Nutritional Neuropathy Treatment & Management

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.

• Prevent trophic changes to the skin and ulceration of the feet with orthotics.
• Consider surgical prophylaxis of osseous deformities.

Refer the patient to an orthopedic surgeon for evaluation of osseous deformities.

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 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.

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.