eMedicine Specialties > Neurology > Neuromuscular Diseases
Nutritional Neuropathy: Treatment & Medication
Updated: Sep 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
If the neuropathy is due to thiamine deficiency in an alcohol-dependent patient, consider instituting an alcohol-withdrawal protocol and providing seizure prophylaxis if indicated.
Surgical Care
- Prevent trophic changes to the skin and ulceration of the feet with orthotics.
- Consider surgical prophylaxis of osseous deformities.
Consultations
Refer the patient to an orthopedic surgeon for evaluation of osseous deformities.
Diet
Establishing an exact nutritional deficiency is often difficult. Many etiologies are often present simultaneously, especially in patients with malnutrition. Nutritional supplements are relatively innocuous. Therefore, for many nutritional neuropathies, the treatment is empirical and establishes the diagnosis. The further the disease has progressed, the lower the likelihood of reversing the symptoms.
- Alcohol: Discontinue alcohol; give folate 1 mg intramuscularly (IM) once daily (qd) for 3 days and thiamine (vitamin B 1 ) 50 mg IM qd and/or 50 mg orally (PO) 3 times daily (tid) for 3 days followed by a maintenance dose of 5-10 mg PO qd.
- Thiamine (vitamin B 1 ) deficiency: Administer parenteral B-complex vitamins, then oral thiamine, 50 mg IM qd for 3 days or 50 mg PO tid for 3 days; the maintenance dose is 5-10 mg PO qd. A maintenance dose of 0.5 mg/100 kcal is required.
- Niacin (vitamin B 3 ) deficiency: The peripheral neuropathy of pellagra does not respond to niacin supplements alone; both niacin and pyridoxine must be added to the diet. Niacin causes a vasocutaneous flush; therefore, administer nicotinamide 100 mg IM or intravenously (IV), followed by 200 mg PO tid. The RDA is 11.3-13.3 niacin equivalents, so named because tryptophan is a niacin precursor such that 60 mg tryptophan is equivalent to 1 mg niacin. This RDA is increased in pregnant women and in those with diets high in leucine (eg, millet).
- Pyridoxine (vitamin B 6 ) deficiency: Treat with excessive amounts of pyridoxine. Be careful of competitive inhibition with thiamine.
- Cyanocobalamin (vitamin B 12 ) deficiency: Give cyanocobalamin (vitamin B 12 ) supplementation and treat the underlying disease responsible for the deficiency state. Administer IM injections 1 mg/day for 1 week followed by 1 mg/week for 1 month. If malabsorption is the etiology, prescribe 1 mg/mo for life. Oral supplementation of 1 mg/d is acceptable if the integrity of the GI tract is preserved; this yields an absorption of 10 mcg/d.
- Folate deficiency: Give 1 mg PO qd. Do not give folate until cyanocobalamin (vitamin B 12 ) deficiency has been positively excluded. Folate corrects the hematologic abnormalities but worsen the neurologic dysfunction.
- Alpha-tocopherol (vitamin E) deficiency: Treatment varies depending on the cause, as follows:
- Cystic fibrosis - 5-10 IU/kg qd
- Cholestatic disease - 15-25 IU/kg qd
- Abetalipoproteinemia - 100-200 IU/kg qd in divided doses with vitamin A 15,000-20,000 IU qd
- Short bowel syndrome - 200-3600 IU qd
- Vitamin E transporter deficiency - 800-3500 IU qd
- Gluten sensitivity: The ideal management is unclear, but a gluten-free diet appears prudent.
- Malnutrition: Thiamine replenishment alone is usually not sufficient to cause resolution of the symptoms; increase the protein in the diet slowly to 1.5-2 g/kg body weight qd.
Activity
Physical therapy is recommended to prevent joint contractures. Therapy consists of daily exercises though full range of motion, the use of splints to prevent foot drop, and the use of orthotics to minimize ulceration at denervated pressure points.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Vitamins
To treat a nutritional neuropathy, replacing the deficient nutrients is necessary. This may involve administration of folate, thiamine (vitamin B 1 ), nicotinamide, pyridoxine (vitamin B 6 ), cyanocobalamin (vitamin B 12 ), alpha-tocopherol (vitamin E), vitamin A, or protein.
Thiamine (Thiamilate)
For thiamine deficiency syndromes.
Adult
50 mg IM qd for 3 d or 50 mg PO tid for 3 d, then maintenance dose of 5-10 mg PO qd
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Sensitivity reactions (intradermal test-dose recommended if sensitivity suspected); deaths have resulted from IV use; administer before or with dextrose-containing fluids in suspected thiamine deficiency
Niacinamide (Vitamin B 3 )
Source of niacin used in tissue respiration, lipid metabolism, and glycogenolysis.
Adult
100 mg IV/IM then 200 mg PO tid
Pediatric
Not established
May potentiate effects of ganglion-blocking and vasoactive drugs, resulting in postural hypotension; may be inactivated by bile-acid sequestrants (colestipol, cholestyramine)—wait 4-6 h before ingestion
Documented hypersensitivity; active liver disease or unexplained, significant increases in AST and ALT levels; large doses of niacin, especially sustained release, associated with severe hepatotoxicity; definite and recent history of peptic ulcer disease can reactivate ulcers
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in those with gallbladder disease, diabetes, or predisposition to gout; monitor blood glucose level; may elevate uric acid levels; pregnancy category C at doses above RDA
Cyanocobalamin (Crystamine)
Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B 12 in humans. Vitamin B 12 synthesized by microbes but not humans or plants. Vitamin B 12 deficiency may result from intrinsic factor deficiency (pernicious anemia), partial or total gastrectomy, or diseases of distal ileum.
Adult
1 mg qd IM for 1 wk then 1 mg/wk for 1 mo
Maintenance dose: 1 mg qmo for life
Pediatric
Not established
None reported
Documented hypersensitivity; hereditary optic nerve atrophy
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Severe hypokalemia may result in vitamin B 12 -megaloblastic anemia (may be fatal) due to increased cellular potassium requirements when anemia corrects
Folate (Folvite)
Important cofactor for enzymes used to produce RBCs.
Adult
1 mg PO qd
Pediatric
Not established
May decrease phenytoin to subtherapeutic levels, increasing seizure frequency
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Benzyl alcohol present in some products as preservative; associated with fatal gasping syndrome in premature infants; resistance may occur with alcoholism and deficiencies of other vitamins; do not administer until cyanocobalamin (vitamin B-12) deficiency ruled out
Alpha-tocopherol (Vita-Plus E Softgels, Vitec, Aquasol E)
Protects polyunsaturated fatty acids in membranes from attack by free radicals and protects RBCs against hemolysis.
Adult
Cystic fibrosis: 5-10 IU/kg PO qd
Cholestatic disease: 15-25 IU/kg PO qd
Abetalipoproteinemia: 100-200 IU/kg in divided doses with 15,000-25,000 IU PO qd of vitamin A
Short bowel syndrome: 200-3600 IU PO qd
Isolated familial vitamin E deficiency: 800-3500 IU PO qd
Pediatric
Not established
Mineral oil decreases absorption of vitamin E; vitamin E delays absorption of iron and increases effects of anticoagulants
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Large doses of vitamin E is pregnancy category C; vitamin E may induce vitamin K deficiency; necrotizing enterocolitis may occur with large doses
Multiple vitamins (MVI-12, Cernevit-12)
Dietary supplement.
Adult
MVI-12: 10 mL/24h IV
Cernevit: 5 mL/24h IV
Pediatric
MVI-12
<12 years: 5 mL/24h IV
>12 years: Administer as in adults
Cernevit
<12 years: 2.5 mL/24h IV
>12 years: Administer as in adults
Hydralazine and isoniazid may decrease effect of pyridoxine; pyridoxine may decrease effect of levodopa
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Pregnancy category C if doses above RDA recommendations; caution in severe renal or liver failure; children may require additional vitamin A
More on Nutritional Neuropathy |
| Overview: Nutritional Neuropathy |
| Differential Diagnoses & Workup: Nutritional Neuropathy |
 Treatment & Medication: Nutritional Neuropathy |
| Follow-up: Nutritional Neuropathy |
| Multimedia: Nutritional Neuropathy |
| References |
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References
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Further Reading
Keywords
malabsorption neuropathy, alcohol neuropathy, Strachan syndrome, Jamaican neuritis, camp foot, dry beriberi, wet beriberi, deficiency amblyopia, nutritional optic amblyopia, tobacco-alcohol amblyopia, pellagra, subacute combined degeneration, vitamin deficiency, nutritional deficiency, peripheral neuropathies
