Dr. Palecki has been a doctor of podiatric medicine in private practice in Baton Rouge, Louisiana, for the past 7 years. He is also the medical director for Pinnacle Home Health.
A 79-year-old white female with non-insulin-dependent diabetes mellitus of long-standing duration and a history of a stroke in 2003 presented with a chief complaint of neuropathic pain to both feet in December 2004. The patient had no history of smoking or alcohol use and was taking Plavix. The patient’s surgical history included hemorrhoidectomy, colon polyp removal, hysterectomy, bladder lift, and cataract surgery. At presentation, she stated not knowing where her feet were when walking. She also complained of a grabbing pain to her feet. This pain would wake her up at night, and it was painful to cover the feet with a blanket when in bed. The pain registered at 9/10 and caused her to lose sleep. These symptoms were of gradual onset and were present before the stroke.
On physical examination, she only felt 1 out of 10 pressure points bilaterally using the 5.07 Semmes-Weinstein monofilament sensitivity test. Vascular exam revealed diminished dorsalis pedis and posterior tibial pulses, warm to cool skin temperature from the leg to the toes, and decreased elasticity and turgor, bilaterally. Positive varicosities were also present bilaterally. Hallux capillary refill time was within normal limits.
The patient was started on Metanx 2 tablets by mouth daily in June 2005. Anodyne therapy was given from December 2004 to January 2005, from April 2005 to May 2005, and from October 2005 to press time. A total of 12 sessions were given with each time frame.
When the patient presented for routine foot care again on October 26, 2005, she was pleased with her pain response since being placed on Metanx. Instead of the grabbing pain in her feet, it was only a soreness. The patient registered it at 6/10. The frequency of the pain was greatly reduced, and she was aware of knowing where her feet were when walking and was more stable. The patient also was pleased to be able to cover her feet with a blanket at night without hurting and was getting better quality sleep. She also stated an awareness of feeling better. The 5.07 Semmes-Weinstein monofilament sensitivity also improved to feeling 4 out of 10, right, and 3 out of 10, left. As of the last exam, there were no changes noted to her vascular findings.
The patient continues to take Metanx twice a day and will be recertified for Anodyne therapy if needed.
Commentary
David E. Allie, MD
This patient has responded to the neuropathic symptoms of diabetes; however, with a history of stroke, the patient should have a vascular and cardiology consultation. The physical exam of the elderly patient with diabetes can be very difficult to interpret, and noninvasive evaluations, such as ankle/brachial indices and Doppler ultrasounds, are inaccurate. This patient would be an ideal candidate for multichannel (16–64) computed tomography angiography, which has revolutionized our PAD practice by providing excellent, immediate, accurate, noninvasive visualization of all infrapopliteal vessels, allowing for immediate diagnosis and treatment planning.
Commentary and Summation
Allen M. Jacobs, DPM
This case, as well as the other cases reviewed in this supplement, illustrates the potential remittive effects of Metanx in the management of symptomatic diabetic neuropathy.
It is important to remember that Metanx is not a panacea for the management of symptomatic diabetic neuropathy. Although this particular case, as well as the other cases presented in this supplement, demonstrated the successful amelioration of symptoms associated with diabetic neuropathy through the use of Metanx, it is not the intention of the participating faculty members to suggest that all cases of symptomatic diabetic neuropathy will resolve with the use of this medication.
Metanx offers the possibility of a true remittive effect on peripheral nerves by potentially offering a method to correct biochemical abnormalities within the nerve itself. In addition, this agent offers the potential advantage of increasing vascular flow to the peripheral nerve. The ability of this agent to increase vascular flow in the periphery has recently been demonstrated as a successful adjunct for the healing of recalcitrant ankle ulcerations.4 The effects of this agent on peripheral vascular flow, and in particular perfusion to the peripheral nerves, is analogous to other currently employed modalities, such as Anodyne therapy, in providing increased levels of nitric oxide to local tissues. The extrapolation for the employment of Metanx as an adjunctive therapy in wound healing is reasonable based upon the mechanism of action of this agent and may prove to be beneficial in the management of recalcitrant poorly healing wounds.
Commonly employed agents for the management of symptomatic diabetic neuropathy include antidepressant medications as well as pharmaceutical agents typically utilized for the management of seizure disorder. Although these drugs may provide symptomatic relief from dysesthesias and unpleasant paresthesias associated with diabetic neuropathy, they do not offer the potential of increasing blood flow to the peripheral nerve or reversing established metabolic effects within the peripheral nerve itself. Metanx, like inositol, alpha lipoic acid, aldose reductase inhibitors, and similar agents, offers the potential to alleviate symptoms and concurrently treat the underlying metabolic defect. In addition, “nutritional” agents, such as Metanx, offer a significant potential benefit to the patient with minimal potential for adverse reaction in properly selected patients. Furthermore, “nutritional” pharmaceutical agents offer the potential to interdict progressive neuropathy involving the autonomic as well as motor nerves, a potential benefit not available from antidepressant or antiseizure medications, which are almost exclusively antinociceptive in their mechanism of action.
The need to evaluate all symptomatic and nonsymptomatic patients with diabetes for the presence of occult peripheral vascular disease has been repeatedly emphasized within this supplement. Similarly, it must be recalled that symptomatic diabetic neuropathy requires management of serum glucose levels for successful amelioration of symptoms. Frequently, peripheral neuropathic symptoms increase during the initial months of glycemic control in patients newly diagnosed with diabetes.
Finally, in recent months, we have seen the addition of new pharmaceutical agents for the management of symptomatic sensory neuropathy associated with diabetes mellitus. It has been my personal experience with these new agents that the addition of Metanx, 1 or 2 tablets daily, has improved the efficacy of those agents with regard to resolving dysesthesias and paresthesias, which had not improved initially with the use of these agents.
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