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Current Insights On Vitamins And Folic Acid For Patients With Wounds And Neuropathy
In a continuing discussion of ensuring patients with wounds get proper nutrition, these panelists explain the use of vitamins, what to prescribe for leg cramps and the benefits of folic acid for patients with diabetic neuropathy.
Q:
What vitamins do you prescribe to promote wound healing?
A:
Kazu Suzuki, DPM, CWS, is aware of some research that vitamin C and zinc supplements may promote wound healing.1,2 However, Dr. Suzuki notes that most of his patients already take daily multivitamin tablets on their own, or consume protein drinks or cereals that contain the daily recommended amount of vitamins. For that reason, he does not recommend extra vitamin C and zinc tablets to his patients individually, saying either vitamin would be one more pill for the patients to purchase and swallow. On the other hand, research has shown pentoxifylline (Trental, Sanofi Aventis), a prescription medication for intermittent claudication, taken 400 mg tablet tid, is an effective adjunct therapy for enhanced healing of venous leg ulcers.3 Dr. Suzuki does consider prescribing pentoxifylline for patients with recalcitrant or chronic venous leg ulcers.
In contrast, Andrew Meyr, DPM, will advise wound care patients to take zinc and vitamin C. He recommends no more than 30 mg/day for zinc and suggests additional vitamin C supplementation. Dr. Meyr discusses nutritional supplementation in patients with chronic wounds who do not respond to standard wound care.
Likewise, James McGuire, DPM, supports the use of vitamin C and zinc in wound care patients. He prescribes a daily dose of 1,000 mg of vitamin C and 50 mg of zinc.
Noting that so many foods today are supplemented with multivitamins, Dr. Suzuki has yet to see a patient with serious vitamin deficiencies in the United States. He notes the exception is patients with occasional vitamin D insufficiency, which physicians discover accidentally during the pre-op workup.
Dr. McGuire also prescribes the following supplements on a case by case basis: 1,000 mg of borage capsules daily, 600 mg of alpha lipoic acid daily and 3,000 mg of arginine three times a day. He has found the following daily dosages particularly effective in facilitating wound healing: 500 mg of acetyl-L-carnitine, 150 mg of benfotiamine and 1,200 mg of fish oil.
Q:
What do you recommend for leg cramping?
A:
For patients with leg cramping, Dr. Meyr rules out underlying vascular disease with non-invasive vascular testing and metabolic deficiencies with a basic lab workup, usually a chemistry 10 panel. If nothing in the workup is abnormal, he will make a push for recommending aerobic exercise to patients and discuss dietary potassium supplementation and drinking tonic water. Dr. Meyr will also sometimes consider compression stocking therapy for leg cramps.
“Leg cramping isn’t really a diagnosis and is often very generalized,” asserts Dr. Meyr. “It has a large differential diagnosis so to me, it is really a matter of how much the patient wants to go chasing after it.”
Dr. Suzuki has tried many supplements and medications for his patients to alleviate leg cramping. So far, what has worked the best for his patients are increased hydration using electrolyte tablets and powders (such as Nuun tablets or Skratch Labs powder), commonly used by athletes and readily available in grocery stores and pharmacies. Dr. Suzuki instructs his patients to dissolve these products in water, to flavor the plain water for better hydration and use electrolyte supplements. Most of these hydration supplements are sugar-free or contain low sugar, and he says they are perfectly safe for all of his patients, including patients with diabetes or those on dialysis, to consume daily. Pedialyte (Abbott Laboratories) is another readily available choice for better hydration, although Dr. Suzuki cautions it may not be suitable for patients with diabetes as it contains dextrose by design.
Dr. McGuire uses horse chestnut extract for leg cramps as well as tonic water with quinine.
Q:
Do you prescribe folic acid for neuropathy?
A:
Dr. McGuire will prescribe 800 mcg of folic acid daily for patients with neuropathy. If a patient cannot get L-methylfolate, methylcobalamin and pyridoxal-5’-phosphate (Metanx, Nestle Health Science), an active form of vitamin B, he will prescribe 1,000 mcg of vitamin B12 and 50 mg of vitamin B6 daily.
Dr. Suzuki also prescribes Metanx capsules BID daily, citing a good body of clinical evidence that it is effective in improving various symptoms of peripheral neuropathy.4 The only drawback Dr. Suzuki cites is that it may take two or three months of taking folic acid before patients see any improvement, and the degree of symptom improvement (pain relief, improved walking, better sleep, etc.) varies depending on individuals. For this reason, Dr. Suzuki usually prescribes Metanx along with conventional neuropathy medications, such as gabapentin (Neurontin, Pfizer), pregabalin (Lyrica, Pfizer) and duloxetine (Cymbalta, Eli Lilly), or if patients have already failed these first- and second-line neuropathy medications. In his experience, Dr. Suzuki notes that Metanx is a well tolerated, safe and effective therapy as it is simply an activated form of vitamin B.
In contrast, Dr. Meyr typically does not prescribe folic acid for neuropathy. While Dr. Meyr will discuss the option of folic acid with patients, he does not push for its use, noting that he is not convinced of the efficacy of folic acid for neuropathy.
Dr. McGuire is the Director of the Leonard Abrams Center for Advanced Wound Healing and is an Associate Professor in the Departments of Podiatric Medicine and Biomechanics at the Temple University School of Podiatric Medicine in Philadelphia.
Dr. Meyr is an Associate Professor within the Department of Surgery at the Temple University School of Podiatric Medicine in Philadelphia.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.
References
- Lansdown ABG, Mirastschijski U, Stubbs N, et al. Zinc in wound healing: Theoretical, experimental, and clinical aspects. Wound Repair Regen. 2007;15(1):2–16.
- Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomized control trial. Clinical Nutrition. 2005;24(6),979-987.
- Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012 Dec 12;12:CD001733.
- Fonseca VA, Lavery LA, Thethi TK, et al. Metanx in type 2 diabetes with peripheral neuropathy: a randomized trial. Am J Med. 2013; 126(2):141-9.
