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Nutritional Neuropathy Treatment & Management

  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
 
Updated: Dec 28, 2015
 

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.

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Surgical Care

See the list below:

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

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

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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 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.
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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.

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Contributor Information and Disclosures
Author

Jasvinder Chawla, MD, MBA Chief of Neurology, Hines Veterans Affairs Hospital; Professor of Neurology, Loyola University Medical Center

Jasvinder Chawla, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Additional Contributors

Milind J Kothari, DO Professor, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center

Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Lawrence D Recht, MD Professor of Neurology and Neurosurgery, Department of Neurology and Clinical Neurosciences, Stanford University Medical School

Lawrence D Recht, MD is a member of the following medical societies: American Academy of Neurology, American Association for Cancer Research, American Neurological Association, and Society for Neuroscience

Disclosure: Nothing to disclose.

R Andrew Sewell, MD Associate Research Scientist in Psychiatry and Mental Illness Research, Education,Veterans Affairs Connecticut Health Care System, Yale University School of Medicine

R Andrew Sewell, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, American Pain Society, and American Psychiatric Association

Disclosure: Nothing to disclose.

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Pernicious anemia. Characteristic lemon-yellow–tinged pallor with raw-beef tongue lacking filiform papillae. Used with permission from Forbes and Jackson.
Ischemic retinopathy caused by severe megaloblastic anemia.
 
 
 
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