A PATIENT’S GUIDE TO NEUROPATHY
Michael Zapf, DPM, MPH, FACFAS
Burning, tingling and painful feet are one of the most common reasons patients visit my office, not surprising since 2 to 10 million people in the United States have these symptoms. In the recent past, David complained that his feet are burning so much with his shoes on that he has resorted to taking his shoes off to drive. Mel complained that his balance is thrown off because he can no longer feel the ground with his feet resulting in tripping and falling. Julie complained that it feels like there is a sock bunched under her toes but every time she looks her sock is smooth. She admits that she even feels this sensation when she is not wearing socks. David, Mel and Julie are all experiencing a phenomenon called neuropathy. When it occurs in the feet and legs (or hands and arms) it is called peripheral neuropathy (PN). Mel and Julie have such severe PN that it is causing them anxiety, depression and loss of sleep. PN often feels worst when you crawl into bed. David says his feet feel like “pins and needles” at night.
As common as PN is, the actual cause is often hard to pinpoint and treatments to get rid of neuropathy are few and rare. However, there are a lot of medicines and other treatments that make the condition easier to live with. This paper will help you understand what is happening with your PN and how to make the most of a bad situation. I will tell you the current “legitimate” diagnoses and treatments and mention several of the non-traditional remedies, some which really seem to help some people.
SYMPTOMS
There are a certain few words that people with PN will use to describe their symptoms: burning, prickling, tingling, throbbing, shooting, electrical shocks, stabbing as well as a common description of the skin feeling asleep or numb. Sometimes there is extreme sensitivity to touch and an exaggerated feeling of pain to something that should not be painful (like your socks or shoes). Sometimes the muscles in the region feel weak and sometimes there is a lack of balance. It is characteristic of the condition that people will use the seemingly contradictory terms numb and painful in the very same sentence.
PN is sometimes associated with restless leg syndrome and foot and leg cramping. Sometimes “jumpy” and “cramping” of the legs and feet are a symptom all by themselves and sometimes they foreshadow the development of PN.
ANATOMY
Nerves are the little wires that connect the brain and spinal cord to the tips of our fingers and toes. The big ones that go from the spinal cord to the muscles are usually covered in an insulating covering called myelin. When motor nerves go bad there is weakness and difficult in moving muscles. Smaller ones go from the spinal cord to the internal organs. When these are bad the organs do not work right. There are tiny ones in the skin with endings that might detect pressure, cold, hot and pain. When these go bad you can feel your feet or hands feeling heavy, cold and painful, respectively, depending on the nerves being affected. The tiniest ones are in the feet and that is why PN often seems to start there and why we see so many people experiencing this in our podiatry office. Because they are almost as far away from the spinal cord as are the feet, hands are the second most common location of PN.
SMALL FIBER PERIPHERAL NEUROPATHY
Mostly, we are going to discuss the microscopic tiny little nerve fibers in the skin that start to get sick and die in PN. Before they die and stop working each nerve fiber gets sick starts firing randomly and frequently. During these death throes of a nerve, it fires so randomly and rapidly that you sense a feeling of pain even though your skin is not against anything painful. If the nerve is a heat sensing nerve you feel burning.
Skin Nerve Biopsy: Once a nerve dies it disappears from the skin. A skin biopsy taken 10cm above the ankle bones can be sent to a special lab where they will actually count the number of nerve fibers in a 3mm sample. The sample is taken in the office under a drop of local anesthesia and does not even require a stitch. Normally there is a range of 8 to 15 nerves in a sample. People with severe PN will often have less than 8 and, in the worst cases, none. This test measures your Small Nerve Fiber Density (SNFD) and it is the gold standard to measure neuropathy. Some treatments reportedly increase your SNFD which can be measured by repeated biopsies. We will talk about these treatments later as well as alternative ways to measure your SNFD.
CAUSES OF LOW SNFD
Many conditions and disease states cause a decrease in you SNFD. The most common is diabetes. Some estimates are that 30%-65% of people who have diabetes will develop small nerve fiber PN. Many times the development of PN precedes the diagnosis of diabetes by many years. With high blood sugars some of the excess sugar in the small nerves is converted to a chemical called sorbitol. Nerves have no way to use sorbitol and it gums up the nerve causing it to die. There have been many therapies designed to stop the conversion of glucose to sorbitol but none have achieved the goal of stopping the development.
If you have diabetes (or pre-diabetes which is nearly as toxic to nerves) I will ask you how you blood sugar is running. One measure of blood sugar is a fasting level drawn in the morning after 10 hours without eating. Blood sugars above 100 or 110 are suspicious of diabetes. I will also ask you about your A1c (Glycosylated Hemoglobin) level which is a measure of your average blood sugar over the last 3 months. You cannot fool the A1c test like you can a random blood sugar. A1c levels below 6% usually do not cause PN while levels above 7% are almost always to blame. Likewise, PN with A1c levels below 5.5% almost always point to another cause for your PN.
Other causes of the death of the tiny skin nerves include: metallic poising (lead, mercury and arsenic), chemicals found in cleaning agents and insecticides, alcohol (remember how your mom said alcohol kills brain cells? Well it kills all nerve cells so be prudent), vitamin deficiency (especially B12), vitamin excess (especially B6), HIV, and many medications, particularly cancer chemotherapy agents and the quinolone antibiotics Cipro and Levaquin. There have been cases were PN has developed after taking just a few capsules of these two antibiotics.
Nerve entrapment can lead to neuropathy. The analogy of a garden hose is often used to describe the effect of a nerve entrapment. When you step on a garden hose when the water is running the stream at the end trickles down until the pressure is released. The same thing seems to happen with nerves. If a nerve is trapped in the spinal cord, at the knee or on the inside or outside of the ankle the symptoms of neuropathy are often felt. This is one case where neuropathy can be reversed by releasing the entrapment. I will discuss more on this later.
Sadly, many times the cause of PN that is not due to diabetes is never found. These are called idiopathic which his medical-speak for “We Don’t Know.”
DIAGNOSIS
When you first come to my office I will ask you about your history of things that might be related to PM. I need to know about your symptoms, their nature and when they started and what might have caused them. I want to know about diabetes, kidney or liver diseases, medications you are or have taken, exposure to heavy metals or other toxins and your alcohol use history.
I will do some basic tests for nerve function. I will test your ankle and knee reflexes with a little rubber hammer. I will see if you can feel a small calibrated filament called a Semmes-Weinstein filament. If you can feel the filament then you are said to have protective sensation which means that you should be able to feel a small cut in the skin, a rock in the shoe or other potential damaging stimuli. I will bang a tuning fork against my palm and hold the end against your skin and see how long you feel the vibration. I have found that a normal person can feel it for almost 20 seconds as the vibration extinguishes. As the SNFD decreases so does the time of tuning fork extinguishing. My personal feeling after doing this for 30 years is that 10 seconds or less qualifies as PN.
THE INTERNIST AND THE NEUROLOGIST
If you have just developed PN our first stop should be your internist or family doctor. He or she will need to carefully check your diabetes status as well as your kidney and liver function.
If you internist gives you a clean of health your next stop will be the neurologist where you need to get three questions answered. I will ask you about these questions so please get clear and understandable answers. Take notes if you have to.
Question 1: What is causing my PN?
Question 2: What will happen to my PN in the future (what is the natural history of my PN)?
Question 3: Is there anything I can do to stop or reverse my PN?
You will likely be offered medication to control your symptoms of PN but THAT IS NOT THE SAME THING AS STOPPING OR REVERSING YOUR PN.
The neurologist will ask you the same questions, and maybe a few more, about your history. He or she will usually run a battery of tests often including a nerve conduction tests (NCV) and electromyogram (EMG) as well as blood and urine tests to help come up with a diagnosis and a treatment plan. Perhaps the neurologist will find that an auto-immune problem or an inherited neuromuscular condition is causing your muscle weakness or sensory changes. Occasionally a spinal tap may be used to determine if there is an autoimmune disorder. At the appointment where you discuss these findings please get your three questions answered.
Usually the neurologist does not measure your SNFD. This can be measured directly with a skin biopsy or indirectly by carefully measuring skin sweating. Sweat glands in the skin are innervated by the same tiny nerve fibers that carry feeling and pain messages. As the nerves die, so does the ability to sweat. Testing sweat gland function is called measuring the sudomotor function that is generally not available in most neurology offices.
COMMON TREATMENTS
Diabetes – first and foremost if you have a high A1c you need to diligently and carefully control you blood sugars as per your internist or family doctor’s instructions. This certainly involves diet and exercise (150 to 300 minutes of walking a week or more) and often involves oral or injected medication. Some of your small nerves may just be stunned and not completely dead and blood sugar control might bring them back to life. When I did my residency it was so long ago that we admitted diabetic patients three days before even a small surgery to carefully control their blood sugar. On admission the anesthesiologist thought general anesthesia would not be necessary because the feet were so numb. However, after three days of a controlled diet, the nerves would come back to life and anesthesia was needed. I was impressed by the need to control blood sugar every single day. The presence of neuropathy causes too many patients to give up on scrupulous control. Don’t be one of those people.
Entrapment syndromes can be treated by surgical release of the nerves, For more about this please see the web site for the association of American Extremity Nerve Surgeons (www.aens.us). What they do is truly amazing.
Pepper cream – there are a variety of pepper containing creams on the market that can help with pain of both arthritis and PN. The active ingredient is capsaicin which is the burning compound in chilies and pepper. When you first rub the cream on the feet and ankles you feel a warm, almost burning, sensation. If you repeat the application of this cream often enough (four times a day) you can actually drain the neurotransmitter from your burning nerves and the exhausted nerves can no longer transmit pain messages. You need to keep the treatment up to keep the nerves exhausted. Many of these creams are now over-the-counter and there is even a recipe for making it yourself using shortening or skin cream and cayenne powder. If you do try this cream please heed the warning to wash your hands before touching sensitive places like your eyes. (Then, again, you will only make this mistake once.)
Vitamin deficiency of B12 can be remedied with supplements and high vitamin levels of B6 can be remedied by lowering the level.
Aspirin and other non-steroidal medications (Naprosyn, Voltaren, Celebrex, etc.) are considered too weak to treat PN and they have their own side effects.
Opioid/narcotics like hydrocodone, morphine and codeine are not targeted to PN and they can lead to dependence.
Autoimmune disorders are treated with immunosuppressant medications or IV gamma globulin.
Neuromodulators are a group of medicines that do not change the level of PN but make you, the patient, better deal with the condition. They are all psychoactive and are or are vaguely (or not so vaguely) related to anti-depressants or anti-epilepsy medicine. The analogy I use for these medications is as follows. Suppose you get the last hotel room in the city over a club playing music you just cannot stand and they are playing loud and long after you need to be asleep. Yes, the perfect answer is to have the players turn down the music, but that is not likely to happen. Instead, you could use a noise cancelling headphones, play your favorite soothing music and fall quietly asleep. Neuromodulators make you less concerned about your PN and function more like you did not have it. Neurologists will invariably suggest one of these medications for you if you have PN:
- Antidepressants like Prozac, Elavil, Lexapro, etc.
- Gabapentin aka Neurontin
- Pregablin aka Lyrica
- Duloxetine aka Cymbalta
Nerve blocks – can stop the pain for a few hours but each nerve needs to be injected. No long term help is expected from a nerve block.
T.E.N.S. – a trans electrical nerve stimulator is a cell phone sized pack with electrodes that are placed on the leg above the neuropathy. There are reports that the unit blocks some of the PN while it is turned on. There is no expectation that this will be long-lasting but it is a harmless remedy that you can try. We have TENS units in the office if you want to give it a try.
Spinal stimulator – this is similar to a TENS unit but it is implanted next to your spinal cord and works 24/7. These are administered by pain control doctors and a trial of their efficacy is usually given before their final implantation.
ALTERNATIVE THERAPIES
Physical therapy, psychological therapy, meditation, prayer, acupuncture, hypnosis, massage therapy, reflexology, magnets and biofeedback have all been reported to be helpful for some people in some studies. I am as skeptical of these as you are so be cautions that you do not spend too much money on them if you are not seeing progress.
NUTRITION
The following pages show a summary of my research on the vitamins or “food supplements” that have at least one study showing that the right doses will lessen neuropathy and, in some cases, even raise the concentration of end nerve fiber density in skin biopsies. I admit that these studies are not all of high quality and taking vitamin supplements might be just a waste of time and money. On the other hand, if you have the time and the money you just might want to investigate. Because they are vitamins they are usually not covered by insurance and the minimum cost seems to be $1 a day, although you can pay considerably more. At the end of the next section I have summarized the findings to make purchasing these supplements a little easier.
WHAT ARE THE SUPPLEMENTS that have sometimes been shown to reduce neuropathy
- Alpha lipoic acid 600mg a day
- B1 Benfotiamine 300mg a say
- B6 – P5P (Pyridoxyl 5-phosphate)– 35 mg a day
- B9 – L-methyl folate 3 mg a day
- B12 – methylcobalamin 1mg a day
- GLA – gamma linolenic acid 200mg a day
For the first four months of vitamin therapy studies seem to suggest that you should take double dosages of these nutrients and then taper off to the amount listed above for the remainder of a year and then decide if it is helping you.
You do not need to take all of these – there is no proof that taking all is better than taking just three. The nutrient we sell in the office is NeuraVite and contains the proper dosage of 1,2, 3 and 5 all for $1 a day ($2 for the first 4 months) A prescription product called Metanx contains 1,2,3 and 6. Neither contains gamma linolenic acid which we sell separately in the form of Borage Oil capsules. You can, of course, buy these supplements from any health food store or the internet. We stand behind products we sell and they are all assayed by an outside independent laboratory.
THE VITAMIN SUPPLEMENTS –i.e. “NUTRITIONAL FOODS”
The claims for arresting or improving the progressively worsening symptoms of diabetic neuropathy are legion. Put neuropathy and vitamins into a search engine and there are never ending claims of relief. Many of the claims have an element of truth. For most of the dietary supplements there is a literature report somewhere that seems to possibly show a positive effect. Careful reading of the reports shows that the studies are all flawed. Sometimes the exact dose of the nutrient is not clearly stated or the end point of the study is dubious and many other times the claims at the end took an incredible leap of imagination. I am going to list the most commonly cited nutrients, the doses that seem most commonly cited in the reports that seem to have the fewest flaws. I am putting my doctoral, my public health and my statistics hat on here, although I know that every study can be doubted by scientists and doctors. If you decide to try any of these nutrients, vitamins or nutraceuticals, please feel free to run them by your family doctor first and get his or her approval.
Alpha-Lipoic-Acid 300mg in the morning and 300 in the evening, preferably 30 minutes before a meal. ALA, also known as thioctic acid, seems to appear more than any other nutrient. It is reported to improve nerve blood flow, nerve conduction velocity and several other functions of nerve metabolism. A review article by Papanas in Expert Opinion on Pharmacotherapy in 2014 stated “There is ample evidence from randomised (sic – they are Indian) double-blind, placebo-controlled clinical trials and meta-analysis, suggesting that ALA is efficacious and safe for the diabetic neuropathy, accomplishing clinically meaningful improvements ,,,improves paraesthesia (sic), numbness, sensory deficits, and muscle strength in addition to neuropathic pain.” Some studies (and a lot of ads) suggest the ALA helps blood sugar control, improves brain function, promotes weight loss, eye and liver health and, I guess, promotes peace on earth. Don’t trust everything you read.
There are two forms “R” and “S”. R is more effective but expires quicker. Do not stock up on the R – it expires a year after manufacture. Most commercial ALA is a mixture of the two, R and S. Intravenous injections/infusions seem to work better but, obviously quite inconvenient for most of us. Probably 200mg of R-ALA is equivalent to 600 of the mixture of ALA. Some reports that the “S” half of the mixture ALA is inert and does not penetrate nerves. (Probably the dose can be halved after 4 months). The NYU Langone Medical website notes that the studies on ALA are not very scientific and that there is evidence that ALA performance is enhanced by also taking gamma linolenic acid, described below.
In our office we have
600mg Mixed ALA in NeuraVite 30 capsules for $30 (along with Benfotiamine, B6and B12)
[Note: on one study 21% of patients taking 1200 mg a day experienced nausea]
Benfotiamine (B1) 150mg – 600mg a day (Best is probably 300 2x a day for first 4 month and then 200 twice a day for maintenance) — Vitamin B1 is thiamine and is quite handy to your body but, as a nutrient, is nearly not absorbed from a pill. Better is to transform the thiamine into Benfotiamine. Balakumar in a critical review in a 2010 article in Pharmacology Research clearly states “the anti-AGE [glycation end products] property of Benfotiamine certainly makes it effective for the treatment of diabetic neuropathy, nephropathy [kidney], and retinopathy [eye].”
100mg in NeuraVite – 30 capsules for $30 (along with Alpha lipoic acid, B6 and B12)
N-Acetyl-L-Cysteine (NAC or NALC) 600-1000mg a day and N-Acetyl-L-Carnitine (250-500mg a day)
The NAL-Cysteine is frequently reported to reduce the phlegm of a cough and to help heal from contrast induced kidney damage. Both of these anti-oxidants have been reported to help heal from chemotherapy induced nerve damage. They has enough side effects to not be added to regular nephropathy regimens but if you buy an all-in-one mixture that has it in just look for uncommon side effects of nausea, vomiting, rash and fever. Actually look for these complications for all of the supplements listed in this article. If you have chemotherapy induced neuropathy, strongly consider trying these two supplements. We can get them for you from Pure Encapsulations.
Vitamin B6 (pyridoxyl 5’-phosphate, P5P, is the best form) – 8mg at 400% daily value.
Studies show that in small doses, B6 can be very beneficial for nerve health. At larger doses, in excess of 100mg per day, it can have an adverse effect on nerves. In a 2011 paper in Rev Neurol Dis authors AM Jacobs and D. Cheng reported that 11 patients with painful diabetic neuropathy had skin biopsies to determine end nerve fiber density (ENFD) in skin samples before and after taking L-Methylfolate, methylcobalamin (methyl B12) and pyridoxyl 5’-phosphate twice a day for six months. “At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias [tingling] and/or dysesthesias [pain and burning].” In a 2010 paper in the same journal Walker, Morris and Cheng reported on a study involving 20 patients with symptomatic diabetic peripheral neuropathy taking a mixture of 3 mg of L-methylfolate, 2mg of Methylcobalamin (B 12) and 35 mg of Pyridoxyl 5’-phosphate. They took a double dose for 4 weeks and then a single dose for an additional 48 weeks. Their conclusion was that “this combination appears to promote restoration of lost cutaneous sensation in DPN (diabetic peripheral neuropathy)” Check with any other vitamins you are taking to make sure you do not exceed 100mg a day of B6.
25 mg in NeuraVite – 30 capsules for $30 (along with Benfotiamine, Alpha lipoic acid and B12)
Vitamin B12 – The methyl version, called methylcobalamin, is superior. In a 2011 paper in Rev Neurol Dis authors AM Jacobs and D. Cheng reported that 11 patients with painful diabetic neuropathy had skin biopsies to determine end nerve fiber density (ENFD) in skin samples before and after taking L-Methylfolate, methylcobalamin (methyl B12) and pyridoxyl 5’-phosphate twice a day for six months. “At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias [tingling] and/or dysesthesias [pain and burning].” In a 2010 paper in the same journal Walker, Morris and Cheng reported on a study involving 20 patients with symptomatic diabetic peripheral neuropathy taking a mixture of 3 mg of L-methylfolate, 2mg of Methylcobalamin (B 12) and 35 mg of Pyridoxyl 5’-phosphate. They took a double dose for 4 weeks and then a single dose for an additional 48 weeks. Their conclusion was that “ this combination appears to promote restoration of lost cutaneous sensation in DPN (diabetic peripheral neuropathy)”
Methyl-B12 500 mcg (1/2 of an mg) in NeuraVite – 30 caps for $30 (along with Benfotiamine, ALA and B6)
Vitamin D 2,000 units a day was also shown to decrease diabetic neuropathy pain by 47% after 3 months. 5000 units a day is not too much. The safety level for oral Vitamin D is very high.
Pure Encapsulation Vitamin D 5000 units – 60 capsules for $15.
B9 – L-Methylfolate Calcium (Metafolin) the active form of Folic Acid B9) – 3mg twice a day = 6mg per day.
This is the same form of folic acid in the widely advertised Metanx which is sold by prescription.
In a 2011 paper in Rev Neurol Dis authors AM Jacobs and D. Cheng reported that 11 patients with painful diabetic neuropathy had skin biopsies to determine end nerve fiber density (ENFD) in skin samples before and after taking L-Methylfolate, methylcobalamin (methyl B12) and pyridoxyl 5’-phosphate twice a day for six months. “At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias [tingling] and/or dysesthesias [pain and burning].” In a 2010 paper in the same journal Walker, Morris and Cheng reported on a study involving 20 patients with symptomatic diabetic peripheral neuropathy taking a mixture of 3 mg of L-methylfolate, 2mg of Methylcobalamin (B 12) and 35 mg of Pyridoxyl 5’-phosphate. They took a double dose for 4 weeks and then a single dose for an additional 48 weeks. Their conclusion was that “ this combination appears to promote restoration of lost cutaneous sensation in DPN (diabetic peripheral neuropathy)”
Pure Encapsulation methylfolate 1mg — 90 capsules for $24.
B-8 Myo-inositol 1000mg day. This is called a vitamin but does not quite meet the definition since our bodies can make it. There are some reports that this can reduce the effects of neuropathy in some patients. Maximum doses, according to the web site Livestrong, are 6 grams a day (6000mg) for four weeks or 4 grams (4000 grams) for 10 weeks. One gram a day seems to be quite a safe dose.
Pure encapsulation 500mg Myo-inositol 180 capsules for $33.
Gamma Linolenic Acid 400-600 mg per day Gamma linolenic acid is an essential fatty acid found in borage oil, grape seed oil, black currant oil, and evening primrose oil that has been shown to be successful in reversing nerve damage in diabetics suffering from peripheral neuropathy. In a double-blind, placebo-controlled study using 480 mg of GLA daily, all the diabetics given the fatty acid experienced gradual reversal of nerve damage and improvement in the symptoms related to the peripheral neuropathy, while those on placebo gradually worsened. It is thought that GLA may help to rebuild the myelin sheath around the nerves. From the NYU Langone Medical Center web site; “There is some evidence that GLA can be helpful if you give it long enough to work. In one double blind placebo-controlled study, 111 people with mild diabetic neuropathy received either 480 mg daily of GLA or placebo. After 12 months, the group taking GLA was doing significantly better than the placebo group. …Diabetic neuropathy is typically treated with about 400 to 600 mg daily (about 4 to 6 grams of evening primrose oil or 2 to 3 grams of borage oil. GLA should be taken with food. Fill benefit (if there are any) may take more than 6 months to develop.” Dose in pills is hard to calculate as the concentration in each vegetable source varies in linolenic acid concentration.
Pure Encapsulation Borage Oil 60 capsules for $24 or 180 for $60 200 mg of Gamma Linolenic Acid. Two capsules a day will give you the daily 400mg of GLA.
Biotin 10-15 mg/day was long ago studied for the treatment of neuropathy in diabetics at the University of Athens. The research showed that regular, long-term use of biotin was very effective both for improvement in nerve conduction and relief of pain. Improvement in nerve conduction occurred after only 4-8 weeks of therapy. In this study, biotin was given via daily intramuscular injection (10 mg/day) for 6 weeks; then 3 times per week (10 mg), intramuscularly, for 6 weeks; then 5 mg/day taken orally for up to two years. Biotin has also been used to strengthen nails and hair and some people report better sleeping habits.
We sell Pure Encapsulation Biotin 8mg 60 capsules for $10
You can purchase off thee nutrients from Pure Encapsulation in Sudbury, MA by calling 978-443-1999 or go to their web site PureEncapsulations.com. Use the code 3805 for a 10% discount from their regular price. You can also get these supplements from your local health food store.
Summary of Treating Neuropathy with Vitamins
Minimum – Take 1 NeuraVite a day for a year
Moderate: Take 2 NeuraVite and 2 Borage Oil capsules a day for 4 months and then one a day for a year
Maximum – Take 2 NeuraVite a day and 2 Borage Oil capsules a day for 4 months and then one a day for a year and add 1 to 6 daily 1-mg MethyFolate tablet(s). Some studies show that 6 mg of methylfolate a day is best.
We always stock the NeuraVite capsules both 30 and 60 bottles.
We try to stock the Borage Oil and the MethyFolate tablets both from Pure Encapsulations (PureCaps)
Take the suggested amount of the six ingredients that have been shown to help neuropathy in at least one study. Get either from your favorite health food store or order from PureCaps (Phone: 978-443-1999) or their web site www.PureEncapsulations.com.
è Use CODE 3805 for a 10% discount from printed prices at PureCaps. For your convenience I listed the PureCaps product code for each supplement below.
Summary of the Summary
| Nutrient Needed Daily | What 2 NeuraVite gives you | What to get from Pure Caps |
| ALA – 1200 mg a day | 1200 | |
| B1 Benfotiamine – 600mg daily | 600 | |
| B6 – P5P 1000 mg daily | 52 (still need all 1000) | |
| B9 L-Methyl Folate 6mg daily | 0 | 1-6 Metafolin Order #: MAS9 90 for $24 |
| B12 – methylcobalamin 2 mg daily | 1mg | |
| GLA 400-600 – daily | 0 | 2 capsules of Borage Oil |
BOG1 – 60 caps $24 BOG6 – 180 caps $65
PureCaps refers to the company Pure Encapsulations of Sudbury, MA. Dr. Zapf has visited the company in Sudbury, MA, and feels confident in recommending their products. Unlike almost any other vitamin and supplement manufacturer, each and every INGREDIENT is ASSAYED BY AN INDEPENDENT OUTSIDE LABOTARORY and you can see a copy of the laboratory reports if you ask.
| Nutrient | Availability from Pure Caps | Item number Pure Caps |
| R-alpha lipoic acid (ALA) |
(regular ALA is 50% “R” form)60 caps 100-mg for $41.20
120 caps 100mg for $75.80RLA1
RLA2B1 Benfotiamine90 caps 200mg for $40.30BFM9 (BenfoMax)Vitamin D60 caps 5000IU for $15.40
120 caps 5000IU for $27
250 caps 5000IU for 448.80CD51
VD52
VD56L-methyl folate (Mentax)M90 caps 1-mg for $24MethylAssistB6 (P5) Myo-inositol60 caps 500mg for $13.90
180 caps 500mg for $35.20P51 (PSP50)
P56 (PSP50)Gamma Linolenic Acid60 caps 200 mg for $23.80
180 caps 200mg for $64.30BOG1 Borage oil
BOG6 Borage oilBiotin60 8mg caps for $10.30
120 8mg caps for 417.80BI1 (Biotin) ß letter “B” and “I” not number 1
BI6 (Biotin) ß letter “B” and “I” not number 1N-A-L-Cysteine (Chemo caused) 600-1000 daily90 600mg caps for $27.20
180 800mg caps for $46.10
360 800mg caps for $81.80NA61 (NAC)
NA62
NA69N-A-L-Carnitine (Chemo Caused) 250-500mg a day60 caps 500mg for $58.80ALC56 (Acetyl-l-carnitine)
