular material" includes preparations of protein in which the protein is separated from cellular components of the cells from which it is isolated or recombinantly produced. Thus, protein that is substantially free of cellular material includes preparations of protein having less than about 30%, 20%, 10%, or 5% (by dry weight) of heterologous protein (also referred to herein as a "contaminating protein"). When the protein or biologically active portion thereof is recombinantly produced, it is also preferably substantially free of culture medium, i.e., culture medium represents less than about 20%, 10%, or 5% of the volume of the protein preparation. When the protein is produced by chemical synthesis, it is preferably

substantially free of chemical precursors or other chemicals, i.e., it is separated from chemical precursors or other chemicals which are involved in the synthesis of the protein. Accordingly such preparations of the protein have less than about 30%, 20%, 10%, 5% (by dry weight) of chemical precursors or compounds other than the polypeptide of interest.

Biologically active portions of an indicator protein include polypeptides comprising amino acid sequences sufficiently identical to or derived from the amino acid sequence of the indicator protein, which include fewer amino acids than the full length protein, and exhibit at least one activity of the corresponding full-length protein. Typically, biologically active portions comprise a domain or motif with at least one activity of the corresponding full- length protein. A biologically active portion of an indicator protein can be a polypeptide which is, for example, 10, 25, 50, 100 or more amino acids in length. Moreover, other biologically active portions, in which other regions of the marker protein are deleted, can be prepared by recombinant techniques and evaluated for one or more of the functional activities of the native form of the indicator protein.

Preferred indicator proteins are encoded by nucleotide sequences provided in the sequence listing. Other useful proteins are substantially identical (e.g., at least about 40%, preferably 50%, 60%, 70%, 80%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98% or 99%) to one of these sequences and retain the functional activity of the corresponding naturally- occurring indicator protein yet differ in amino acid sequence due to natural allelic variation or mutagenesis.

To determine the percent identity of two amino acid sequences or of two nucleic acids, the sequences are aligned for optimal comparison purposes (e.g., gaps can be introduced in the sequence of a first amino acid or nucleic acid sequence for optimal alignment with a second amino or nucleic acid sequence). The amino acid residues or nucleotides at corresponding amino acid positions or nucleotide positions are then compared. When a position in the first sequence is occupied by the same amino acid residue or nucleotide as the corresponding position in the second sequence, then the molecules are identical at that position. Preferably, the percent identity between the two sequences is calculated using a global alignment. Alternatively, the percent identity between the two sequences is calculated using a local alignment. The percent identity between the two sequences is a function of the number of identical positions shared by the sequences (i.e., % identity = # of identical positions/total # of positions (e.g., overlapping positions) xlOO). In one embodiment the two sequences are the same length. In another embodiment, the two sequences are not the same length.

The determination of percent identity between two sequences can be accomplished using a mathematical algorithm. A preferred, non-limiting example of a mathematical algorithm utilized for the comparison of two sequences is the algorithm of Karlin and Altschul (1990) Proc. Natl. Acad. Sci. USA 87:2264-2268, modified as in Karlin and Altschul (1993) Proc. Natl. Acad. Sci. USA 90:5873-5877. Such an algorithm is

incorporated into the BLASTN and BLASTX programs of Altschul, et al. (1990) J. Mol. Biol. 215:403-410. BLAST nucleotide searches can be performed with the BLASTN program, score = 100, wordlength = 12 to obtain nucleotide sequences homologous to a nucleic acid molecules of the invention. BLAST protein searches can be performed with the BLASTP program, score = 50, wordlength = 3 to obtain amino acid sequences homologous to a protein molecules of the invention. To obtain gapped alignments for comparison purposes, a newer version of the BLAST algorithm called Gapped BLAST can be utilized as described in Altschul et al. (1997) Nucleic Acids Res. 25:3389-3402, which is able to perform gapped local alignments for the programs BLASTN, BLASTP and BLASTX.

Alternatively, PSI-Blast can be used to perform an iterated search which detects distant relationships between molecules. When utilizing BLAST, Gapped BLAST, and PSI-Blast programs, the default parameters of the respective programs (e.g., BLASTX and BLASTN) can be used. See http://www.ncbi.nlm.nih.gov. Another preferred, non-limiting example of a mathematical algorithm utilized for the comparison of sequences is the algorithm of Myers and Miller, (1988) CABIOS 4: 11-17. Such an algorithm is incorporated into the ALIGN program (version 2.0) which is part of the GCG sequence alignment software package. When utilizing the ALIGN program for comparing amino acid sequences, a PAM120 weight residue table, a gap length penalty of 12, and a gap penalty of 4 can be used. Yet another useful algorithm for identifying regions of local sequence similarity and alignment is the FASTA algorithm as described in Pearson and Lipman (1988) Proc. Natl. Acad. Sci. USA 85:2444-2448. When using the FASTA algorithm for comparing nucleotide or amino acid sequences, a PAM120 weight residue table can, for example, be used with a k-tuple value of 2. The percent identity between two sequences can be determined using techniques similar to those described above, with or without allowing gaps. In calculating percent identity, only exact matches are counted.

Another aspect of the invention pertains to antibodies directed against a protein of the invention. In preferred embodiments, the antibodies specifically bind a marker protein or a fragment thereof. The terms "antibody" and "antibodies" as used interchangeably herein refer to immunoglobulin molecules as well as fragments and derivatives thereof that comprise an immunologically active portion of an immunoglobulin molecule, (i.e., such a portion contains an antigen binding site which specifically binds an antigen, such as a marker protein, e.g., an epitope of a marker protein). An antibody which specifically binds to a protein of the invention is an antibody which binds the protein, but does not substantially bind other molecules in a sample, e.g., a biological sample, which naturally contains the protein.

Examples of an immunologically active portion of an immunoglobulin molecule include, but are not limited to, single-chain antibodies (scAb), F(ab) and F(ab')₂ fragments. An isolated protein of the invention or a fragment thereof can be used as an immunogen to generate antibodies. The full-length protein can be used or, alternatively, the invention provides antigenic peptide fragments for use as immunogens. The antigenic peptide of a protein of the invention comprises at least 8 (preferably 10, 15, 20, or 30 or more) amino acid residues of the amino acid sequence of one of the proteins of the invention, and encompasses at least one epitope of the protein such that an antibody raised against the peptide forms a specific immune complex with the protein. In certain embodiments, the protein is post-translationally modified. Preferred epitopes encompassed by the antigenic peptide are regions that are located on the surface of the protein, e.g., hydrophilic regions. Hydrophobicity sequence analysis, hydrophilicity sequence analysis, or similar analyses can be used to identify hydrophilic regions. In preferred embodiments, an isolated marker protein or fragment thereof is used as an immunogen.

The invention provides polyclonal and monoclonal antibodies. The term "monoclonal antibody" or "monoclonal antibody composition", as used herein, refers to a population of antibody molecules that contain only one species of an antigen binding site capable of immunoreacting with a particular epitope. Preferred polyclonal and monoclonal antibody compositions are ones that have been selected for antibodies directed against a protein of the invention. Particularly preferred polyclonal and monoclonal antibody preparations are ones that contain only antibodies directed against a marker protein or fragment thereof. Methods of making polyclonal, monoclonal, and recombinant antibody and antibody fragments are well known in the art.

2. Isolated Nucleic Acid Indicators

One aspect of the invention pertains to isolated nucleic acid molecules, including nucleic acids which encode Enol or a portion thereof. Isolated nucleic acids of the invention also include nucleic acid molecules sufficient for use as hybridization probes to identify Enol nucleic acid molecules, and fragments thereof, e.g., those suitable for use as PCR primers for the amplification of a specific product or mutation of marker nucleic acid molecules. As used herein, the term "nucleic acid molecule" is intended to include DNA molecules (e.g., cDNA or genomic DNA) and RNA molecules (e.g., mRNA) and analogs of the DNA or RNA generated using nucleotide analogs. The nucleic acid molecule can be single- stranded or double- stranded, but preferably is double- stranded DNA.

An "isolated" nucleic acid molecule is one which is separated from other nucleic acid molecules which are present in the natural source of the nucleic acid molecule. In one embodiment, an "isolated" nucleic acid molecule (preferably a protein-encoding sequences) is free of sequences which naturally flank the nucleic acid (i.e., sequences located at the 5' and 3' ends of the nucleic acid) in the genomic DNA of the organism from which the nucleic acid is derived. For example, in various embodiments, the isolated nucleic acid molecule can contain less than about 5 kb, 4 kb, 3 kb, 2 kb, 1 kb, 0.5 kb or 0.1 kb of nucleotide sequences which naturally flank the nucleic acid molecule in genomic DNA of the cell from which the nucleic acid is derived. In another embodiment, an "isolated" nucleic acid molecule, such as a cDNA molecule, can be substantially free of other cellular material, or culture medium when produced by recombinant techniques, or substantially free of chemical precursors or other chemicals when chemically synthesized. A nucleic acid molecule that is substantially free of cellular material includes preparations having less than about 30%, 20%, 10%, or 5% of heterologous nucleic acid (also referred to herein as a "contaminating nucleic acid").

A nucleic acid molecule of the present invention can be isolated using standard molecular biology techniques and the sequence information in the database records described herein. Using all or a portion of such nucleic acid sequences, nucleic acid molecules of the invention can be isolated using standard hybridization and cloning techniques (e.g., as described in Sambrook et al., ed., Molecular Cloning: A Laboratory Manual, 2nd ed., Cold Spring Harbor Laboratory Press, Cold Spring Harbor, NY, 1989).

A nucleic acid molecule of the invention can be amplified using cDNA, mRNA, or genomic DNA as a template and appropriate oligonucleotide primers according to standard PCR amplification techniques. The nucleic acid so amplified can be cloned into an appropriate vector and characterized by DNA sequence analysis. Furthermore, nucleotides corresponding to all or a portion of a nucleic acid molecule of the invention can be prepared by standard synthetic techniques, e.g., using an automated DNA synthesizer.

In another preferred embodiment, an isolated nucleic acid molecule of the invention comprises an Enol molecule which has a nucleotide sequence complementary to the nucleotide sequence of a marker nucleic acid or to the nucleotide sequence of a nucleic acid encoding Enol. A nucleic acid molecule which is complementary to a given nucleotide sequence is one which is sufficiently complementary to the given nucleotide sequence that it can hybridize to the given nucleotide sequence thereby forming a stable duplex. Moreover, a nucleic acid molecule of the invention can comprise only a portion of a nucleic acid sequence, wherein the full length nucleic acid sequence comprises an Enol nucleic acid or which encodes an Enol protein. Such nucleic acids can be used, for example, as a probe or primer. The probe/primer typically is used as one or more substantially purified oligonucleotides. The oligonucleotide typically comprises a region of nucleotide sequence that hybridizes under stringent conditions to at least about 15, more preferably at least about 25, 50, 75, 100, 125, 150, 175, 200, 250, 300, 350, or 400 or more consecutive nucleotides of Enol.

Probes based on the sequence of Enol can be used to detect transcripts or genomic sequences corresponding to Enol. In certain embodiments, the probes hybridize to nucleic acid sequences that traverse splice junctions. The probe comprises a label group attached thereto, e.g., a radioisotope, a fluorescent compound, an enzyme, or an enzyme co-factor. Such probes can be used as part of a diagnostic test kit or panel for identifying cells, tissues, or individuals which express or mis-express the Enol protein, such as by measuring levels of a nucleic acid molecule encoding Enol in a sample from a subject, e.g., detecting mRNA levels or determining whether a gene encoding Enol or its translational control sequences have been mutated or deleted. The invention further encompasses nucleic acid molecules that differ, due to degeneracy of the genetic code, from the nucleotide sequence of nucleic acids encoding Enol protein (e.g., protein having the sequence provided in the sequence listing), and thus encode the same protein. It will be appreciated by those skilled in the art that DNA sequence polymorphisms that lead to changes in the amino acid sequence can exist within a population (e.g., the human population). Such genetic polymorphisms can exist among individuals within a population due to natural allelic variation. An allele is one of a group of genes which occur alternatively at a given genetic locus. In addition, it will be appreciated that DNA polymorphisms that affect RNA expression levels can also exist that may affect the overall expression level of that gene (e.g., by affecting regulation or degradation).

As used herein, the phrase "allelic variant" refers to a nucleotide sequence which occurs at a given locus or to a polypeptide encoded by the nucleotide sequence.

As used herein, the terms "gene" and "recombinant gene" refer to nucleic acid molecules comprising an open reading frame encoding a polypeptide corresponding to an indicator of the invention. Such natural allelic variations can typically result in 1-5% variance in the nucleotide sequence of a given gene. Alternative alleles can be identified by sequencing the gene of interest in a number of different individuals. This can be readily carried out by using hybridization probes to identify the same genetic locus in a variety of individuals. Any and all such nucleotide variations and resulting amino acid polymorphisms or variations that are the result of natural allelic variation and that do not alter the functional activity are intended to be within the scope of the invention.

In another embodiment, an isolated nucleic acid molecule of the invention is at least 15, 20, 25, 30, 40, 60, 80, 100, 150, 200, 250, 300, 350, 400, 450, 550, 650, 700, 800, or more nucleotides in length and hybridizes under stringent conditions to an Enol nucleic acid or to a nucleic acid encoding Enol. As used herein, the term "hybridizes under stringent conditions" is intended to describe conditions for hybridization and washing under which nucleotide sequences at least 60% (65%, 70%, preferably 75%) identical to each other typically remain hybridized to each other. Such stringent conditions are known to those skilled in the art and can be found in sections 6.3.1-6.3.6 of Current Protocols in Molecular Biology, John Wiley & Sons, N.Y. (1989). A preferred, non-limiting example of stringent hybridization conditions are hybridization in 6X sodium chloride/sodium citrate (SSC) at about 45°C, followed by one or more washes in 0.2X SSC, 0.1% SDS at 50-65°C.

F. Indicator Applications

The invention provides methods for diagnosing elevated blood glucose, e.g., pre- diabetes, type 2 diabetes, type 1 diabetes, gestational diabetes, in a subject. The invention further provides methods for prognosing or monitoring progression or monitoring response of a subject with elevated blood glucose to a therapeutic treatment.

In one aspect, the present invention constitutes an application of diagnostic information obtainable by the methods of the invention in connection with analyzing, detecting, and/or measuring the level of Enol with at least one other indicator of blood glucose, e.g., blood glucose, e.g., fed blood glucose, fasting blood glucose, glucose tolerance, ketone level; and HblAc levels.

For example, when executing the methods of the invention for detecting and/or measuring a polypeptide indicator, as described herein, one contacts a biological sample with a detection reagent, e.g, a monoclonal antibody, which selectively binds to the indicator of interest, forming a protein-protein complex, which is then further detected either directly (if the antibody comprises a label) or indirectly (if a secondary detection reagent is used, e.g., a secondary antibody, which in turn is labeled). Thus, the method of the invention transforms the polypeptide indicators of the invention to a protein-protein complex that comprises either a detectable primary antibody or a primary and further secondary antibody. Forming such protein-protein complexes is required in order to identify the presence of the biomarker of interest and necessarily changes the physical characteristics and properties of the indicator of interest as a result of conducting the methods of the invention.

The same principal applies when conducting the methods of the invention for detecting Enol nucleic acids. In particular, when amplification methods are used to detect an Enol mRNA, the amplification process, in fact, results in the formation of a new population of amplicons - i.e., molecules that are newly synthesized and which were not present in the original biological sample, thereby physically transforming the biological sample. Similarly, when hybridization probes are used to detect Enol, a physical new species of molecules is in effect created by the hybridization of the probes (optionally comprising a label) to the target biomarker mRNA (or other nucleic acid), which is then detected. Such polynucleotide products are effectively newly created or formed as a consequence of carrying out the method of the invention.

The invention provides, in one embodiment, methods for diagnosing elevated blood glucose, e.g., pre-diabetes, diabetes, e.g., type 2 diabetes, type 1 diabetes, gestational diabetes. The methods of the present invention can be practiced in conjunction with any other method used by the skilled practitioner to prognose the occurrence or recurrence of elevated blood glucose and/or the response to a therapeutic intervention of a subject being treated for elevated blood glucose. The diagnostic and prognostic methods provided herein can be used to determine if additional and/ or more complex or cumbersome tests or monitoring (e.g., glucose tolerance test, continuous glucose monitoring) should be performed on a subject. It is understood that a disease as complex as pre-diabetes or diabetes is rarely diagnosed using a single test. Therefore, it is understood that the diagnostic, prognostic, and monitoring methods provided herein are typically used in conjunction with other methods known in the art. For example, the methods for detection of the level of Enol as provided by the invention may be performed in conjunction with a detection of HblAc levels, detection of blood glucose levels under fasting or fed conditions, or glucose tolerance test.

Methods for assessing the efficacy of a treatment regimen, e.g., drug treatment, behavior modification, surgery, or any other therapeutic approach useful for treating elevated blood glucose in a subject are also provided. In these methods the amount of Enol in a pair of samples (a first sample obtained from the subject at an earlier time point or prior to the treatment regimen and a second sample obtained from the subject at a later time point, e.g., at a later time point when the subject has undergone at least a portion of the treatment regimen) is assessed. It is understood that the methods of the invention include obtaining and analyzing more than two samples (e.g., 3, 4, 5, 6, 7, 8, 9, or more samples) at regular or irregular intervals for assessment of marker levels. Pairwise comparisons can be made between consecutive or non-consecutive subject samples. Trends of marker levels and rates of change of marker levels can be analyzed for any two or more consecutive or non- consecutive subject samples. Measurement of Enol levels can be performed in conjunction with other methods for the detection an monitoring of blood glucose. The methods of the invention may also be used to select a compound that is capable of modulating blood glucose by modulation of Enol expression or activity. In this method, a cell, preferably a cell with altered insulin sensitivity or altered glucose uptake is contacted with a test compound, and the ability of the test compound to modulate the expression and/or activity of Enol in the cell is determined, thereby selecting a compound that is capable of modulating Enol expression or activity, preferably increasing Enol expression or activity thereby increasing glucose uptake in the cell. Using the methods described herein, a variety of molecules, may be screened in order to identify molecules which modulate, preferably increase the expression and/or activity of Enol. Compounds so identified can be provided to a subject in order to normalize blood glucose by one or more of increasing glucose uptake, increasing insulin sensitivity, and/or decreasing insulin resistance thereby treating elevated blood glucose, e.g., pre-diabetes or diabetes, e.g., type 2 diabetes, type 1 diabetes, or gestational diabetes.

The present invention pertains to the field of predictive medicine in which diagnostic assays, prognostic assays, pharmacogenomics, and monitoring clinical trials are used for prognostic (predictive) purposes to thereby treat an individual prophylactically. Accordingly, one aspect of the present invention relates to diagnostic assays for determining the level of expression of Enol protein or nucleic acid, in order to determine whether an individual is at risk of developing a disease or disorder related to elevated blood glucose, such as, without limitation, pre-diabetes or diabetes including type 2 diabetes, type 1 diabetes, or gestational diabetes. Such assays can be used for prognostic or predictive purposes to thereby prophylactically treat an individual prior to the onset of the disorder. Yet another aspect of the invention pertains to monitoring the influence of agents

(e.g., drugs or other therapeutic compounds) or behavioral and/or diet modifications on the expression or activity of Enol in clinical trials. These and other applications are described in further detail in the following sections.

1. Diagnostic Assays An exemplary method for detecting the presence or absence or change of an indicator protein or nucleic acid in a biological sample involves obtaining a biological sample (e.g. blood or serum) from a test subject and contacting the biological sample with a compound or an agent capable of detecting the polypeptide or nucleic acid (e.g., mRNA or cDNA). The detection methods of the invention can thus be used to detect mRNA, cDNA, or protein including post-translationally modified proteins, for example, in a biological sample in vitro as well as in vivo. Methods provided herein for detecting the presence, absence, change of the level of an indicator protein or nucleic acid in a biological sample include obtaining a biological sample from a subject that may or may not contain the marker protein or nucleic acid to be detected, contacting the sample with an indicator- specific binding agent (i.e., one or more marker- specific binding agents) that is capable of forming a complex with the indicator protein or nucleic acid to be detected, and contacting the sample with a detection reagent for detection of the indicator— indicator- specific binding agent complex, if formed. It is understood that the methods provided herein for detecting a level of an indicator in a biological sample includes the steps to perform the assay. In certain embodiments of the detection methods, the level of the indicator protein or nucleic acid in the sample is none or below the threshold for detection.

The methods include formation of either a transient or stable complex between the indicator and the indicator- specific binding agent. The methods require that the complex, if formed, be formed for sufficient time to allow a detection reagent to bind the complex and produce a detectable signal (e.g., fluorescent signal, a signal from a product of an enzymatic reaction, e.g., a peroxidase reaction, a phosphatase reaction, a beta-galactosidase reaction, or a polymerase reaction).

In certain embodiments, all of the indicators are detected using the same method. In certain embodiments, all of the indicators are detected using the same biological sample (e.g., same body fluid). In certain embodiments, different indicators are detected using different methods. In certain embodiments, indicators are detected in different biological samples (e.g., blood and serum).

2. Protein Detection In certain embodiments of the invention, the indicator to be detected is a protein. In certain embodiments, the indicator to be detected is a post-translationally modified protein. Proteins are detected using a number of assays in which a complex between the indicator protein to be detected and the indicator specific binding agent would not occur naturally, for example, because one of the components is not a naturally occurring compound or the indicator for detection and the indicator specific binding agent are not from the same organism (e.g., human indicator proteins detected using indicator- specific binding antibodies from mouse, rat, or goat). In a preferred embodiment of the invention, the indicator protein for detection is a human indicator protein. In certain detection assays, the human indicators for detection are bound by indicator- specific, non-human antibodies, thus, the complex would not be formed in nature. The complex of the indicator protein can be detected directly, e.g., by use of a labeled indicator- specific antibody that binds directly to the indicator, or by binding a further component to the indicator— indicator- specific antibody complex. In certain embodiments, the further component is a second indicator- specific antibody capable of binding the indicator at the same time as the first indicator- specific antibody. In certain embodiments, the further component is a secondary antibody that binds to an indicator- specific antibody, wherein the secondary antibody preferably linked to a detectable label

(e.g., fluorescent label, enzymatic label, biotin). When the secondary antibody is linked to an enzymatic detectable label (e.g., a peroxidase, a phosphatase, a beta-galactosidase), the secondary antibody is detected by contacting the enzymatic detectable label with an appropriate substrate to produce a colorimetric, fluorescent, or other detectable, preferably quantitatively detectable, product. Antibodies for use in the methods of the invention can be polyclonal, however, in a preferred embodiment monoclonal antibodies are used. An intact antibody, or a fragment or derivative thereof (e.g., Fab or F(ab')₂) can be used in the methods of the invention. Such strategies of indicator protein detection are used, for example, in ELISA, RIA, western blot, and immunofluorescence assay methods. In certain detection assays, the indicator present in the biological sample for detection is an enzyme, e.g., Enol, and the detection reagent is an enzyme substrate (e.g., 2- phosphoglycerate (2-PG) or phosphoenolpyruvate (PEP), or an analog of either of the compounds that produces a detectable product). In preferred embodiments, the substrate which forms a complex with the indicator enzyme to be detected is not the substrate for the enzyme in a human subject.

In certain embodiments, the indicator— indicator-specific binding agent complex is attached to a solid support for detection of the indicator. The complex can be formed on the substrate or formed prior to capture on the substrate. For example, in an ELISA, RIA, immunoprecipitation assay, western blot, immunofluorescence assay, in gel enzymatic assay the indicator for detection is attached to a solid support, either directly or indirectly. In an

ELISA, RIA, or immunofluorescence assay, the indicator is typically attached indirectly to a solid support through an antibody or binding protein. In a western blot or immunofluorescence assay, the indicator is typically attached directly to the solid support. For in-gel enzyme assays, the indicator is resolved in a gel, typically an acrylamide gel, in which a substrate for the enzyme is integrated.

3. Nucleic Acid Detection In certain embodiments of the invention, the indicator is a nucleic acid, e.g., an Enol nucleic acid. Nucleic acids are detected using a number of assays in which a complex between the indicator nucleic acid to be detected and an indicator- specific probe would not occur naturally, for example, because one of the components is not a naturally occurring compound. In certain embodiments, the analyte comprises a nucleic acid and the probe comprises one or more synthetic single stranded nucleic acid molecules, e.g., a DNA molecule, a DNA-RNA hybrid, a PNA, or a modified nucleic acid molecule containing one or more artificial bases, sugars, or backbone moieties. In certain embodiments, the synthetic nucleic acid is a single stranded is a DNA molecule that includes a fluorescent label. In certain embodiments, the synthetic nucleic acid is a single stranded oligonucleotide molecule of about 12 to about 50 nucleotides in length. In certain embodiments, the nucleic acid to be detected is an mRNA and the complex formed is an mRNA hybridized to a single stranded DNA molecule that is complementary to the mRNA. In certain embodiments, an RNA is detected by generation of a DNA molecule (i.e., a cDNA molecule) first from the RNA template using the single stranded DNA that hybridizes to the RNA as a primer, e.g., a general poly-T primer to transcribe poly-A RNA. The cDNA can then be used as a template for an amplification reaction, e.g., PCR, primer extension assay, using a marker- specific probe. In certain embodiments, a labeled single stranded DNA can be hybridized to the RNA present in the sample for detection of the RNA by fluorescence in situ hybridization (FISH) or for detection of the RNA by northern blot. For example, in vitro techniques for detection of mRNA include northern

hybridizations, in situ hybridizations, and rtPCR. In vitro techniques for detection of genomic DNA include Southern hybridizations. Techniques for detection of mRNA include PCR, northern hybridizations, and in situ hybridizations. Methods include both qualitative and quantitative methods. A general principle of such diagnostic, prognostic, and monitoring assays involves preparing a sample or reaction mixture that may contain a nucleic acid for detection, and a probe, under appropriate conditions and for a time sufficient to allow the indicator nucleic acid and probe to interact and bind, thus forming a complex that can be removed and/or detected in the reaction mixture. These assays can be conducted in a variety of ways known in the art, e.g., PCR, FISH, northern blot. 4. Detection of Expression Levels

Enol levels can be detected based on the absolute expression level or a normalized or relative expression level. Detection of absolute Enol levels may be preferable when monitoring the treatment of a subject or in determining if there is a change in the blood glucose level or blood glucose regulation in a subject. For example, the expression level of Enol can be monitored in a subject undergoing treatment for abnormal blood glucose, e.g., at regular intervals, such a monthly intervals. A modulation in the level of Enol can be monitored over time to observe trends in changes in Enol levels. The expression level of Enol in the subject may be higher than the expression level of Enol in a normal sample, but may be higher than the prior expression level, thus indicating a benefit of the treatment regimen for the subject. Similarly, rates of change of an Enol level can be important in a subject who is being treated with behavior or diet modification rather than therapeutic interventions. Changes, or no changes, in Enol levels in an individual subject may be more relevant to treatment decisions for the subject than Enol levels present in the population. Rapid changes in Enol levels in a subject who otherwise appears to have a normal blood glucose may be indicative of an abnormal blood glucose or a predisposition to develop a condition related to abnormal blood glucose, even if the markers are within normal ranges for the population. Enol level can be determined or monitored in conjunction with one or more additional indicators of elevated blood glucose, e.g., HbAlc, increased blood glucose including one or more of increased fed or fasting blood glucose, or decreased rate of glucose clearance in a glucose tolerance test.

As an alternative to making determinations based on the absolute expression level of Enol, determinations may be based on the normalized expression level of Enol. Expression levels are normalized by comparing the absolute expression level of an indicator to the expression of a gene that is not an indicator, e.g., a housekeeping gene that is constitutively expressed. Suitable genes for normalization include housekeeping genes such as the actin gene and suitable proteins for normalization in blood or serum include albumin. This normalization allows the comparison of the expression level in one sample, e.g., a sample from a subject with normal blood glucose, to another sample, e.g., a sample from a subject suspected of having or having abnormal blood glucose, or between samples from different sources.

Alternatively, the expression level can be provided as a relative expression level as compared to an appropriate control, e.g., population control, earlier time point control, etc.. Preferably, the samples used in the baseline determination will be from samples from subjects with normal blood glucose. The choice of the cell source is dependent on the use of the relative expression level. In addition, as more data is accumulated, the mean expression value can be revised, providing improved relative expression values based on accumulated data.

5. Monitoring Clinical Trials

Monitoring the influence of agents (e.g., drug compounds) on the level of an indicator of blood glucose can be applied not only in basic drug screening or monitoring the treatment of a single subject, but also in clinical trials. For example, the effectiveness of an agent to affect Enol expression can be monitored in clinical trials of subjects receiving treatment for elevated blood glucose. In a preferred embodiment, the present invention provides a method for monitoring the effectiveness of treatment of a subject with an agent (e.g., an agonist, antagonist, peptidomimetic, protein, peptide, nucleic acid, small molecule, or other drug candidate) comprising the steps of (i) obtaining a pre-administration sample from a subject prior to administration of the agent; (ii) detecting the level of expression of the indicator Enol and optionally one or more further indicators of blood glucose, e.g., blood glucose, ketone, or HbAlc in the pre-administration sample; (iii) obtaining one or more post- administration samples from the subject; (iv) detecting the level of expression of the indicator(s) in the post-administration samples; (v) comparing the level of indicator(s) in the pre-administration sample with the level of the indicator(s) in the post-administration sample or samples; and (vi) altering the administration of the agent to the subject accordingly. For example, decreased Enol expression and lack of normalization of other indicator(s) during the course of treatment may indicate ineffective dosage and the desirability of increasing the dosage. Conversely, increased expression of Enol and normalization of other indicator(s) may indicate efficacious treatment and no need to change dosage. VI. TREATMENT OF IMPAIRED BLOOD GLUCOSE LEVELS, IMPAIRED BLOOD GLUCOSE LEVEL CONTROL, AND DIABETES

As demonstrated herein, administration of Enol protein improves glucose uptake and response, normalizing blood glucose levels and control of blood glucose levels. The invention provides methods of treatment of subjects suffering from impaired glucose tolerance, increased blood glucose, insulin resistance, insulin insufficiency, and diabetes, e.g., type 2 diabetes, type 1 diabetes, pre-diabetes, and gestational diabetes by administering Enol to the subject to ameliorate at least one sign or symptom of the conditions. In certain embodiments, Enol, preferably transcript variant 1 of Enol, can be administered to a subject wherein at least one additional agent for the treatment of impaired glucose tolerance, increased blood glucose, insulin resistance, insulin insufficiency, or diabetes is administered to the subject. As used herein, the agents can be administered sequentially, in either order, or at the same time. Administration of multiple agents to a subject does not require co- formulation of the agents or the same administration regimen. The method of treatment of impaired glucose tolerance, increased blood glucose, insulin resistance, insulin insufficiency, or diabetes, especially type 2 diabetes, using Enol can be combined with known methods and agents for the treatment of diabetes. Many agents and regimens are currently available for treatment of diabetes. The specific agent selected for treatment depends upon the subject, the specific symptoms and the severity of the disease state. For example, in certain embodiments, Enol can be administered in conjunction with dietary and/or behavior modification, e.g., caloric restriction, alone or in combination with bariatric surgery, and/or with increased physical activity. In certain embodiments, Enol can be administered with agents for the treatment of type 2 diabetes, e.g., metformin

(Glucophage, Glumetza, others), glitazones, e.g., pioglitazone (Actos), glipizide (Glucotrol), glyburide (Diabeta, Glynase), glimepiride (Amaryl), acarbose (Precose), metformin

(Glucophage), Sitagliptin (Januvia), Saxagliptin (Onglyza), Repaglinide (Prandin),

Nateglinide (Starlix), Exenatide (Byetta), Liraglutide (Victoza), or insulin. Insulins are typically used only in treatment of later stage type 2 diabetes and include rapid-acting insulin (insulin aspart (NovoLog), insulin glulisine (Apidra), and insulin lispro (Humalog)); short- acting insulin (insulin regular (Humulin R, Novolin R)); intermediate- acting insulin (insulin NPH human (Humulin N, Novolin N)), and long-acting insulin (insulin glargine (Lantus) and insulin detemir (Levemir)). Treatments for diabetes can also include behavior modification including exercise and weight loss which can be facilitated by the use of drugs or surgery. Treatments for elevated blood glucose and diabetes can be combined. For example, drug therapy can be combined with behavior modification therapy. Insulins for use in treatment of type 1 diabetes include, but are not limited to Insulins are typically used only in treatment of later stage type 2 diabetes and include rapid-acting insulin (insulin aspart (NovoLog), insulin glulisine (Apidra), and insulin lispro (Humalog)); short-acting insulin (insulin regular (Humulin R, Novolin R)); intermediate- acting insulin (insulin NPH human (Humulin N, Novolin N)), and long-acting insulin (insulin glargine (Lantus) and insulin detemir

(Levemir)). Accordingly, in some aspects, the invention relates to a method of treating elevated blood glucose in a subject, comprising: (a) obtaining a biological sample from a subject suspected of having elevated blood glucose, (b) submitting the biological sample to obtain diagnostic information as to the level of Enol, and (c) administering a therapeutically effective amount of an anti-diabetic therapy to the subject when the level of Enol in the sample is above a threshold level.

In some aspects, the invention relates to a method of treating elevated blood glucose in a subject, comprising: (a) obtaining diagnostic information as to the level of Enol in a biological sample from the subject, and (b) administering a therapeutically effective amount of an anti-diabetic therapy to the subject when the level of Enol in the sample is above a threshold level.

In some aspects, the invention relates to a method of treating elevated blood glucose in a subject, comprising: (a) obtaining a biological sample from a subject suspected of having elevated blood glucose for use in identifying diagnostic information as to the level of Enol, (b) detecting the level of Enol in the biological sample, (c) recommending to a healthcare provider to administer a blood glucose lowering therapy to the subject when the level of Enol in the sample is below a threshold level.

The methods described above may further comprising obtaining diagnostic information as to the level of one or more additional indicators of elevated blood glucose. In some embodiments the methods further comprise measuring a level of one or more additional indicators of elevated blood glucose. The one or more additional indicators of elevated blood glucose may be selected from the group consisting of HbAlc level, fasting glucose level, fed glucose level, and glucose tolerance.

In some embodiments of the aforementioned methods, step (c) further comprises administering a therapeutically effective amount of a glucose lowering therapy to the subject if the level of Enol in the sample is below a threshold level and at least one of the additional indicators of elevated blood glucose is detected. In some embodiments step (c) further comprises recommending to a healthcare provider to administer a glucose lowering therapy to the subject if the level of Enol in the sample is below a threshold level and at least one of the additional indicators of elevated blood glucose is detected.

In some embodiments of the methods described above, the biological sample is blood or serum. In some embodiments, the level of Enol is determined by immunoassay or ELISA. In some embodiments, the level of Enol is determined by (i) contacting the biological sample with a reagent that selectively binds to the Enol to form a biomarker complex, and (ii) detecting the biomarker complex. In some embodiments, the reagent that selectively binds to the Enol to form a biomarker complex is an anti-Enol antibody that selectively binds to at least one epitope of Enol .

In some embodiments of the methods described above, the level of Enol is detected by measuring the amount of Enol mRNA in the biological sample. The amount of Enol mRNA may be detected, for example, by an amplification reaction. In some embodiments, the amplification reaction is (a) a polymerase chain reaction (PCR); (b) a nucleic acid sequence -based amplification assay (NASBA); (c) a transcription mediated amplification (TMA); (d) a ligase chain reaction (LCR); or (e) a strand displacement amplification (SDA).

In some embodiments, a hybridization assay is used for detecting the amount of Enol mRNA in the biological sample. In some embodiments, an oligonucleotide that is complementary to a portion of a Enol mRNA is used in the hybridization assay to detect the Enol mRNA. VI. ANIMAL MODELS OF DIABETES AND INSULIN RESISTANCE

A number of genetic and induced animal models of metabolic syndromes such as type 1 and type 2 diabetes, insulin resistance, hyperlipidemia, are well characterized in the art. Such animals can be used to demonstrate the effect of Enol in the treatment of insulin resistance and diabetes. Models of type 1 diabetes include, but are not limited to, NOD mice and streptozotocin-induced diabetes in rats and mice (models of type 1 diabetes). Genetic and induced models of type 2 diabetes include, but are not limited to, the leptin deficient ob/ob mouse, the leptin receptor deficient db/db mouse, and high fat fed mouse or rat models. In each of the models, the timeline for development of specific disease characteristics are well known. Enol can be administered before or after the appearance of symptoms of diabetes or insulin resistance to demonstrate the efficacy of Enol in the prevention or treatment of diabetes and/or insulin resistance in these animal models.

Depending on the specific animal model selected and the time of intervention, e.g., before or after the appearance of diabetes and/or insulin resistance, the animal models can be used to demonstrate the efficacy of the methods provide herein for the prevention, treatment, diagnosis, and monitoring of diabetes and/or insulin resistance.

VII. DRUG SCREENING

Administration of Enol results in normalization of blood glucose in animals with induced diabetes, making Enol an attractive targets for identification of new therapeutic agents via screens to detect compounds or entities that enhance expression of Enol.

Accordingly, the present invention provides methods for the identification of compounds potentially useful for modulating blood glucose and diabetes. In particular, the present invention provides methods for the identification of compounds potentially useful for modulating Enol wherein the compounds modulate blood glucose and diabetes. Such assays typically comprise a reaction between Enol and one or more assay components, e.g., test compounds. The other components may be either a test compound itself, or a combination of test compounds and a natural binding partner of Enol.

Compounds identified via assays such as those described herein may be useful, for example, for modulating, e.g., inhibiting, ameliorating, treating, or preventing the disease. Compounds identified for modulating the expression level of Enol are preferably further tested for activity useful in the treatment of abnormal blood glucose and/or diabetes, e.g., normalizing fed and/or fasting glucose, normalizing glucose clearance and/or insulin levels in a glucose tolerance test, normalizing HbAlc levels.

The test compounds used in the screening assays of the present invention may be obtained from any available source, including systematic libraries of natural and/or synthetic compounds. Test compounds may also be obtained by any of the numerous approaches in combinatorial library methods known in the art, including: biological libraries; peptoid libraries (libraries of molecules having the functionalities of peptides, but with a novel, non- peptide backbone which are resistant to enzymatic degradation but which nevertheless remain bioactive; see, e.g., Zuckermann et al., 1994, J. Med. Chem. 37:2678-85); spatially addressable parallel solid phase or solution phase libraries; synthetic library methods requiring deconvolution; the 'one-bead one-compound' library method; and synthetic library methods using affinity chromatography selection. The biological library and peptoid library approaches are limited to peptide libraries, while the other four approaches are applicable to peptide, non-peptide oligomer or small molecule libraries of compounds (Lam, 1997, Anticancer Drug Des. 12: 145).

Examples of methods for the synthesis of molecular libraries can be found in the art, for example in: DeWitt et al. (1993) Proc. Natl. Acad. Sci. U.S.A. 90:6909; Erb et al. (1994) Proc. Natl. Acad. Sci. USA 91: 11422; Zuckermann et al. (1994). J. Med. Chem. 37:2678; Cho et al. (1993) Science 261: 1303; Carrell et al. (1994) Angew. Chem. Int. Ed. Engl.

33:2059; Carell et al. (1994) Angew. Chem. Int. Ed. Engl. 33:2061; and in Gallop et al. (1994) J. Med. Chem. 37: 1233.

Libraries of compounds may be presented in solution (e.g., Houghten, 1992,

Biotechniques 13:412-421), or on beads (Lam, 1991, Nature 354:82-84), chips (Fodor, 1993, Nature 364:555-556), bacteria and/or spores, (Ladner, USP 5,223,409), plasmids (Cull et al, 1992, Proc Natl Acad Sci USA 89: 1865-1869) or on phage (Scott and Smith, 1990, Science 249:386-390; Devlin, 1990, Science 249:404-406; Cwirla et al, 1990, Proc. Natl. Acad. Sci. 87:6378-6382; Felici, 1991, J. Mol. Biol. 222:301-310; Ladner, supra.).

The screening methods of the invention comprise contacting a cell, e.g., a diseased cell, especially a cell with abnormal insulin response and/or glucose uptake, with a test compound and determining the ability of the test compound to modulate the expression and/or activity of Enol in the cell. The expression and/or activity of Enol, optionally in combination with methods of detection of blood glucose levels, can be determined using any methods known in the art, such as those described herein.

In another embodiment, the invention provides assays for screening candidate or test compounds which are substrates of Enol or biologically active portions thereof. In yet another embodiment, the invention provides assays for screening candidate or test compounds which bind to Enol or biologically active portions thereof. Determining the ability of the test compound to directly bind to Enol can be accomplished, for example, by any method known in the art.

This invention further pertains to novel agents identified by the above-described screening assays. Accordingly, it is within the scope of this invention to further use an agent identified as described herein in an appropriate animal model. For example, an agent capable of modulating the expression and/or activity of Enol can be used in an animal model to determine the efficacy, toxicity, or side effects of treatment with such an agent.

Alternatively, an agent identified as described herein can be used in an animal model to determine the mechanism of action of such an agent. Furthermore, this invention pertains to uses of novel agents identified by the above-described screening assays for treatment as described above.

In certain embodiments, the screening methods are performed using cells contained in a plurality of wells of a multi-well assay plate. Such assay plates are commercially available, for example, from Stratagene Corp. (La Jolla, Calif.) and Corning Inc. (Acton, Mass.) and include, for example, 48-well, 96-well, 384-well and 1536-well plates.

Reproducibility of the results may be tested by performing the analysis more than once with the same concentration of the same candidate compound (for example, by incubating cells in more than one well of an assay plate). Additionally, since candidate compounds may be effective at varying concentrations depending on the nature of the compound and the nature of its mechanism(s) of action, varying concentrations of the candidate compound may be tested. Generally, candidate compound concentrations from 1 fM to about 10 mM are used for screening. Preferred screening concentrations are generally between about 10 pM and about 100 μΜ. The screening methods of the invention will provide "hits" or "leads," i.e., compounds that possess a desired but not optimized biological activity. Lead optimization performed on these compounds to fulfill all physicochemical, pharmacokinetic, and toxicologic factors required for clinical usefulness may provide improved drug candidates. The present invention also encompasses these improved drug candidates and their use as therapeutics for modulating blood glucose and insulin response. VIII. KITS/PANELS

The invention also provides compositions and kits for diagnosing, prognosing, or monitoring a disease or disorder, recurrence of a disorder, or survival of a subject being treated for a disorder (e.g., abnormal blood glucose and/or diabetes). These kits include one or more of the following: a detectable antibody that specifically binds to Enol, a detectable antibody that specifically binds to Enol, reagents for obtaining and/or preparing subject tissue samples for staining, and instructions for use.

The invention also encompasses kits for detecting the presence of Enol protein or nucleic acid in a biological sample. Such kits can be used to determine if a subject is suffering from or is at increased risk of developing an abnormal blood glucose and/or diabetes. For example, the kit can comprise a labeled compound or agent capable of detecting Enol protein or nucleic acid in a biological sample and means for determining the amount of the protein or mRNA in the sample (e.g., an antibody which binds the protein or a fragment thereof, or an oligonucleotide probe which binds to DNA or mRNA encoding the protein). Kits can also include instructions for use of the kit for practicing any of the methods provided herein or interpreting the results obtained using the kit based on the teachings provided herein. The kits can also include reagents for detection of a control protein in the sample not related to abnormal blood glucose, e.g., actin for tissue samples, albumin in blood or blood derived samples for normalization of the amount of the Enol present in the sample. The kit can also include the purified marker for detection for use as a control or for quantitation of the assay performed with the kit.

Kits include a panel of reagents for use in a method to diagnose abnormal blood glucose in a subject (or to identify a subject predisposed to developing abnormal blood glucose and/or diabetes), the panel comprising at least two detection reagents comprising a reagent for detection of Enol level and a reagent for detection of another indicator of blood glucose, e.g., HbAlc.

I l l For antibody-based kits, the kit can comprise, for example: (1) a first antibody (e.g., attached to a solid support) which binds to a Enol; and, optionally, (2) a second, different antibody which binds to either Enol or the first antibody and is conjugated to a detectable label. In certain embodiments, the kit includes (1) a second antibody (e.g., attached to a solid support) which binds to a second marker protein; and, optionally, (2) a second, different antibody which binds to either HbAlc or hemoglobin (either total or unmodified hemoglobin) or the second antibody and is conjugated to a detectable label. The first and second marker proteins are different.

For oligonucleotide-based kits, the kit can comprise, for example: (1) an

oligonucleotide, e.g., a detectably labeled oligonucleotide, which hybridizes to a nucleic acid sequence encoding Enol or (2) a pair of primers useful for amplifying an Enol nucleic acid molecule. In certain embodiments, the kit includes a third primer specific for each nucleic acid marker to allow for detection using quantitative PCR methods. In certain embodiments, the kit further includes instructions to measure blood glucose in the subject, either directly or indirectly (e.g., using HbAlc levels).

For chromatography methods, the kit can include markers, including labeled markers, to permit detection and identification of one or more indicators of blood glucose, e.g., Enol and HbAlc by chromatography. In certain embodiments, kits for chromatography methods include compounds for derivatization of one or more blood glucose indicators. In certain embodiments, kits for chromatography methods include columns for resolving the indicators of the method.

Reagents specific for detection of Enol allow for detection and quantitation of the marker in a complex mixture, e.g., serum, blood. In certain embodiments, the reagents are species specific. In certain embodiments, the Enol reagents are not species specific. In certain embodiments, the Enol reagents are isoform specific. In certain embodiments, the Enol reagents are not isoform specific. In certain embodiments, the reagents detect total Enol.

In certain embodiments, the kits for the diagnosis, monitoring, or characterization of elevated blood glucose and/or diabetes comprise at least one reagent specific for the detection of the level of expression of Enol. In certain embodiments, the kits further comprise instructions to detect the level of blood glucose in a sample, either directly or indirectly, or both. In certain embodiments, the kit includes at least one reagent for detection of the level of HbAlc.

In certain embodiments, the kits can also comprise, e.g., a buffering agents, a preservative, a protein stabilizing agent, reaction buffers. The kit can further comprise components necessary for detecting the detectable label (e.g., an enzyme or a substrate). The kit can also contain a control sample or a series of control samples which can be assayed and compared to the test sample. The controls can be control serum samples or control samples of purified proteins or nucleic acids, as appropriate, with known levels of indicators. Each component of the kit can be enclosed within an individual container and all of the various containers can be within a single package, along with instructions for interpreting the results of the assays performed using the kit.

The kits of the invention may optionally comprise additional components useful for performing the methods of the invention.

For example, in some aspects the present invention relates to a kit for detecting Enol in a biological sample comprising at least one reagent for measuring the level of Enol in the biological sample, and a set of instructions for measuring the level of Enol . In some embodiments, the reagent is an anti-Enol antibody. In some embodiments, the kit further comprises a means to detect the anti-Enol antibody. In some embodiments, the means to detect the anti-Enol antibody is a detectable secondary antibody. In some embodiments, the reagent for measuring the level of Enol is an oligonucleotide that is complementary to an Enol mRNA.

In some embodiments of the aforementioned kits, the instructions set forth an immunoassay or ELISA for detecting the Enol level in the biological sample. In some embodiments, the instructions set forth an amplification reaction for assaying the level of Enol mRNA in the biological sample. In some embodiments, the amplification reaction is used for detecting the amount of Enol mRNA in the biological sample. In some

embodiments, the amplification reaction is (a) a polymerase chain reaction (PCR); (b) a nucleic acid sequence-based amplification assay (NASBA); (c) a transcription mediated amplification (TMA); (d) a ligase chain reaction (LCR); or (e) a strand displacement amplification (SDA). In some embodiments of the aforementioned kits, the instructions set forth a hybridization assay for detecting the amount of Enol mRNA in the biological sample. In some embodiments, the kit further comprises at least one oligonucleotide that is

complementary to a portion of an Enol mRNA. The invention further provides panels of reagents for detection of one or more blood glucose indicators in a subject sample and at least one control reagent. In certain

embodiments, the control reagent is to detect the indicator in the biological sample wherein the panel is provided with a control sample containing the indicator for use as a positive control and optionally to quantitate the amount of indicator present in the biological sample. In certain embodiments, the panel includes a detection reagent for a protein or nucleic acid not related to an abnormal blood glucose that is known to be present or absent in the biological sample to provide a positive or negative control, respectively. The panel can be provided with reagents for detection of a control protein in the sample not related to the abnormal blood glucose, e.g., albumin in blood or blood derived samples for normalization of the amount of the indicator present in the sample. The panel can be provided with a purified indicator, e.g., Enol, for detection for use as a control or for quantitation of the assay performed with the panel.

In a preferred embodiment, the panel includes reagents for detection of Enol, preferably in conjunction with a control reagent. In the panel, Enol is detected by a reagent specific for that Enol. In certain embodiments, the panel further includes a reagent for the detection of HbAlc. In certain embodiments, the panel includes replicate wells, spots, or portions to allow for analysis of various dilutions (e.g., serial dilutions) of biological samples and control samples. In a preferred embodiment, the panel allows for quantitative detection of one or more indicators of blood glucose. In certain embodiments, the panel is a protein chip for detection of one or more markers. In certain embodiments, the panel is an ELISA plate for detection of one or more markers. In certain embodiments, the panel is a plate for quantitative PCR for detection of one or more markers.

In certain embodiments, the panel of detection reagents is provided on a single device including a detection reagent for one or more markers of the invention and at least one control sample. In certain embodiments, the panel of detection reagents is provided on a single device including a detection reagent for two or more markers of the invention and at least one control sample. In certain embodiments, multiple panels for the detection of different markers of the invention are provided with at least one uniform control sample to facilitate comparison of results between panels.

In certain embodiments, panels and kits further include instructions or advice for measuring blood glucose in a subject. In certain embodiments, the kit or panel is provided with one or more reagents or devices for the measurement of blood glucose.

The invention also provides kits for treatment of at least one of diabetes, e.g., type 1 diabetes, type 2 diabetes, gestational diabetes, pre-diabetes, insulin resistance, glucose intolerance, abnormal blood glucose, and loss of blood glucose control. The kits include Enol and one or more of instructions for use and a device for administration, as appropriate.

This invention is further illustrated by the following examples which should not be construed as limiting. The contents of all references and published patents and patent applications cited throughout the application are hereby incorporated by reference.

EXAMPLES

Example 1 - Employing Platform Technology to Identify Enolase 1 (Enol) as an

Important Node of Activity in the Etiology of Diabetes

In this example, the platform technology described in detail in international Patent Application No. PCT/US2012/027615 was employed to integrate data obtained from a custom built diabetes model, and to identity novel proteins/pathways driving the pathogenesis of diabetes, particularly type 2 diabetes. Relational maps resulting from this analysis have identified Enol as an important node of activity in the etiology of diabetes. Therefore, Enol is an important diabetes treatment target, as well as a diagnostic/prognostic marker associated with diabetes.

Example 2 - Enol Regulation of Glucose Uptake in Myotubes

Enol was recombinantly expressed in E. coli as a 6X HIS protein tag using a commercially available expression vector. The tagged Enol was purified using affinity chromatography methods known in the art. Preferably, the 6X HIS tag was cleaved to produce the protein for use in the methods provided herein. Human skeletal muscle myoblasts (HSMM) were procured from PromoCell and were cultured in growth media recommended by the vendor. HSMM myoblasts (20,000 cells/well) were differentiated with 2% horse serum in 96 well plates for 7 days before experiment. Cells were treated with human Enol (500 ug/ml). Cells were washed twice with 200 μΐ MBSS modified balanced salt solution (MBSS) buffer containing 0.1% BSA, and then serum starved with 100 ul MBSS 0.1% BSA for 4 hours. Upon initiation of insulin stimulation, 100 ul 2x reagents in MBSS 0.1% BSA buffer was added to 100 ul starvation media to make lx concentration for the experiment. The 2x reagents are: insulin (0, 20 nM, and 200 nM); a fluorescent glucose analog 2-NBDG (500 uM). Cells were treated with insulin and the fluorescent deoxy-glucose analog 2-NBDG for 30 min, then washed twice with MBSS buffer, then 50 ul MBSS buffer were added to wells. Glucose uptake was detected with fluorometer along with background detection with wells with no cells in them. After fluorometer readout, a fixative (formalin, 50 ul) was added to 50 ul MBSS in the wells, then 100 ul luM DAPI was added to 100 ul formalin and MBSS mixture. As shown in Figure 1A and IB, treatment of myo tubes with Enol significantly increased glucose uptake in both the absence and presence of insulin (p = 0.025 insulin independent glucose uptake untreated vs. Enol treated). These results demonstrate a role for Enol in both insulin dependent and insulin independent glucose uptake. The insulin dependent glucose uptake induced by Enol demonstrates that Enol is intricately connected with the insulin signaling pathway in at least skeletal muscle in subjects sensitive to insulin. The results also demonstrate a role for Enol in insulin independent glucose uptake. This observation is important for treatment of subjects with both type 1 and type 2 diabetes who suffer from insulin resistance and who may also have hyper insulinemia, so that insulin action is compromised and hence a insulin independent. These results demonstrate that Enol is useful in stimulating glucose uptake even in individuals who no longer have normal insulin signaling.

Cell cultures of human skeletal muscle myotubes were treated for 48 hours with the purified Enol protein described above to measure Enol uptake. Enol levels in the cells were then determined by Western blot. As shown in Figures 2A and 2B, Enol levels in cells treated with 500 μg/ml Enol or 1000 μg/ml Enol had significantly higher levels of Enol relative to untreated cells. Enol levels in cells treated with 1000 μg/ml Enol were also higher than in cells treated with 500 μg/ml Enol. These results indicate that Enol is delivered into human skeletal muscle myotubes in a dose dependent manner.

To determine the role of Enol enzyme activity in glucose uptake, purified Enol was heat inactivated by treatment at 88°C for 90 seconds, and activity levels of native and heat inactivated Enol were compared. Enol activity was determined by colorimetric assay using the Enol human activity assay kit from Abeam (Cambridge, MA; Cat. No. abl 17994). As shown in Figure 3 A, heat inactivation greatly reduced Enol enzyme activity, but some residual activity remained.

The effect of native and heat inactivated Enol on glucose uptake was compared in human skeletal muscle myotubes following the methods described above. As shown in

Figure 3B, myotubes treated with native (active) Enol exhibited significantly higher glucose uptake relative to myotubes that were not treated with Enol. Myotubes treated with heat inactivated Enol exhibited significantly lower glucose uptake compared to myotubes treated with active Enol. These results indicate that the effect of Enol on glucose uptake is dependent on Enol enzyme activity. The increase in glucose uptake observed in the heat inactivated Enol relative to the control containing no Enol was likely due to the residual Enol activity of the heat inactivated enzyme.

Example 3 - Mouse Models of Diet Induced Obesity (DIO) Mice

Two essentially equivalent models of diet induced obesity were used in the methods provided herein.

In the first method, male C57BL/6J mice were obtained from Jackson Laboratories (Bar Harbor, ME) and initially housed 4-5 per cage at 22°C on a 12: 12hr day-night cycle. Beginning at 6 weeks of age, mice were fed with a high-fat diet (Research Diets Cat #: D 12492; 60 kcal fat, 20 kcal protein, and 20 kcal carbohydrate). Lean control mice were also obtained and fed a standard diet. Body weight of DIO mice before experiments was significantly heavier than that of lean control mice. In one study, DIO mice weighed 38.4 + 0.6g whereas lean mice weighed 29.9 + 0.5 g (p < 0.05).

In the second method, diet induced obese male C57BL/6J mice (12 week old) and control lean mice (12 week old) were obtained from Jackson Laboratories (Bar Harbor, ME) and initially housed 4-5 per cage at 22°C on a 12: 12hr day-night cycle. Mice were acclimated in animal facility for one week before treatments and maintained with a high-fat diet for DIO group (Research Diets Cat #: D 12492; 60 kcal% fat, 20 kcal% protein, and 20 kcal% carbohydrate) or a low fat diet (10% kcal% fat) for lean group.

Example 4 - Treatment of Glucose Intolerance with Enol in Diet Induced Obesity (DIO) Mice The experimental protocol was started when the mice (n = 10 per group) were obese after being maintained for 7 weeks on a high fat diet. Osmotic minipumps (Model 1004, Alzet, Cupertino, CA) were filled following manufacturer's guidelines with 0.1 ml of the Enol peptide or vehicle (phosphate buffered saline (PBS), pH 7.0). The pumps were primed in sterile saline at 4°C overnight. Mice were anesthetized with isoflurane (1-3% in 100% oxygen) and scrubbed with 70% isopropanol and betadine solutions before surgery. A small subcutaneous incision was made in the midscapular region, the pump was inserted and the wound was sutured. Animals were allowed to recover before returning to their home cages. The implantation of the subcutaneous osmotic minipumps continuously infused peptide at a constant rate of 0.11 μΐ/hr for four weeks. Pump-exchange surgeries were performed every 4 weeks. The purified Enol treatment doses calculated by pump infusion rate was 10 g/kg body weight.

Glucose tolerance tests (GTT) were performed after 6h of fasting using routine methods. Briefly, initial fasting blood glucose levels were determined, followed by intraperitoneal (ip) injection of 20% dextrose solution at a dose of 1.5 g/kg body weight. Blood glucose levels were measured from the tail vein at 15, 30, 60, 90, and 120 minutes after the glucose injection using an ACCU-CHEK® Advantage glucometer (ROCHE® Diagnostics, Indianapolis, IN). The area under the curve (AUC) during the GTT was calculated with Graphpad Prism® software, and student t-tests were performed for significance between different treatment groups. The results are shown in Figures 4A and 4B.

As can readily be observed, mice treated with Enol had a significant decrease in blood glucose area under the curve as compared to untreated mice (p = 0.017). These data demonstrate that treatment of obese mice with Enol protein increases glucose tolerance as demonstrated by a glucose tolerance test and indicate that Enol is effective in the treatment of insulin resistance, glucose intolerance, and type 2 diabetes. Example 5 - Generation of a PAMAM Dendrimer, Muscle Targeted Enol

Having demonstrated the efficacy of Enol in increasing glucose uptake in myotubes and increasing glucose tolerance upon systemic administration, a muscle targeted Enol was generated to analyze its efficacy in increasing glucose tolerance. Detectably labeled G5- PAMAM dendrimers containing the muscle targeting peptide (MTP) ASSLNIA and/ or Enol were generated using the methods described below. A range of different ratios of MTP to dendrimer were evaluated, including MTP containing dendrimers which contained about 10 MTP peptides per dendrimer, about 3 MTP peptides per dendrimer, or about 1 MTP peptide per dendrimer. The process of preparing Enol dendrimer complexes includes the identification of optimal ratios and concentrations of the reagents. Stock solutions of Enol were prepared in buffer and the protein solution was mixed with G5 dendrimer-muscle targeting peptide (MTP) conjugate in different ratios. A range of different ratios of dendrimer to Enol were also evaluated, including Enol containing dendrimers which contained about one dendrimer per molecule of Enol protein or about five dendrimers per molecule of Enol protein.

The stability of the Enol-dendrimer-SMTP complex was evaluated at different temperatures, and stability was determined over a 3-4 month time period by measuring Enol activity using a commercially available Enol assay. The selected conjugates were also evaluated using biophysical techniques, including Dynamic Light Scattering (DLS) and UV- Vis spectroscopy to confirm complexation between the dendrimer-peptide conjugate and Enol.

Determination of the Purity of Enol : The purity of a 5.32 mg/mL solution of Enol protein was checked by Coomassie and Silver staining and Western blotting. Several dilutions of the Enol protein ranging from 10 μg/well to 100 ng/well were prepared and loaded on a 12-well, 4-12% mini-PROTEAN® TGX gel [BIO-RAD Cat# 456-1095

Lot#4000 79200]. The lane assignments were as follows; Lane 1: Ladder (Precision Plus Protein Standard Dual Color [BIO-RAD Cat#l 61-0374]; Lane 2: Enol (10.0 μg); Lane 3: Enol (1.0 μg); Lane 4: Enol (0.1 μg);Lane 5: Ladder (Precision Plus Protein Standard Dual Color [BIO-RAD Cat#161-0374];Lane 6: Enol (10.0 μg); Lane 7: Enol (1.0 μg); Lane 8: Enol (0.1 μg); Lane 9: Ladder (Precision Plus Protein Standard Dual Color [BIO-RAD Cat#161-0374]; Lane 10: Enol (10.0 μg); Lane 11 : Enol (1.0 μg); Lane 12: Enol (0.1 μg). The SDS-PAGE was run at 200 V for 20-25 min.

Coomassie Staining: After the gel was run, the gel was split into 3 equal parts. One of the parts was stained with Coomassie Stain. Briefly, the gel was soaked in 100 mL of Coomassie Stain solution (0.025% Coomassie Stain in 40% Methanol and 7% Acetic Acid) and heated for one minute in a microwave. Then the gel was left to stain with gentle agitation for 45 minutes. After the staining was complete, the gel was destained using destaining solution (40% Methanol and 7% Acetic Acid) until the background staining was acceptable.

As shown in Figure 5, the protein ran as a single band of about 47 KDa, which is consistent with the size of Enol.

Silver Staining: Since Coomassie Staining is not a sensitive method for visualization of the protein bands, another portion of the gel was stained with Silver Stain using BIO- RAD's Silver Staining Kit [BIO-RAD Cat#161-0443]. The Modified Silver Stain Protocol was followed.

As shown in Figure 6, extra bands can be seen in each lane, which correspond to the bands of the ladder. This is due to the leakage of the ladder into the neighboring lanes. The three bands marked with an arrow are not from the ladder. The most prominent band is about 47 kDa, which is consistent with the size of Enol. There are two extra bands in the purified protein but these bands are faint, indicating that overall purity of the Enol was relatively high.

Western Blot Analysis: The identity of Enol was further confirmed by Western blot. For this purpose, the final portion of the gel was transferred into 100 mL of Tris-Glycine buffer and transferred onto 0.2 μιη PVDF membrane (BIO-RAD) using a transblot SD semi- dry transfer apparatus (BIO-RAD) at 20 V for 2.0 h. The efficiency of the transfer was checked by observing the presence of the pre-stained ladder bands on the membrane. The membrane was dried for 1.0 h. The membrane was then wetted with methanol for 1.0 min and blocked with 15.0 mL ODYSSEY® Blocking Buffer (LICOR) at room temperature for 2.0 h. After the blocking was complete, the membrane was incubated with 15.0 mL

ODYSSEY® Blocking Buffer containing 30 of anti-ENOA-1 m-Ab (mouse) (purchased from ABNOVA) overnight at 4 °C. Then the membrane was washed with 3x30 mL of IX PBS-T with shaking for 5 minutes each. The membrane was incubated with 15.0 mL ODYSSEY® Blocking Buffer containing 5 μΐ_^ of Goat anti-mouse secondary antibody labeled with IRDye® 800CW (purchased from LICOR) for 2.0 h at room temperature. After the incubation, the membrane was washed with 3x30 mL of IX PBS-T followed by 2x30 mL of IX PBS with shaking for 5 minutes each. Finally, the membrane was imaged using the LICOR ODYSSEY Infrared Imager. As shown in Figure 7, Western Blot analysis confirmed that the dominant band at 47 kDa was Eno 1.

Zeta ( )-Potential Characterization of Enolase-I/G5-PAMAM-SMTP: Enol and Generation 5 PAMAM dendrimers decorated with 2-3 Skeletal Muscle Targeting Peptides (SMTPs) were complexed at varied ratios to form Enol/G5-SMTP protein/dendrimer complexes. The concentration of the dendrimer was kept constant at 1.0 μΜ and the Enol concentration was varied between 0.1 μΜ- 10.0 μΜ. Table 2 below describes how the Enolase-I/G5-dendrimer/SMTP mixtures were prepared.

Table 2. Various combinations of Enol and G5-dendrimer/SMTP for formation of dendrimer complexes.

Each sample was prepared by adding G5-dendrimer/SMTP to the respective amount of PBS. Enolase was then added to the G5-dendrimer/SMTP solution in a drop wise fashion while vortexing at low speed. The sample was then incubated at room temperature for 20 minutes prior to analysis. Size measurements were made using the Zetasizer Nano Z90s instrument from

Malvern Instruments. The default parameters were used for the measurements and three separate measurements of each sample were collected. Figure 8 shows representative Zeta ^-Potential data for three samples of Enol/G5-dendrimer/SMTP complexes having a 2: 1 molar ratio of Enol to dendrimer/SMTP. Zeta ^-Potential was measured using Dynamic Light Scattering. As shown in Figure 8, the peaks of the three samples are matching, indicating a uniform charge distribution of the Enolase-SMTP dendrimer complex.

Stability of Enolase-I/G5-SMTP complexes: The stability of the Enolase-I/G5- dendrimer/SMTP conjugates was measured by using the ENOl Human Activity Assay Kit (ABCAM, Cambridge, MA; Catalogue No. abl 17994). Briefly, the sample was added to a microplate containing a monoclonal mouse antibody specific to Enol. The microplate was incubated at room temperature for 2 hours, and Enol was immunocaptured within the wells of the microplate. The wells of the microplate were washed to remove all other enzymes. Eno 1 activity was determined by following the consumption of NADH in an assay buffer that included pyruvate kinase (PK), lactate dehydrogenase (LDH) and the required substrates 2-phospho-D-glycerate (2PG) and NADH. Enol converts 2PG to phosphoenolpyruvate, which is converted to pyruvate by PK. Pyruvate is converted to lactate by LDH, and this reaction requires NADH. The consumption of NADH was monitored as decrease of absorbance at 340 nm.

The activity of Enolase-I/G5-dendrimer/SMTP conjugates that were stored at different temperatures at different time points was measured using the assay described above. A concentration of 500 ng of Enol was selected for testing because this concentration falls in the middle of the dynamic range of the assay kit. Two different sets of solutions were prepared. One set (control) contained Enol alone (i.e. unconjugated Enol) and the other set contained Enol/G5-dendrimer/SMTP mixtures. These mixtures were then kept at -80 °C, -20 °C, 4 °C, 22 °C, and 37 °C. The results showed that in the first week all of the samples were active, and the Enol/G5-dendrimer/SMTP conjugates seemed to have a slightly higher activity than Enol alone. However, the activities of the solutions, regardless of whether or not they contained dendrimers, steadily decreased in the next two weeks. By week 3, the solutions that were stored at 4 °C, 22 °C, and 37 °C showed no activity, while the solutions that were stored at -80 °C, and -20 °C showed significant stability. At the end of the study (Week 10), The Enol/G5-dendrimer/SMTP solution that was kept at -80 °C retained about 90% of its activity whereas Enol alone was only 35% active. On the other hand, Enol/G5- dendrimer/SMTP solution that was kept at -20 °C was about 24 % active, whereas Enol alone stored at -20 °C was not active (Figure 9).

Example 6 - In Vivo Enol Targeting Studies With G5 PAMAM dendrimers

A detectably labeled PAMAM dendrimer complex containing Enol was prepared using the method provided in the prior example and analyzed for tissue distribution in mice after subcutaneous injection. Specifically, for 72 hours prior to injection mice were fed alfalfa free food to limit background fluorescence. Mice were injected with 3μg

ENOl/mouse subcutaneously 150μ1 total (75μ1 left laterally, 75μ1 right laterally). The molar ratio of dendrimer to Enol in the complex was 5: 1. One, 4, and 24 hours post injection animals were sacrificed, skinned, and organs removed in preparation for LI-COR imaging. The results are shown in Figure 10A.

As shown, at 1 hour, general systemic distribution of the Enol -PAMAM dendrimer was observed. After 4 hours, significant accumulation of the Enol -PAMAM dendrimer was observed in liver, kidney, and subcutaneous fat, as well as in the upper torso. After 24 hours, the Enol-dendrimer complex was substantially cleared and observed substantially in the liver and kidney.

A follow-up study was performed using the skeletal muscle targeted Enol -PAMAM dendrimer complex containing the SMTP "ASSLNIA". A detectably labeled PAMAM dendrimer complex containing Enol and SMTP ((Enolase-Vivo Tag680xl)-(G5-SMTP)) was prepared using the method provided in the prior example. The molar ratio of dendrimer to SMTP in the complex was 1: 1. The experiments were performed essentially as described above. The skeletal muscle targeted Enol -PAMAM dendrimer complex was administered at a dose of 50 μg/kg body weight. These images in Figure 10B were taken after 1 hr of injection. Organs, other than the heart, were retained in the body. As can be readily observed, the muscle-targeted Enol dendrimer complex was targeted to skeletal muscle, not heart. These results demonstrate that the skeletal muscle targeted Enol-PAMAM dendrimer complex can be used for the delivery of Enol to skeletal muscle cells.

Example 7 - Treatment of Glucose Intolerance with Muscle Targeted Eno 1 in Diet Induced Obesity (DIO) Mice Diet induced obese male C57BL/6J mice (12 week old) and control lean mice (12 week old) were obtained from Jackson Laboratories (Bar Harbor, ME) and initially housed 4- 5 per cage at 22°C on a 12: 12hr day-night cycle. Mice were acclimated in animal facility for one week before treatments and maintained with a high-fat diet for DIO group (Research Diets Cat #: D 12492; 60 kcal fat, 20 kcal protein, and 20 kcal carbohydrate) or a low fat diet (10% kcal% fat) for lean group.

Beginning at 13 weeks of age, all mice received daily subcutaneous injections of either saline or different complexes with combinations of G5 dendrimer, skeletal muscle targeting peptide (SMTP), and purified Enol (50 g/kg body weight) for duration of 4 weeks. During the 4 weeks of the treatment portion of the experiment, intraperitoneal glucose tolerance tests (JPGTT) were performed weekly. Body weight, fed glucose, and fasted glucose were measured weekly during treatment period. The treatment groups are shown below:

1. LFD - Lean Controls - no injection

2. HFD - saline control (volume equivalent to G5+ SMTP + Enol)

3. HFD - G5 only (equivalent to 50μg/kg of G5 + SMTP + Enol)

4. HFD - G5+SMTP (equivalent to 50μg/kg of G5+ SMTP + Enol)

5. HFD — G5+Enol(50μg/kg body weight)

6. HFD - G5+SMTP+Enol (50μg/kg body weight )

The molar ratio of dendrimer to Enol in the complexes was 5: 1, the molar ratio of dendrimer to SMTP in the complexes was 1: 1, and the dendrimer was acetylated. Results from the study are provided in Figures 11, 12, 13, 14 and 15.

In this small cohort, none of the treatment regimens were found to have a significant effect on body weight in the DIO mice at any time during the study (see Figure 11). Treatment of mice with a single dose of the dendrimer bound muscle targeted Eno 1 was demonstrated to have an effect on blood glucose levels at the earliest time points tested. As shown in Figure 12, one hour after administration of 50 μg/kg of G5+SMTP+Enol, a reduction of blood glucose was observed as compared to a saline control, with the maximum reduction observed at 4 hours. The effect was no longer observed at 24 hours after the single injection.

At one week after initiation of administration of the dendrimer bound muscle targeted Enol, glucose tolerance in the DIO mice treated with the Enol dendrimer SMTP complex (DIO Enolase-l+NP+SMTP) were significantly lower than glucose tolerance in DIO mice treated with the dendrimer SMTP complex alone (DIO NP+SMTP) (see Figures 13A and 13B).

At two weeks after initiation of administration of the dendrimer bound muscle targeted Enol, glucose tolerance in the DIO mice was still significantly improved (see Figures 6C and 6D). The improvement of glucose tolerance was dependent on the presence of Eno 1 in the dendrimer complex (DIO G5 +SMTP vs. DIO Eno 1 G5 +SMTP, p = 5.7 x 10^"5, p = 0.002). The effect was no longer observed 23 hours after the single injection (data not shown).

The beneficial effect of G5+SMTP+Enol treatment observed at weeks 1 and 2 was sustained through week 4 (see Figures 14A and 14B). Specifically glucose tolerance in the DIO Eno 1 G5 +SMTP treated mice was similar to that in lean mice. The improvement of glucose tolerance was significant and dependent on the presence of Eno 1 in the dendrimer complex (DIO G5 +SMTP vs. DIO Eno 1 G5 +SMTP, p = 0.0017). The effect was no longer observed 23 hours after the single injection (data not shown).

These results show that dendrimer bound, muscle targeted Eno 1 is effective in increasing glucose tolerance in a model of diet induced obesity, and that G5+SMTP+Enolis effective in normalizing blood glucose in a mouse model of diet induced obesity. These results demonstrate that Enol is useful in the treatment of elevated blood glucose, glucose intolerance, and diabetes, particularly type 2 diabetes.

The mice were treated as described above for an additional 4 weeks (8 weeks treatment in total), and serum lactate levels were determined in lean mice, diet induced obesity (DIO) mice, DIO mice treated with G5-dendrimer, and DIO mice treated with Enol/G5-dendrimer/SMTP complex after 8 weeks of treatment. Lactate levels in serum were measured using a lactate colorimetric assay kit from Biovision (Milpitas, CA). As shown in Figure 15, Enol/G5-dendrimer/SMTP complex significantly reduced lactate serum levels. This result suggests that the reduced glucose levels observed in the DIO mice treated with the Enol/G5-dendrimer/SMTP complex is due to increased glucose oxidation, rather than shunting of glycolysis to lactate. This would minimize the undesirable effects of lactate acidosis.

Example 8 - Treatment of Glucose Intolerance with Muscle Targeted Eno 1 in a Genetic Model of Obesity, db/db Mice

Male obese and diabetic db/db mice (male BKS.Cg-m +/+ Lepr^db/J) mice were obtained from a commercial vendor. All mice were housed 2-3 per cage at 22°C on a 12: 12hr day-night cycle and are acclimated for 3 weeks at animal facility on a standard chow diet. At 8 weeks of age, the following subcutaneous injections of either saline or different complexes with combinations of G5 dendrimer, skeletal muscle targeting peptide (SMTP), and purified Enol were administered once daily by subcutaneous administration (n = 6 per group). The treatment groups are as follows:

1. db/db with saline injection

2. db/db with G5+SMTP (volume equivalent to Eno 1+G5+SMTP at 25 ug/kg dose)

3. db/db with Eno 1 (25 ug/kg body weight)+G5+SMTP

4. db/db with Eno 1 (50 ug/kg body weight)+G5+SMTP

The molar ratio of dendrimer to Enol in the complexes was 5: 1, and the molar ratio of dendrimer to SMTP in the complexes was 1 : 1, and the dendrimer was acetylated. At day 7, the mice were administered the appropriate agent and returned to the cage for 6 hours without food prior to administration of an IPGTT as described in the Example above. The results are shown in Figures 16A and 16B. As can be readily observed, treatment of mice with Enol+G5+SMTP resulted in an increase in glucose tolerance after glucose challenge with a significant increase in glucose clearance observed in the mice treated with Enol (50 ug/kg body weight)+G5+SMTP as compared to the mice treated with G5+SMTP (p=0.015).

The study was continued with three out of the six mice in each of the treatment groups listed above. Mice were administered the indicated agent for an additional week (2 weeks total). The effect of Enol on lowering fed blood glucose was tested. Specifically, without controlling the intake of food, blood glucose levels in mice were assessed for two hours immediately after administration of the active agent. The results are shown in Figures 17 A and 17B. As shown, administration of Enol(50 ug/kg body weight)+G5+SMTP was demonstrated to decrease fed blood glucose and resulted in a statistically significant reduction in blood glucose 30 minutes after administration as compared to administration of

G5+SMTP. However, the reduced blood glucose observed 30 minutes after

Enol+G5+SMTP treatment were not maintained at 24 hours after Enol injection (Figure 18).

Accordingly, the effect of twice daily dosing of Enol+G5+SMTP on blood glucose levels was also evaluated in the db/db mice. Treatments were administered by subcutaneous injection twice daily, once in the morning and once in the evening, for four weeks. The treatment groups were as follows:

1. PBS

2. 100 μg/kg body weight Enol+G5+SMTP

3. 200 μg/kg body weight Enol+G5+SMTP

The molar ratio of dendrimer to Enol in the Enol+G5+SMTP complex was 5: 1, and the molar ratio of dendrimer to SMTP in the Enol+G5+SMTP complex was 1: 1, and the dendrimer was acetylated.

The total daily dose for treatment group 2 was 200 μg/kg body weight

Enol+G5+SMTP and the total daily dose for treatment group 3 was 400 μg/kg body weight Enol+G5+SMTP. Without controlling the intake of food, fed blood glucose levels were assessed in the mice 16 hours after the evening injection (i.e. before the morning injection). As shown in Figure 19, twice daily injection of 200 μg/kg body weight Enol+G5+SMTP decreased fed blood glucose levels relative to the control PBS treatment. Thus, treatment of mice with Eno 1 G5 +SMTP was shown to normalize glucose response in db/db mice. The data described in Examples 7 and 8 together demonstrate that Enol is effective in increasing glucose tolerance in both an induced and a genetic model of type 2 diabetes. Example 9 - Comparative Toxicity of Acylated vs. Non- Acylated SMTP Containing Dendrimers

The toxicity of acylated and non-acylated dendrimers containing SMTP were compared using creatine kinase and caspase 3 assays. Mice were injected with one of staurosporine (positive control), staurosporine + inhibitor (negative control); G5 PAMAM dendrimers, SMTP-G5 PAMAM dendrimers , and acylated SMTP-G5 PAMAM dendrimers. The molar ratio of dendrimer to Enol in the complexes was 5: 1, and the molar ratio of dendrimer to SMTP in the complexes was 1 : 1. After injection samples were collected and assayed for the creatine kinase levels as a percent of total cell lysate and caspase 3 activity using commercially available kits. The results are shown in Figure 20. As shown in Figure 20, administration of the G5 PAMAM dendrimers at both 1 uM and 3uM concentrations and administration of SMTP-G5 PAMAM dendrimers at 3 uM concentration resulted in a significant increase in creatine kinase activity. No such effect was observed with the acylated SMTP-G5 PAMAM dendrimers. Similarly, a significant increase in caspase 3 activity was observed after administration of 3uM G5 PAMAM dendrimers and SMTP-G5 PAMAM dendrimers.

However, no increase in caspase 3 activity was observed upon administration of the acylated SMTP-G5 PAMAM dendrimers. These results demonstrate that acylation of SMTP-G5 PAMAM dendrimers reduces toxicity.

Example 10 - Treatment of Glucose Intolerance with Muscle Targeted Eno 1 in a Genetic and Induced Models of Type 2 and Type 1 Diabetes Male obese mice, diabetic db/db mice (male BKS.Cg-m +/+ Lepr^db/J), NODI mice, or streptazocin treated mice are obtained or generated. All mice are housed 2-3 per cage at 22°C on a 12: 12hr day-night cycle and are acclimated for at least 1 week at animal facility on an appropriate chow diet (i.e., high fat diet for obese mice, normal chow for other mice). At an appropriate age, typically about 8 weeks of age, subcutaneous injections of either saline or different complexes with combinations of G5 dendrimer, skeletal muscle targeting peptide (SMTP), and purified Enol (25 or 50 g/kg body weight) are administered daily for duration of 1-2 weeks. Implantable pumps (e.g., ALZET pumps) as described above can be used for administration on a daily or continuous basis. Alternatively, the agents can be administered intramuscularly in various formulations. Intramuscular injections are typically performed on a less frequent basis than subcutaneous injections (e.g., typically about once per week).

During the 2 weeks of time-course, intraperitoneal glucose tolerance tests (IPGTT) are performed and fasting and fed blood glucose is monitored, either randomly or in a time course after administration of the agent. Body weight is measured weekly during treatment period. The treatment groups include at least one control (e.g., 1 or 2) and at least one Enol treatment from the list shown below:

1. Saline injection 2. G5+SMTP (volume equivalent to Enol+G5+SMTP at 25 ug/kg body weight/day)

3. Eno 1 (25 ug/kg body weight/day)+G5+SMTP

4. Eno 1 (50 ug/kg body weight/day)+G5+SMTP

5. Eno 1 (25 ug/kg body weight/day) 6. Eno 1(50 ug/kg body weight/day)

Dosages provided are exemplary and are not to be considered limiting.

Treatment of mice with Eno 1 G5 +SMTP is demonstrated to normalize glucose response in the diabetic mice.

Example 11 - Assessment of Glucose Levels and Glucose Response in Mice

The intraperitoneal glucose tolerance test (IPGTT) is described above and routinely used to assess glucose tolerance and insulin response. Other exemplary methods that can be used to confirm the efficacy of Eno 1 in normalizing blood glucose and insulin response are provided below. Methods to assess body composition and metabolism are also provided below. Intraperitoneal Insulin Tolerance Test (IPITT)

Insulin tolerance test (ITT) is performed after 1 hour fasting to assess pyruvate metabolism. Initial blood glucose levels is determined, followed by injection (ip) of human insulin (1-2 U/kg; Humulin R; Eli Lilly, Indianapolis, IN). Blood glucose levels are measured from the tail vein as described above at 15, 30, 60, 90, and 120 min after the insulin injection. The insulin injection amount is determined empirically by insulin response due to the onset of the hepatic insulin resistance in the mice subjected to the high fat diet. Intraperitoneal Pyruvate Tolerance Test (IPPTT)

Pyruvate challenge test is administered after 6h of fasting. Initial blood glucose levels are determined, followed by injection (ip) of pyruvate dissolved in saline (2 g/kg; Sigma, St. Louis, MO). Blood glucose levels are measured from the tail vein as described above at 15, 30, 60, 90, and 120 min after the pyruvate injection. The area under the curve (AUC) during the test is calculated.

Fed Blood Glucose Levels

Blood samples are obtained from mice fed ad libitum either randomly or at a defined time or time interval after administration of an agent of interest. Blood glucose levels are measured. Fasting Blood Glucose Levels

Blood samples are obtained from mice after a fast of a predefined time period

(typically about 6-8 hours) at a defined time or time interval after administration of an agent of interest. Blood glucose levels are measured.

Assessment of Indicator Levels to Assess Blood Glucose Levels Mouse models of type 1 or type 2 diabetes are treated with one or more agents of the invention and appropriate controls. Levels of HbAlc and/or Enol protein and/or RNA are monitored to determine blood glucose levels over a sustained period.

Dual-energy X-ray absorptiometry (DEXA)

The body mass composition of different treatment groups is determined by dual- energy x-ray absorptiometry (DEXA) scanning using LUNAR PlXImus® mouse

densitometer following the procedures recommended by the manufacturer. Lean body mass, fat body mass, total body tissue weight, bone density, and bone mineral content are recorded and analyzed.

Comprehensive Lab Animal Monitoring System (CLAMS) The CLAMS (Columbus Instruments, Columbus, OH, USA) metabolic monitoring cages are used to simultaneously monitor horizontal and vertical activity, feeding and drinking, oxygen consumption, and C0₂ production. ASO injected and control mice are individually placed in CLAMS cages and monitored over a 4-day period after acclimation to the cages for 1-2 days. The various parameters are recorded in both fasted and fed conditions. Food and water consumption are measured directly as accumulated data. Hourly files display all measurements for each parameter: volume of oxygen consumed, ml/kg per h (V0₂), volume of carbon dioxide produced, ml/kg per h (VC0₂), respiratory exchange ratio, heat (kcal/h), accumulated food (g), accumulated drink (g), XY total activity (all horizontal beam breaks in counts), XY ambulatory activity (minimum three different, consecutive horizontal beam breaks in counts), and Z activity (all vertical beam breaks in counts). The data are recorded during the 30-s sampling period. The CLAMS data are analyzed by normalizing with lean body mass.

Example 12 - Effect of Enol on insulin stimulated p-Akt in Human Skeletal Muscle Myotubes

The effect of purified Eno-1 on insulin stimulated p-Akt (S473) protein levels was determined in cell cultures of human skeletal muscle myotubes with our without insulin treatment. p-Akt protein levels were measured by ELISA. As shown in Figure 21, insulin treatment increased p-Akt protein levels in the absence of Enol treatment, and the effect of insulin on p-Akt protein levels was similar with or without Enol treatment. These results indicate that Enol does not influence insulin stimulation of p-Akt protein levels, suggesting that the effects of Enol on glucose uptake in muscle cells are independent of insulin and would occur in cells exhibiting insulin resistance.

Example 13 - Enol is Associated with Increased Glucose Flux in Human Skeletal Muscle Myotubes

Glucose transporter 1 (Glutl) and Glucose transporter 4 (Glut4) are involved in the transport of glucose across the plasma membrane and are the predominant facilitative glucose transporters within skeletal muscle (Jones et al., 1998, Journal of Applied Physiology, Vol. 84, pp. 1661-1666). Glut4 is responsible for insulin-regulated glucose transport into the cell. Myogenin is a muscle specific transcription factor that may be involved in regulating Glutl and Glut4 expression (see Jones et al., above). Hexokinase 2 (HK2) phosphorylates glucose to form glucose-6-phosphate (G6P) and is the predominant hexokinase in skeletal muscle. Expression of Glutl, Glut 4, HK2 and myogenin was measured in cell cultures of human skeletal muscle myotubes with or without Enol treatment. The myotubes were treated with purified Enol which was prepared as described in Example 2. Glutl, Glut4, HK2 and myogenin mRNA levels were determined by quantitative PCR. Glutl protein levels were determined by MS proteomics analysis. As shown in Figures 22A and 22B, Enol treatment increased Glutl, Glut4 and HK2 mRNA levels, and Glutl protein levels. Because these proteins are involved in glucose transport and metabolism, these results indicate that Enol treatment is associated with increased glucose flux in skeletal muscle.

To further investigate the role of Enol in glucose flux, G6P and phosphoenol pyruvate (PEP) levels were measured in glucose starved and glucose stimulated human skeletal muscle myotubes with or without treatment with purified Enol. Glucose starving was performed by incubating the myotubes in glucose free DMEM for 15 min. Glucose stimulation was performed by treating the myotubes with 5 mM glucose for 15 min. G6P and PEP levels were measured using assay kits from Biovision (Milpitas, CA; Cat. Nos. K657- 100 and K365-100). As shown in Figures 23 and 24, Enol treatment increased G6P and PEP levels in both glucose starved and glucose stimulated human skeletal muscle myotubes, further indicating that Enol treatment is associated with increased glucose flux in skeletal muscle.

Example 14 - Enol Mode of Action To further investigate the mode of action of Enol in glucose uptake, the oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) were measured in human skeletal muscle myotube cells. OCR is an indicator of mitochondrial respiration and ECAR is an indicator of glycolysis.

For OCR experiments, various compounds were added sequentially to the cells to induce changes in OCR. For example palmitate and carbonyl cyanide m- chlorophenylhydrazone (CCCP, an uncoupler of oxidative phosphorylation) were added to increase OCR and etomoxir (a fatty acid oxidation inhibitor) was added to decrease OCR. KHB buffer (pH 7.4) was added to each well and measurements were performed every 3 min with 2 min intermeasurement mixing. BSA-conjugated palmitate (final concentration 200 mmol/L), CCCP (final concentration 2 μΜ) and etomoxir (final concentration 50 mmol/L) were injected sequentially. As shown in Figure 25, Enol treatment increased OCR. These results indicate that Enol treatment is associated with increased mitochondrial free fatty acid oxidation in human skeletal muscle myotubes.

For ECAR experiments with glucose as a substrate, sodium carbonate and

glucose/pyruvate-free DMEM were used. Glucose, oligomycin and 2-DG were injected sequentially to give final concentrations of 25 mmol/L. As shown in Figure 26, Enol treatment increased ECAR, indicating that Enol treatment is associated with increased glycolytic activity and capacity.

To determine the mitochondrial content of human skeletal muscle myotubes treated with Enol, myotubes were treated with 500 ug/ml or 1000 μg/ml Enol for 48 hours and then Mitotracker green (Invitrogen), a green fluorescent mitochondrial stain, was added. After 15 min of staining , the myotubes were trypsinized, washed, and subjected to flow cytometry to determine mitochondrial content. As shown in Figure 27 A, Enol treatment does not influence mitochondrial content.

Mitochondrial ROS was also detected in the Enol treated human skeletal muscle myotubes described above. Mitochondrial ROS was determined by treating cells with

Dihydrorhodamin 123 (Life Technologies), an uncharged and nonfluorescent reactive oxygen species (ROS) indicator that can passively diffuse across membranes where it is oxidized to cationic rhodamine 123 which localizes in the mitochondria and exhibits green fluorescence. The myotubes were then trypsinized, washed, and subjected to flow cytometry. Treatment of human skeletal muscle myotubes with Enol did not affect mitochondrial reactive oxygen species production (Figure 27B).

These results indicate that the mode of action of Enol is not due to changes in mitochondrial content or ROS production.

To further investigate the mode of action for Enol, non-phosphorylated 5' AMP activated protein kinase (AMPK) and phosphorylated AMPK (pAMPK) levels were measured in basal and serum starved human skeletal muscle myotubes treated with 0, 500, or 1000 μg/ml Enol. Basal human skeletal muscle myotubes were treated with normal differentiation medium containing 2% horse serum, while serum-starved myotubes were starved with serum free DMEM containing 0.5% BSA for 3 hours before lysis of the myotubes. AMPK and pAMPK levels were determined by Western blot using antibodies specific to the phosphorylated or non-phosphorylated form of the kinase. An antibody specific to Lamin A/C was used to confirm even loading among samples. As shown in Figures 28A and 28B, Enol treatment did not affect pAMPK levels in basal or serum starved myotubes. AMPK activation or phosphorylation is one of the major insulin independent pathways that regulate glucose uptake in skeletal muscle, for example during muscle contraction. Accordingly, the lack of an effect of Enol on pAMPK levels suggest a novel mode of action for Enol beyond conventional signal transduction.

Example 15 - Enol Binding Partners in Human Skeletal Muscle Myotubes

To further investigate the mode of action for Enol, the binding partners of Enol were compared in untreated human skeletal muscle myotubes (containing endogenous Enol) and human skeletal muscle myotubes treated with 50 μg/ml or 100 μg/ml of 6X Histidine tagged exogenous Enol. Endogenous Enol was immunoprecipitated in the untreated myotubes using an antibody specific to Enol. The exogenous Enol was immunoprecipitated using the 6X Histidine Tag antibody. The binding partners of endogenous Enol and exogenous Enol were identified by quantitative proteomics, and the identity of the binding partners was confirmed by Western blot and/or reverse immunoprecipitation. Nicotinamide phosphoribosyltransferase (Nampt) was identified as a binding partner of both endogenous and exogenous Enol. Nampt catalyzes the synthesis of nicotinamide mononucleotide (NMN) from nicotinamide and is involved in muscle contraction and secretion. Enol may interact with Nampt as part of the glycolysis complex, as depicted in Figure 29. Example 16 - Interaction of Enol and Nampt

Nampt activity was determined in human skeletal muscle myotubes treated with 500 ug/ml or 1000 μg/ml Enol in differentiation medium for 48 hours after 4 days of

differentiation. Myotube lysates were subjected to immunoprecipitation using either IgG or anti-Nampt antibody (Clone AF-1E12) from Cyclex (Nagano, Japan). The

immunoprecipitated myotube lysates were subjected to Nampt activity assay using Cyclex Nampt activity assay kit (#CY-1251). As shown in Figure 30, Enol treatment increased Nampt activity. Enol treatment also increased secretion of Nampt (eNampt) in human skeletal muscle myotubes (data not shown).

2-DG uptake was measured in human skeletal muscle myotubes which had been serum starved for 3 hours and then treated with recombinant extracellular Nampt (eNampt) from Abeam (Cambridge, MA). 2-DG uptake was measured using a fluorometric glucose uptake assay kit from Abeam (Cat. No. abl36956). As shown in Figure 31, addition of eNampt increased 2-DG uptake.

To determine the role of Nampt in Enol induced glucose uptake, human skeletal muscle myotubes were treated with Enol for 48 hours as described above, and the Nampt inhibitor FK866 was added 24 hours after initiation of Enol treatment, for a total FK866 treatment time of 24 hours. 2-DG uptake was measured after 3 hours serum starvation using the Abeam glucose uptake assay kit described above. As shown in Figure 32, Nampt inhibition by FK866 abolished Enol induced glucose uptake. This result indicates that Nampt plays a role in Enol induced glucose uptake.

Equivalents

Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments and methods described herein. Such equivalents are intended to be encompassed by the scope of the following claims.

Incorporation by reference

Each reference, patent, patent application, and GenBank number referred to in the instant application is hereby incorporated by reference as if each reference were noted to be incorporated individually. Description of Sequences

Claims

1. A pharmaceutical composition comprising Enol or a fragment thereof and a muscle targeting peptide.

2. The pharmaceutical composition of claim 1, wherein the composition is for delivery to a muscle cell.

3. The pharmaceutical composition of claim 1, wherein the Enol comprises an Enol polypeptide or a fragment thereof.

4. The pharmaceutical composition of claim 1, wherein the Enol comprises an Enol nucleic acid or a fragment thereof.

5. The pharmaceutical composition of claim 1, 2 or 4, wherein the composition further comprises an expression vector encoding for the Enol or fragment thereof.

6. The pharmaceutical composition of any one of claims 1-3, wherein the Enol or fragment thereof is biologically active.

7. The pharmaceutical composition of any one of claims 1-3, wherein the Enol or fragment thereof has at least 90% of the activity of a purified endogenous human Enol polypeptide.

8. The pharmaceutical composition of any one of claims 1-7, wherein the Enol is human Enol.

9. The pharmaceutical composition of any of claims 1-7, wherein the composition further comprises a microparticle.

10. The pharmaceutical composition of any of claims 1-7, wherein the composition further comprises a nanoparticle.

11. The pharmaceutical composition of any of claims 1-7, wherein the composition further comprises an in situ forming composition.

12. The pharmaceutical composition of any of claims 1-7, wherein the composition further comprises a liposome.

13. The pharmaceutical composition of claim 1-7, wherein the composition further comprises a dendrimer.

14. The pharmaceutical composition of claim 3, wherein the composition comprises a complex comprising the Enol polypeptide and the muscle targeting peptide.

15. The pharmaceutical composition of claim 14, wherein the Enol polypeptide is human Enol polypeptide.

16. The pharmaceutical composition of claim 15, wherein the muscle targeting peptide comprises an amino acid sequence selected from the group consisting of: ASSLNIA; WDANGKT; GETRAPL; CGHHPVYAC; and HAIYPRH.

17. The pharmaceutical composition of claim 14, wherein the complex further comprises a linker.

18. The pharmaceutical composition of claim 17, wherein the linker is selected from the group consisting of a covalent linker, a non-covalent linkage, and a reversible linker.

19. The pharmaceutical composition of any one of claims 14-18, wherein the complex further comprises a pharmaceutically acceptable dendrimer.

20. The pharmaceutical composition of claim 19, wherein the pharmaceutically acceptable dendrimer is a PAMAM dendrimer.

21. The pharmaceutical composition of claim 19, wherein the pharmaceutically acceptable dendrimer is a G5 dendrimer.

22. The pharmaceutical composition of claim 19, wherein the pharmaceutically acceptable dendrimer is an uncharged dendrimer.

23. The pharmaceutical composition of claim 19, wherein the pharmaceutically acceptable dendrimer is an acylated dendrimer.

24. The pharmaceutical composition of claim 19, wherein the pharmaceutically acceptable dendrimer is a PEGylated dendrimer or an acetylated dendrimer.

25. The pharmaceutical composition of any one of claims 14-18, wherein the complex further comprises a liposome.

26. The pharmaceutical composition any one of claims 14-18, wherein the complex further comprises a microparticle.

27. The pharmaceutical composition of any one of claims 14-18, wherein the complex further comprises an in situ forming composition.

28. The pharmaceutical composition of any one of claims 14-27, wherein the Enol is released from the complex upon delivery to a muscle cell.

29. The composition of any of claims 20-24, wherein the dendrimer and the ENOl are present in the complex at a ratio of about 1: 1 to about 10: 1.

30. The composition of any of claims 20-24, wherein the dendrimer and the ENOl are present in the complex at a ratio of about 3: 1 to about 5: 1.

31. The composition of any of claims 20-24, wherein the muscle targeting moiety and the dendrimer are present in the complex at a ratio of about 0.1: 1 to about 10: 1.

32. The composition of any of claims 20-24, wherein the muscle targeting moiety and the dendrimer are present in the complex at a ratio of about 1: 1 to about 3: 1.

33. The composition of any of claims 14-24, wherein the Enol and the muscle targeting moiety are present in the complex at a ratio of about 1: 1 to about 1:30.

34. The pharmaceutical composition of any one of claims 1-33, wherein the composition is formulated for parenteral administration.

35. The pharmaceutical composition of any one of claims 1-33, wherein the composition is formulated for oral administration.

36. The pharmaceutical composition of any one of claims 1-33, wherein the composition is formulated for intramuscular administration, intravenous administration, or subcutaneous administration.

37. A method of decreasing blood glucose in a subject with elevated blood glucose, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby decreasing blood glucose in the subject.

38. A method of increasing glucose tolerance in a subject with decreased glucose tolerance, the method comprising administering to the subject the pharmaceutical

composition of any of claims 1-19, thereby increasing glucose tolerance in the subject.

39. A method of improving insulin response in a subject with decreased insulin sensitivity and/or insulin resistance, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby improving insulin response in the subject.

40. A method of treating diabetes in a subject, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby treating diabetes in the subject.

41. The method of claim 40, wherein diabetes is type 2 diabetes or type 1 diabetes.

42. The method of claim 40, wherein diabetes is pre-diabetes.

43. A method of decreasing an HbAlc level in a subject with an elevated HblAc level, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby decreasing the HbAlc level in the subject.

44. A method of improving blood glucose level control in a subject with abnormal blood glucose level control, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby improving blood glucose level control in the subject.

45. The method of any one of claims 37-44, wherein glucose flux in a skeletal muscle cell of the subject is increased.

46. A method of increasing glucose flux in a subject, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby increasing glucose flux in the subject.

47. A method of increasing glycolytic activity or capacity in a skeletal muscle cell of a subject, the method comprising administering to the subject the pharmaceutical composition of any of claims 1-19, thereby increasing glycolytic activity or capacity in a skeletal muscle cell of the subject.

48. A method of increasing mitochondrial free fatty acid oxidation in a skeletal muscle cell of a subject, the method comprising administering to the subject the

pharmaceutical composition of any of claims 1-19, thereby increasing mitochondrial free fatty acid oxidation in a skeletal muscle cell of the subject.

49. The method of any of claims 37-48, wherein the Enol is administered parenterally.

50. The method of any of claims 37-48, wherein the Enol is administered orally.

51. The method of claim 49, wherein the Enol is administered by a route selected from the group consisting of intramuscular, intravenous, and subcutaneous.

52. The method of any one of claims 37-48, wherein the subject has any one or more of elevated blood glucose, decreased glucose tolerance, decreased insulin sensitivity and/or insulin resistance, diabetes, elevated HblAc level, and abnormal blood glucose level control.

53. The method of any one of claims 37-48, further comprising selecting a subject having any one or more of elevated blood glucose, decreased glucose tolerance, decreased insulin sensitivity and/or insulin resistance, diabetes, elevated HblAc level, and abnormal blood glucose level control.

54. The method of any one of claims 37-53, wherein the subject is human.