When it comes to adjunctive modalities for the treatment of diabetic neuropathy, podiatrists may want to consider the supplement Metanx (Pamlab). Two podiatrists cite the modality as a safe and effective treatment option for those with diabetic neuropathy. Comprised of 2.8 mg of L-methylfolate, 25 mg of pyrioxal 5’-phosphate (B6) and 2 mg of methylcobalamin (B12), Metanx has been proven to increase nitric oxide (NO) synthesis and improve endothelial function, according to Allen Jacobs, DPM, and Theodore Varoz, DPM, PCPM, DFW. Dr. Jacobs notes that B6 facilitates neural regeneration and B12 is essential for neural function. Dr. Varoz says hyperhomocysteinemia has been “strongly associated” with cardiovascular disease, especially peripheral arterial disease (PAD), and most recently diabetic neuropathy. Dr. Jacobs concurs and notes that Metanx can be effective with homocysteine levels as well. “In addition to a direct neural effect, the components of Metanx are associated with lowering serum homocysteine levels,” explains Dr. Jacobs, a Fellow of the American College of Foot and Ankle Surgeons. With all other factors being equal, Dr. Jacobs says Metanx is typically his “first pharmacologic choice in the management of diabetic neuropathy related signs and symptoms.” In his experience with this medication, Dr. Jacobs says he expects to see some improvement in neuropathic signs and symptoms within eight to 12 weeks. He adds that 30 to 40 percent of his patients are satisfied with relief of paresthesias and dysethesias, or analgesia dolorosa with the medication. Dr. Varoz has also had a favorable experience with this medication in his practice. “In my experience, 80 percent of my patients with diabetes achieve 80 percent resolution of their neuropathic pain,” offers Dr. Varoz. Can It Facilitate Improved Wound Healing? Drs. Jacobs and Varoz also suggest that Metanx may have adjunctive benefit in wound healing. Dr. Varoz says the elevation of NO levels associated with Metanx can facilitate angiogenesis, collagen deposition and the formation of granulation tissue. Dr. Jacobs concurs. “The elevation of NO levels and concurrent improvement in vascular endothelial function with the use of Metanx and similar agents offers the potential to assist in the reduction of microvascular associated pathology, including problematic wound healing,” adds Dr. Jacobs, an Adjunct Associate Clinical Professor at the St. Louis University School of Medicine. A Safe Alternative Pamlab notes that paresthesia, somnolence, nausea and headache have been reported with Pyrioxal5’-phosphate. The company also notes that mild transient diarrhea, itching and transitory exanthema have been associated with methylcobalamin. However, Dr. Varoz and Jacobs agree that Metanx does not have a significant side effect profile. According to Dr. Varoz, the medication is a safe option for patients with diabetes who may be taking multiple medications for systemic diseases. He says Metanx has “minimal risk of harmful drug interactions.” Overall, Dr. Varoz says Metanx “truly enhances our mission in podiatry to save the tips of toes, limbs and lives.” Editor’s Note: For related articles, visit the archives at www.podiatrytoday.com .