Can Benfotiamine Provide Relief For Patients With Painful Peripheral Neuropathy?

Jeffrey Bowman DPM MS

Do you have patients with diabetes, geriatric patients, patients with hypertension, patients who have had a gastric bypass or patients who suffer from alcoholism? These patients probably cover a large percentage of your patient demographic.

Thiamine (vitamin B1) deficiency is a common problem among those patient types. It is a commonly accepted cause of peripheral neuropathy. A 2007 study linked patients with type I and II diabetes with a 75 percent decrease in plasma thiamine levels in comparison to patients without diabetes.1 This is evident in a significantly higher amount of thiamine clearance in the urine in patients with diabetes. A patient with hypertension who is on diuretics experiences the same increase in urine thiamine levels.

The treatment of painful peripheral neuropathy has been a difficult challenge among healthcare providers. The list of non-specific medications with adverse side effects is extensive. Injections, therapy and topical treatment modalities are insufficient. Thiamine supplementation has traditionally had little success combating neuropathy. However, using benfotiamine, a lipid soluble thiamine analogue, has had significant success internationally since the 1960s.2-8

To implement this in your practice, consider the following steps.

First visit. Order a plasma thiamine test via high-performance liquid chromatography (Quest Diagnostics test number 922). The diagnosis is peripheral neuropathy. Have the patient return to the clinic when the blood work comes back (usually within a week). Epidermal nerve fiber density testing through Bako Pathology is a good way to see any measurable differences. The company can assess the extent of the neuropathy and you can following it over time to visualize any progress of nerve density.

Second visit. Go over the blood work with the patient. Normal values are 58.5–69.7 nmoL/L. If the values are 45 nmoL/L or below, consider initiating thiamine supplementation in the form of NeuRemedy (Realm Labs) at one 150 mg capsule bid. Have the patient return to the clinic in two weeks.

Third visit. Check the patient’s improvement in symptoms and note any side effects. If the patient is having improvement without side effects, continue the treatment for six weeks. If the patient has used thiamine supplementation for a total of eight weeks without improvement, the therapy has failed. Warn your patients though that ceasing NeuRemedy can lead to a regression as they will continue to urinate thiamine.

Other considerations regarding oral OTC treatment for painful diabetic peripheral neuropathy includes supplementation with other vitamins. Clinical Therapeutic Solutions also offers NeuRx-TF, which contains a formulation of alpha-lipoic acid (350 mg), acetyl L-carnitine (250 mg) and methyl B12 (1,000 mcg).

In Conclusion

We all have those patients who have tried every oral form of treatment for peripheral neuropathy and have either had to stop because of the side effects or because they found no relief of symptoms. Some of those same patients have tried selective injections, topical creams and even oral opioid treatments.

Painful peripheral neuropathy is one of the biggest challenges we face in podiatry. There is wide debate about what the definitive treatment is for this condition. I believe we need an alternative to the mainstream treatment protocols. The most commonly prescribed oral medications for neuropathy have significant and strenuous side effects.

This is not a sales pitch. I have no financial benefit in promoting these products. I simply want to offer something else to my patients that may help relieve painful peripheral neuropathy.


1. Thornalley PJ, Babaei-Jadidi R, Al Ali H, et al. High prevalence of low plasma thiamine concentration in diabetes linked to a marker of vascular disease. Diabetologia. 2007; 50(10):2164-70.

2. Haupt E, Ledermann H, Kopcke W. Benfotiamine in the treatment of diabetic polyneuropathy--a three-week randomized, controlled pilot study (BEDIP study). Int J Clin Pharmacol Ther. 2005; 43(2):71-7.

3. Woelk J, Lehrl S, Bitsch R, Kopcke W. Benfotiamine in treatment of alcoholic polyneuropathy: an 8-week randomized controlled study (BAP I Study). Alcohol Alcoholism. 1998; 33(6):631-8.

4. Winkler G, Pal B, Nagybeganyi E, et al. Effectiveness of different benfotiamine dosage regimens in the treatment of painful diabetic neuropathy. Arzneimittelforschung. 1999; 49(3):220-4.

5. Sadekov RA, Danilov AB, Vein AM. Diabetic polyneuropathy treatment by milgamma-100 preparation. Zh Nevrol Pskihiatr Im S S Korsakova. 1998; 98(9):30-32.

6. Simeonov S, Pavlova M, Mitkov M, et al. Therapeutic efficacy of "Milgamma" in patients with painful diabetic neuropathy. Folia Med (Plovdiv). 1997; 39(4):5-10.

7. Stracke H, Lindemann A, Federlin K. A benfotiamine-vitamin B combination in treatment of diabetic polyneuropathy. Exp Clin Endocrinol Diabetes. 1996; 104(4):311-16.

8. Stracke H, Gaus W, Achenbach U. Benfotiamine in diabetic polyneuropathy (BENDIP): results of a randomized, double blind, placebo-controlled clinical study. Exp Clin Endocrinol Diabetes. 2008; 116(10):600-5.

9. Thornalley PJ. The potential role of thiamine (vitamin B1) in diabetic complications. Curr Diabetes Rev. 2005; 1(3):287-98.

10. Brownlee M. The pathobiology of diabetic complications a unifying mechanism. Diabetes. 2005; 54(6):1615-25.

11. Saito N, Kimura M, Kuchiba A, Itokawa Y. Blood thiamine levels in outpatients with diabetes mellitus. J Nutr Sci Vitaminol (Tokyo). 1987; 33(6):421-30.

12. Hammes HP, Du X, Edelstein D, et al. Benfotiamine blocks three major pathways of hyperglycemic damage and prevents experimental diabetic retinopathy. Nat Med. 2003; 9(3):294-9.

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These vitamin foods do work to some extent as symptomatic tx. Peripheral nerve fibers lack vitamin B isoforms (B1, B9, and B12).

But nerve blocks also help with neuropathy in the feet. Local anesthetics relieve inflammatory pain and neuropathic pain. Bupivacaine or lidocaine can be used in ankle blocks or in individual nerve blocks for mono-neuritis multiplex in the feet in a series of injections. Patients can get more lasting symptom relief from these nerve blocks (in lower dosages than used in surgery) that last even longer than prescription medications like pregabalin, gabapentin, nortriptyline, Neuremedy, Metanx or oxycodone.

Unfortunately, there are no placebo controlled randomized controlled trials (RCT) in allopathic MD and osteopathic DO evidence-based medicine (EBM) literature that support nerve blocks are improving the function of periperal nerves suffering from physical damage. There are only case studies and care series articles.

RCTs should be started for serial nerve blocks for neuropathic pain syndromes in the distal lower extremity in the DPM podiatric EBM literature. Podiatrists should start this endeavor since no MD allopathic or DO osteopathic physician have started it yet.

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