1. Diabetic Peripheral Neuropathy
Optimal Assessment and Management

2. Presentation Objectives
Understand the clinical impact of DPN
Distinguish between “symptoms” and “signs” DPN
Describe the proposed etiology of diabetic neuropathy
Understand the potential MOA of currently used medications in the management of DPN Symptoms

3. Chronic Diabetes Complications
Stroke
Retinopathy
Cardiovascular Disease (CVD)
Hypertension
Nephropathy
Peripheral Vascular Disease (PVD)
Peripheral Neuropathy
Long-term complications of diabetes develop gradually. The longer you have diabetes — and the less controlled your blood sugar — the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening. Diabetes is the 7th leading cause of death in the U.S.
Diabetes is a major cause of stroke / heart disease and new cases of blindness among adults in the U.S. Diabetes is also the leading cause of renal failure.
Of all the complications that diabetes patients live with, peripheral neuropathy appears to be the most common and can be found in up to 90% of people with diabetes depending on the criteria used for diagnosis. This is alarming because nerve and blood vessel damage from diabetes is a major cause of nontraumatic lower-limb amputations.
most common complication
50% to 90% of diabetes patients depending
upon criteria used for diagnosis
Tavakoli M, et al. Current Pain and Headache Reports. 2008;12:

4. Diabetes Statistics…Did you know…?
Up to 70% of those with diabetes will lose sensation in their feet
Peripheral sensory neuropathy is the leading factor to diabetic foot ulcerations
Approximately 25% of those with diabetes will develop a foot ulcer
More than half of all foot ulcers will become infected, requiring hospitalization and 1 in 5 will require an amputation
After a major amputation, 30% of patients will have their other limb amputated within 3 years
5-year mortality rate after limb amputation is reported as high as 74%, when compared to cancer- it is greater than colorectal, breast, and prostate cancer
Up to 70% of those with diabetes will lose sensation in their feet
Peripheral sensory neuropathy is the leading factor to diabetic foot ulcerations
Approximately 25% of those with diabetes will develop a foot ulcer
More than half of all foot ulcers will become infected, requiring hospitalization and 1 in 5 will require an amputation
After a major amputation, 30% of patients will have their other limb amputated within 3 years
5-year mortality rate after limb amputation is reported as high as 74%, when compared to cancer- it is greater than colorectal, breast, and prostate cancer
Dyck et al. Diabetic Neuropathy 1999; Singh et al. J Amer Med Assoc 2005; Robbins, et al. J Am Podiatr Med Assoc 2008.

5. Diabetic Peripheral Neuropathy: What is it?
Nerve damage and dysfunction secondary to diabetes mellitus type 1 or 2
Consensus definition: “the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes”
Diabetic peripheral neuropathy (DPN) is a diffuse disease and represents a broad term for the many kinds of nerve damage that often accompany diabetes mellitus.
The consensus definition includes the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes
Tavakoli M, et al. Current Pain and Headache Reports. 2008;12: 5

6. Impact of Diabetic Neuropathy
60-70% of foot ulcers are preceded by neuropathy
85% of diabetes related lower limb amputations are preceded by a foot ulcer
Most Common Proximate, Nontraumatic Cause of Amputations
Largest number of diabetes related hospital bed-days
The impact of diabetic neuropathy is overwhelming. The predominant feature of DPN is sensory loss. Sensory loss is the number one predictor of foot ulceration and non-traumatic amputations in the United States.
The cost of diabetes and the complications of neuropathy to the healthcare system are staggering and as previously mentioned diabetes is getting worse not better.
3 out of 10 patients who undergo lower limb amputation will lose another leg within 3 years and over half of them will die within the first 5 years of the first amputation
Every day in the U.S. approximately 225 people – the equivalent of a 747 airplane filled to capacity- require lower limb amputation due to diabetes. Averaging $60,000 per amputation, this represents an annual cost exceeding $5 billion.
As a result of the numbness associated with neuropathy, this ends up happening (picture of amputated foot): DPN is much more than just “my feet are numb” or “my feet tingle”. You have to think to yourself-if you can control the glucose and treat the underlying pathology, then maybe this patient would have felt the problem before it got to this point.
As previously mentioned most non-traumatic lower extremity ulcerations in the United States are preceded by diabetes induced neuropathy and ulceration. We have to begin thinking about how we can prevent this type of outcome resulting from diabetes.
Frykberg R, et al. Journ of Foot and Ankle Surgery 2006;45(5):S2-S8.
Gordois et al. Diabetes Care. 2003;26:
Reiber G, et al. Diabetes in America. 1995; 2nd ed:
Reiber GE, Vilekyte L, Bokyo EJ et al. Diabetes Care.1999;22.
Pecoraro RE, Reiber GE, Burgess EM. Diabetes Care. 1990;13. 6

7. Clinical Unmet Needs in DPN
Improved efficacy
There are a wide range of treatments available for neuropathic pain
This prescribing pattern suggests that there is no one treatment that addresses all the factors
Despite a spectrum of drugs available with different modes of action, many patients remain inadequately treated in several aspects of the disease
Improved side effect profile
Reduced time to onset of action
Increasing level of importance
Fewer drug-drug interactions
There are a wide range of treatments available neuropathic pain
This prescribing pattern suggests that there is no one treatment that addresses all the factors.
Some treatments have specific indications and some are off-label
Reduced pill burden
Datamonitor Research 2008. 7

8. Peripheral Nervous System
A simplified view of the peripheral nervous system. Clinical presentation of small and large fiber neuropathies.
A alpha fibers are large myelinated fibers that mediate motor functions and muscle control. A alpha/beta fibers are large myelinated fibers that mediate perception of touch, vibration and position sense.
A delta fibers are small myelinated fibers transmitting pain stimuli and cold perception. C fibers can be myelinated or unmyelinated and have both sensory (warmth perception and pain) and autonomic neurotransmission (blood pressure and heart rate regulation, sweating, etc.).
Vinik et al. Nature Clinical Practice Endocrinology & Metabolism

9. Diagnostic Tools for DPN: Large Fiber
5.07 Semmes-Weinstein Monofilament
Biosthesiometer®
Calibrated Tuning Fork
Nerve Conduction Velocity
These are some commonly employed diagnostic techniques that assess the function of large nerve fibers only and are thus normal in small fiber neuropathy. If you look a peripheral nerves 95% are small and 5% are large fibers. What is the consequence? These techniques diagnose neuropathy at a relatively late stage in the game.
Quatrini C, Boulton A, et al. Diabetologia. 2008;51(6):
Boulton AJ, et al. Diabetes Care. 2004;27(6):
Boulton AJ, et al. Prev and Treatment of Diab and its Compli. 1998;82(4):
Barber MA, et al. J Am Podiatr Med Assoc. 2001;91(10):
Kiso T, et al. Journ of Pharmaco and Experi Therap. 2001;297(1):

10. Small Fiber Neuropathy Biopsy
Diabetic Neuropathy: A Small Fiber Disease
Normal Skin Biopsy
Small Fiber Neuropathy Biopsy
Loss of intraepidermal nerve fibers is a major cause of pain in the hands and feet. The affected nerve fibers are the small-diameter A-delta and unmyelinated C fibers, which mediate pain, thermal sensation, and autonomic function.
Skin biopsy may show a paucity of nerve fibers. Picture on the left represents NORMAL nerve fiber density. Picture on the right represents no nerve fibers consistent with small fiber neuropathy. Skin biopsy analysis is a reliable tool for diagnosing small fiber neuropathy and is a safe and painless procedure that can demonstrate the selective degeneration of somatic unmyelinated fibers that convey pain and thermal sensations.
A reduction in intraepidermal nerve fiber density predicts the transition to symptomatic neuropathy.
The ideal therapy should prevent or arrest the progress loss of nerve fibers, improve symptoms and have minimal or ideally no side effects.
Normal innervation with small nerve fibers seen in the epidermis (arrows). Skin biopsy specimens with protein gene product 9.5 immunostaining.
A specimen from a patient with small fiber neuropathy shows denervation with no small nerve fibers seen in the epidermis
TAVEE J , ZHOU L Cleveland Clinic Journal of Medicine 2009;76:

11. Diabetic Peripheral Neuropathy
Symptoms and Signs of
Diabetic Peripheral Neuropathy
Symptoms
Small Fiber
Numbness or loss of feeling (asleep or “bunched up sock under toes” sensation)
Prickling/Tingling
Aching Pain
Burning Pain
Lancinating Pain
Allodynia
Defective Thermal Sensation
Decreased Sweating
Signs
Large Fiber
Diminished vibratory perception
Decreased knee and ankle reflexes
Reduced protective sensation such as pressure, hot and cold, pain
Diminished ability to sense position of toes and feet
Pain is deep, aching or cramping
Small sensory fiber damage causes occurs early in progression of DPN and often causes severe superficial burning pain, tingling, or numbness that typically affects the limbs in a distal-to-proximal gradient. Symptoms are usually worse at night and often affect sleep. Some patients say that their feet have become so exquisitely tender that they cannot bear having the bed sheets touch them, known as allodynia, and so they sleep with their feet uncovered.
Whereas, involvement of large sensory fibers is more often associated with signs of neuropathy including paresthesias, loss of ankle/knee reflexes and decreased balance
Symptoms and signs
progress from distal
to proximal over time
Boulton AJ, et al. Diabetes Care April; 28(4):

12. Etiology of DPN Endothelial Dysfunction in DPN: Hyperglycemia
Metabolic Abnormalities
AGEsOxidative StressPolyolsEFA
Endothelial Abnormalities
ETAIINOPGI2
Microvascular Insufficiency
Neuronal and Schwann Cell
Dysfunction
NERVE DEGENERATION
Endothelial Dysfunction in DPN:
Endothelium: a biologically active organ
Deranged nitric oxide pathways
Persistent high blood sugar and other metabolic abnormalities have been implicated in the etiology of progressive diabetic neuropathy but the common final path in neuropathy may be endothelial dysfunction / microvascular insufficiency which results in reduced capillary blood flow, nerve hypoxia dysfunction and ultimately nerver degeneration.
So this seems to show that endothelial dysfunction seems to have primacy in diabetic neuropathy marked by increased oxidative stress and deficiency of the vasodilators nitric oxide and prostacyclin.
We are getting away from the blood sugar as a primary cause into a cardiovascular cause
The endothelium is the largest vascular organ that is responsible for regulating vascular homeostasis. Endothelial dysfunction can be characterized by deranged nitric oxide pathways and vasoconstriction
Vinik A. The Amer Journal of Med. August 1999

13. Endothelial Dysfunction in the Diabetic Foot
A consequence of low nitric
oxide levels
poor microcirculation
loss of protective sensation
foot ulceration
The relationship between endothelial dysfunction and neuropathy results in an inability to increase blood flow in the diabetic foot under conditions of stress, permitting the development of foot ulceration.
Endothelial dysfunction is a consequence of low nitric oxide levels and is a major contributing factor to: poor microcirculation, loss of protective sensation, foot ulceration and DPN pain
DPN pain
Moncada S., Higgs A.N Engl J Med 1993; 329:
Schäffer M, et al. Nitric Oxide Regulates Wound Healing. J Surg Res 1996; 63:
Schwentker A, et al. Nitric Oxide and Wound Repair. Surg Clin N Am 2003; 83:

14. Putative Pathogenic Sequence
Hyperglycemia
Endoneurial Ischemia
Impaired Neuronal Regeneration
Neuronal Injury
Therapies should aim at Restoration of Vascular and Neuronal Normalcy
Progressive Diabetic Peripheral Neuropathy

15. Clinical Impact of DPN TOTAL Symptoms
Painful
Neuropathy
Sensory Loss
Impairment
Disability
Handicap
Mortality
Foot Ulcers
Cost
Painful symptoms of DPN can lead to disability and reduce overall quality of life
The neuronal deficit leading to sensory loss is the real problem. Sensory loss is a significant predictor of foot ulceration, foot deformation and amputation ultimately death.
Quality of
Life
Infection
(skin, bone)
Charcot
Foot
Surgery,
Amputation
Boulton A. NCVH. Oral Presentations

16. Microvascular Damage Leads to DPN
Normal nerve
Damaged nerve
Damage to myelinated and unmyelinated nerve fibers
Healthy nerves receive a rich supply of blood from the neural microvasculature, otherwise known as the vasa nervorum. Here we see the interrelationship between the neural tissues of the nerve axons and the surrounding microvasculature.
Vascular changes include increased permeability, increased vasoconstriction, and decreased blood flow, which in turn appear to cause motor and sensory nerve fiber degeneration.
Diabetic neuropathy is caused by both imbalances in neuron metabolism and impaired nerve blood flow. Maintenance of an adequate supply of blood through vas nervorum is essential to prevent the development of neuroapthy.
The clinical manifestations of these effects include numbness, prickling, tingling, and pain. They may also include diminished vibration perception, ankle reflexes, and nerve conduction velocity measurements. Eventually, these vascular and neural deficits can lead to ulcer formation.
Occluded vasa nervorum
Examination of tissues from patients with diabetes reveals capillary damage, including occlusion in the vasa nervorum
Reduced blood supply to the neural tissue results in impairments in nerve signaling that affect both sensory and motor function
Dyck PJ, Giannini C. J Neuropathol Exp Neurol. 1996;55: Sheetz MJ, King GL. JAMA. 2002;288:

17. Progression of Symptomatic DPN
DPN patients are labor intensive and require multiple therapies to mask pain as disease continues progressing
Progressive loss of epidermal nerve fibers may be the earliest manifestation of DPN and correlates with increased severity of neuropathy and a higher risk of developing neuropathic symptoms
Current palliative therapies do not address the underlying progression of nerve damage and at best, achieve partial alleviation of the symptoms, due to significant side effects.
Most DPN patients require two or more palliative therapies to mask painful symptoms with an average annual cost of $1600.
Tavakoli M, et al. Current Pain and Headache Reports Tavakoli M and Malik RA. Expert opin Pharmacother Argoff CE, et al. Mayo Clin Proc 2006.

18. Association of Metformin and Clinically Worsened DPN
Clinical Markers of Neuropathy Severity
A prospective study of 122 symptomatic DPN patients compared those who had > 6 months of metformin to those without metformin
Results demonstrate that metformin contributes to the severity of DPN (P<0.001) by inhibiting absorption of methlB12
The severity of DPN positively correlates to increases in the cumulative metformin dose (P<0.001)
Neuropathy Severity
P<0.001
A prospective study of 122 symptomatic DPN patients compared those who had > 6 months of metformin to those without metformin
Results demonstrate that metformin contributes to the severity of DPN (p<0.001) by inhibiting absorption of methlB12
The severity of DPN positively correlates to increases in the cumulative metformin dose (p<0.001)
The Neuropathy Impairment Scale has been designed in an effort to maximize the measurement of potential changes in all motor, sensory and reflex activity in the lower limbs. Total score ranges from normal = 0 to maximum of 16. n = 122
Wile DJ, et al. Diabetes Care 2009.

19. TOTAL Symptom Management
DPN Treatment Options
Glucose Management
Pain Management
Amitryptiline, Duloxetine
Gabapentin / Pregabalin
Opioids
TOTAL Symptom Management
Tight glucose control is the number one priority to reduce the severity of symptomatic DPN.
Current therapies focus on masking the painful symptoms but do nothing to address the underlying pathophysiology. It is best to tell patients not to expect 100% relief of symptomatic neuropathic pain. Although that is the goal of treatment, patients need to understand that to control their diabetes, they need to control a number of factors, but in general, they can expect between 30% and 50% relief of pain.
Most patients with symptomatic diabetic neuropathy need two drugs to get closer to 100% improvement.
An emerging medical food therapy is available that has proven efficacy in managing DPN TOTAL symptoms including numbness, tingling and burning pain. Metanx is a prescription medical food containing 3 active components (L-methylfolate, Methylcobalamin and Pyridoxal 5’-phosphate)
L-methylfolate – active form of folate recognized by the cell. Main component to increase the synthesis of nitric oxide in the endothelium
Methylcobalamin – neurologically active form of B12 involved in protein synthesis within the neuron
Pyridoxal 5’-phosphate – active form of B6 that may inhibit the deleterious effects of AGE’s
LMF MeCbl, PLP
Adapted from Tavakoli M and Malik R. Expert Opin Pharmacother
Fonseca V. et al. Poster presented at the 20th Anniversary 2011 American Academy of Clinical Endocrinology Annual Meeting and Clinical Congress *These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

20. Medical Food – Regulated by FDA
L-Methylfolate mg
Methylcobalamin mg
Pyridoxal 5’ –phosphate mg
LMF-MeCbl-PLP
Medical Food – Regulated by FDA
Nutritional support specifically modified for the management of the distinct nutrient needs that result from the disease or condition, as determined by medical evaluation.
Dispensed by prescription under supervision of a HCP
Address the underlying condition such as endothelial dysfunction / DPN
Evidence in peer-reviewed literature
U.S. Food and Drug Administration. Guidance for Industry: Frequently Asked Questions About Medical Foods. Available at: Accessed August 3, 2011. 20

21. The Role of LMF-MeCbl-PLP in DPN
Diabetes
Diabetes
LMF-MeCbl-PLP
BH4 / UNCOUPLED eNOS
LMF-MeCbl-PLP
Oxidative / Nitrosative Stress
Nerve Blood Flow
Nerve Repair / Regeneration
Diabetes-induced uncoupling of endothelial nitric oxide synthase (eNOS) leads to increased oxidative and nitrosative stress, reduction in nutritive blood flow, and endoneurial hypoxia leading to impaired peripheral nerve repair and regeneration, all known to play an important role in progressive symptomatic diabetic neuropathy.
Metanx increases the production of tetrahydrobiopterin (BH4) , a cofactor of eNOS to counteract eNOS uncoupling and oxidative-nitrosative stress resulting in increased endoneural blood flow and peripheral nerve repair and regeneration resulting in improved symptoms of diabetic neuropathy.
Symptomatic
Diabetic Neuropathy
Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations

22. Clinical Evidence in DPN
Diabetic peripheral neuropathy can be caused by an imbalance in the metabolic processes that regulate blood vessel and nerve health.
LMF-MeCbl-PLP is designed to nutritionally manage these metabolic imbalances resulting in the following clinical benefits.

23. Clinical Evidence Overview
Type of Study (n)
Endpoint
Duration
Results
Therapeutic Efficacy Evaluation
ZDF Rat Model (50)*
Bioanalytical Assays:
Nitrotyrosine; Nitrite/Nitrate
Nerve Conduction Velocity
IENFD
Thermal/Mechanical Algesia; Tactile Allodynia
1 month
Significant improvements compared to control group:
Nitrotyrosine (p<.005)
Nitrite/Nitrate (p=.047)
Sensory NCV (p<.05)
IENFD (p<.02)
Thermal/Mechanical Algesia (p<.0025)
Prospective,
Open Label Trial (16)
Established sensory loss measured utilizing QST at 6 and 12 months
1 year
Improved Sensory Perception at 6 months (p=0.006); at 12 months (p<0.001)
Open Label Trial (24)*
Neuropathic pain
5 months
LMF-MeCbl-PLP group experienced a reduction of paresthesias compared to control group at 5 months. (P<0.001)
Open Label Trial (11)
Epidermal nerve fiber density (ENFD) measured utilizing skin punch biopsy
6 months
97% increase IENFD (p=0.004)
Randomized-Controlled, Double-blind, Multicenter (214)*
Vibratory Perception
Neuropathy TOTAL Symptoms
Quality of Life
No effect on VPT
Improved TOTAL Symptoms (p<0.03)
Improved QoL (p=0.03)
Jacobs AM and Cheng D Rev Neurol Dis Walker MJ, et al. Rev Neurol Dis 2010.
* These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

24. Evaluation of LMF-MeCbl-PLP on DPN in Zucker diabetic fatty (ZDF) rats
A commonly used animal model for type 2 diabetes with the potential to yield useful insights in the pathophysiology of disease.
Study Design:
To assess LMF-MeCbl-PLP on the disease and biomarkers of DPN versus ZDF controls.
So again, the goal here was to primarily study the hallmarks of the pathophysiology of DPN: Nerve Conduction Velocity and Nerve Fiber Density in addition to some of the biomarkers implicated in the etiology of DPN
According to Dr. Obrosova, the ZDF Rat model is the best one to accomplish this because this model mimics human Type 2 diabetes.
The study was completed in 50 ZDF rats for 1 month to assess the efficacy of Metanx on the disease, biomarkers and symptoms of DPN versus ZDF controls.
Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations

25. Evaluation of LMF-MeCbl-PLP on diabetic peripheral neuropathy in Zucker diabetic fatty (ZDF) rats
Findings:
ZDF Rats developed the following:
Sensory and Motor nerve conduction velocity deficits
~ 26% loss of intraepidermal nerve fibers
Abnormal Nitrotyrosine levels
Because of the diabetes, the ZDF rats developed the following:
Sensory and Motor nerve conduction velocity deficits – NCV is a test of the speed of electrical signals through a nerve, the slower the signal, the worse the nerve function, in this case the sensory and motor nerves were studied.
~ 26% loss of intraepidermal nerve fibers – which is a measure of small c-fibers
Abnormal Nitrotyrosine – this biomarker is implicated in the progression of DPN by causing oxidative stress in the vasculature and peripheral nerve fibers
Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations

26. Evaluation of LMF-MeCbl-PLP on Diabetic Peripheral Neuropathy in Zucker Diabetic Fatty (ZDF) Rats
sNCV Results
ZDF controls developed sensory NCV deficits
After nutritional mgmt, LMF- MeCbl-PLP Group demonstrated a significant increase in sensory NCV compared to controls
P<0.05
m/s
Nerve conduction velocity is a measure of Large fiber function. ZDF controls developed sensory nerve conduction velocity deficits. The Metanx® Group demonstrated a significant increase in sensory nerve conduction velocity compared to controls
Nerve conduction velocity is the “gold standard” in measuring the pathophysiology of peripheral nerve functions and improvements in NCV equate with influencing the natural history of the disease.
Control LMF-MeCbl-PLP
Controls
Metanx® Group
Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations

27. Evaluation of LMF-MeCbl-PLP on diabetic peripheral neuropathy in Zucker diabetic fatty (ZDF) rats
ZDF Controls
ZDF + LMF-MeCbl-PLP
Controls experienced 26% loss of small fibers
As seen in the top 3 images, the ZDF control group experienced an approximate 26% loss of intraepidermal nerve fibers
Intraepidermal nerve fiber density was 15% higher in the Metanx group compared to ZDF controls. Again, this suggests that Metanx is influencing the natural history of the disease by inducing small nerve fiber regeneration.
Taking the NCV and the INFD information into context, Metanx seems to influence large and small fiber functions.
After nutritional mgmt with LMF-MeCbl-PLP, ENFD was 15% higher in the LMF-MeCbl-PLP group compared to controls
Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations

28. Clinical Endpoint Results:
Evaluation of LMF-MeCbl-PLP on Diabetic Peripheral Neuropathy in Zucker Diabetic Fatty (ZDF) Rats
After nutritional mgmt with LMF- MeCbl-PLP, the dose currently employed in clinical practice, alleviated multiple manifestations of DPN, including:
SNCV deficit
Small fiber regeneration
Nitrosative/Oxidative stress
Clinical Endpoint Results:
Clinical Endpoint
P Value vs. Controls
Sensory NCV
.05
Motor NCV ns
Nerve Fiber Density
.02
Nitrotyrosine
.005
The Overall Clinical Endpoints of this disease study compared to controls are as follows:
There was a statistically significant improvement in Sensory nerve conduction velocity but not Motor NCV. Small fiber regeneration was seen marked by an improvement in Intraepidermal nerve fiber density compared to controls.
Nitrotyrosine, a marker of nitrosative stress, was tested in the peripheral nerve tissue and was significantly decreased in the metanx group compared to controls
Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations

29. Eight Outcome Measurements
16 consecutive DPN patients with established sensory loss were quantified utilizing the PSSD
Outcomes measured at baseline, 6 months & 1 year after LMF-MeCbl-PLP
Eight Outcome Measurements
This is a study in 16 patients with diabetic neuropathy experiencing sensory loss. Patients were given a quantitative sensory test utilizing the PSSD. The PSSD measures 2 pt static touch which correlates with nerve density.
Patients received Metanx twice daily and were followed for 1 year. There were 8 outcome measurements for the left and right foot for both 1 and two point static touch at the medial heel and great toe
Foot
Medial Heel
Great Toe Pulp
Left / Right
1 & 2 point static touch
Walker MJ, et al. Rev Neurol Dis.2010;

30. Restoration of Cutaneous Sensorum
Baseline, 6 month, & 1 year follow up 60 50 40 30 20 10
gm/mm2
Baseline
6 months
1 year
P=0.006†
P<0.001‡
Normal*
2 Point Static Great Toe Left/Right Combined
*<25.7 gm/mm2 represents normal pressure thresholds for Pressure Specified Sensory Device™ (PSSD) 99% Confidence level.
†Baseline vs. 6 month. ‡Baseline vs. 1 year. n = 16
2 Point Static Medial Heel Left/Right Combined 60 50 40
P<0.001†
Normal*
gm/mm2 30 20
P<0.001‡ 10
Graph on the left represents great toe. You can see that the pressure it took to distinguish between the two points was dramatically reduced at 6 months and even more so after 1 year.
Graph on the right represents medial heel where you see even more dramatic results which makes sense considering neuropathy is a length dependent disease and the nerves shorter nerves take less time to heal
Diabetes patients with sensory loss in this cohort experienced a statistically significant improvement in sensory perception after 6 months and 1 year compared to baseline. This is exciting because it’s the sensory loss that predicts the late complications such as ulceration and amputation
Baseline
6 months
1 year
*<30.0 gm/mm2 represents normal pressure thresholds for Pressure Specified Sensory Device™ (PSSD) 99% Confidence level.
†Baseline vs. 6 month. ‡Baseline vs. 1 year. n = 16
Improved sensory perception at the medial heel and great toe following nutritional mgmt with LMF-MeCbl-PLP
Walker MJ, et al. Rev Neurol Dis 2010.

31. Mean Pain Reduction From Baseline
LMF-MeCbl-PLP Administration to Pregabalin Partial-Responders for Management of DPNP
Mean Pain Reduction From Baseline
Results from a 20 week, open trial of 24 patients to evaluate LMF-MeCbl-PLP with ≤ 50% response to pregabalin (VAS score).
After nutritional management with
LMF-MeCbl-PLP:
The average absolute pain reduction after 20 weeks in the study group was 3.0 compared to .25 in the active control group (P<0.001)
After 20 weeks, the study group experienced greater pain relief compared to the active control group, 87.5% vs. 25.0% reduction in NPS respectively (P=0.005)
-0.5 -1
-1.5 -2
-2.5 -3
-3.5 20
Weeks
Pain Reduction
P<0.001
Pregabalin
LMF, MeCbl, PLP/ Pregabalin
Results from a 20 week, open trial of 24 patients to evaluate Metanx in patients with ≤ 50% response to pregabalin (VAS score).
Methodology
24 consecutive patients who received pregabalin > 4 months with partial (<50% NPS reduction) resolution of paresthesias
were enrolled.
Study group (n=16) continued the pretrial pregabalin dose to which oral L-methylfolate, Me-Cbl, and P-5-P was added twice daily.
Control group (n=8) maintained pregabalin therapy.
A numeric pain scale (0-10) was evaluated at baseline and 20
weeks.
After 20 weeks, the metanx/pregabalin group experienced a statistically significant improvement in neuropathic pain compared to pregabalin group alone.
Jacobs AM. NCVH Oral Presentations 2008. 31

32. 11 patients symptomatic DPN patients
The Pharmacological Management of Diabetic Small Fiber Neuropathy Utilizing LMF-MeCbl-PLP as a Neurotrophic Agent
11 patients symptomatic DPN patients
Baseline / 6 month skin biopsies (n=22)
LMF-MeCbl-PLP B.I.D. for 6 months demonstrated 97% ↑ ENFD
P=0.004
This is a study that was presented at the diabetic global foot conference in march of 2009 that looked at small fiber neuropathy.
11 symptomatic DPN patients were enrolled into this trial and a baseline skin punch biopsy was performed. Patients were given Metanx twice daily and followed for 6 months where a repeat skin punch biopsy was performed.
As you can see in the bar chart, after 6 months of Metanx there was a 97% increase in epidermal nerve fiber density which correlated with improvements in numbness, tingling and burning sensations in the feet.
This preliminary study suggests that the administration of Metanx appears to be associated with increased ENFD in patients with DPN.
The increased epidermal nerve fiber density may be associated with diminished symptoms of anesthesia, paresthesia, or dysesthesia.
Jacobs AM and Cheng D. Rev Neurol Dis 32

33. Clinical Case Outcome I
Baseline
6 months
Here is an image from one of the DPN patients in the cohort.
As you can see on the left, this patient had reduced nerve fibers marked by the horizontal arrow. Six month follow up image on the left demonstrates an improvement of nerve fiber density suggesting the neurotrophic effect that Metanx may exert on peripheral nerves.
Patient received baseline skin punch biopsy and given LMF, MeCbl, PLP twice daily and followed for six months. Left image represents baseline skin punch biopsy at right calf. Right image represents six month follow up skin punch biopsy at right calf. Patient average increase of 3.02 nerve fibers per mm. Skin Punch Biopsy Analysis and Images Performed by Therapath, LLC
Jacobs AM and Cheng D. Rev Neurol Dis

34. Clinical Case Outcome II
Baseline
6 months
This is an image from another patient in this cohort, again, demonstrating an improvement in small fiber neuropathy after 6 months of Metanx twice daily.
Patient received baseline skin punch biopsy and given LMF, MeCbl , PLP twice daily and followed for six months. Left image represents baseline skin punch biopsy at right calf. Right image represents six month follow up skin punch biopsy at right calf. Patient averaged an increase of .76 nerve fibers per mm. Skin Punch Biopsy Analysis and Images Performed by Therapath, LLC.
Jacobs AM and Cheng D. Rev Neurol Dis

35. “A 24 week, double-blind, placebo-controlled, multisite study of LMF-MeCbl-PLP in subjects with diabetic peripheral neuropathy (DPN).”
The protocol for this Metanx trial was approved in late 2007 by the institutional review board at each site.
This was a 6 month double-blind, placebo-controlled, multisite study of Metanx in subjects with DPN and was conducted from 2008 thru 2010.
As you can see, there were six investigators or sites in this study with Dr. Vivian Fonseca serving as the primary investigator. Dr. Fonseca is the professor of Medicine & Pharmacology at Tulane University Health Sciences Center in New Orleans. He is also the 2012 incoming president of the American Diabetes Association and yes…finally, because of the results of this study, Dr. Fonseca is now a consistent prescriber of Metanx which is one giant leap for mankind!
As sales leadership, we will need to leverage these points going forward to further promote credibility in the specialty of Endocrinology.

36. “A 24 week, double-blind, placebo-controlled, multisite study of LMF-MeCbl-PLP in subjects with diabetic peripheral neuropathy (DPN).”
Study Objective:
To assess LMF-MeCbl-PLP (compared to placebo) twice daily in 214 persons with established diabetic peripheral neuropathy
Fonseca V. et al. Poster presented at the 20th Anniversary 2011 American Academy of Clinical Endocrinology Annual Meeting and Clinical Congress

37. Primary Endpoint: Vibration Perception Threshold (VPT)
Study Findings:
Change in VPT with LMF-MeCbl-PLP was no different than with placebo
Patients enrolled in this trial had a VPT >25V, which is regarded as abnormal and has been shown to be strongly predictive of subsequent foot ulceration.
In this study Metanx improved VPT but the change in VPT was no different than with placebo after 6 months.
This was likely due to short follow-up period. A decline VPT happens slowly over years, these severe patients would need to be followed for at least 1 and half years out to 3 years to detect a difference, if any.
To date, no therapy has demonstrated an improvement in vibration perception threshold compared to placebo.

38. Study Findings: Neuropathy Total Symptom Score-6 (NTSS-6)*
Mean scores in the LMF-MeCbl-PLP group improved more at 16 and 24 weeks compared to placebo
NTSS-6:
Numbness
Tingling
Aching pain
Burning pain
Lancinating pain
Allodynia
As represented here in this graph, the Metanx group began to separate from the placebo group fairly early in the trial and the improvement in Numbness, Tingling, Aching-Burning-Lancinating Pain and Allodynia was statistically significant at 4 months and 6 months compared to placebo.
This is particularly important because Diabetic Neuropathy is characterized by TOTAL symptoms and NOT JUST PAIN. As you can imagine, this will come into play when you think about how the current available palliative therapies only address ONE symptom…and that is PAIN.
LMF-MeCbl-PLP
-0.54
-0.9
-0.96
PLACEBO
-0.33
-0.4
-0.53
Fonseca V. et al. Poster presented at the 20th Anniversary 2011 American Academy of Clinical Endocrinology Annual Meeting and Clinical Congress *These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

39. Findings: Quality of Life
SF-36 Health Survey Summary Mental Component Scale (MCS)*
Mental Health Feels peaceful, happy and calm all of the time Role Emotional No problems with work or other daily activities Social Function Performs normal social activities without interference due to physical or emotional problems Vitality Feel full of pep and energy all of the time
LMF-Me-Cbl-PLP
Placebo
P=0.031
Again, as represented here in this graph, the Metanx group began to separate from the placebo group fairly early in the trial and reached statistical improvement at 6 months. You can also see that the placebo in this case had a fairly positive response at first but then demonstrated a significant decline which ultimately correlated with a deterioration or worsening in quality of life.
Specific quality of life measures that were improved in the Metanx group compared to placebo included the following:
no problems with work or other daily activities
performs normal social activities without interference due to physical or emotional problems
feels peaceful, happy and calm all of the time
fells full of pep and energy all of the time
To put this in perspective, research has demonstrated that improving quality of life ranks as one of the top most important aspects when reviewing therapies that manage DPN.
Bottom Line here is this: Metanx statistically significantly improves health-related quality of life in DPN patients after 6 months compared to placebo. This improvement correlates with improved activities at work and social activities, feeling peaceful, calm and happy as well as feeling full of energy.
Fonseca V. et al. Poster presented at the 20th Anniversary 2011 American Academy of Clinical Endocrinology Annual Meeting and Clinical Congress *These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

40. Safety Profile Similar to Placebo*
LMF-MeCbl-PLP safety profile is NO DIFFERENT than placebo
Individual AEs reported were < 2%
No patient discontinued trial due to AEs in either group
Most common AE with LMF- MeCbl-PLP was rash (1) mild GI upset (1)
Percent of Patients Reporting Total Adverse Events
100%
75%
% of Patients
50%
25% 0%
LMF-MeCbl-PLP
Placebo
Treatment Group
Fonseca V. et al. Poster presented at the 20th Anniversary 2011 American Academy of Clinical Endocrinology Annual Meeting and Clinical Congress *These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

41. “A 24 week, double-blind, placebo-controlled, multisite study of LMF-MeCbl-PLP in subjects with diabetic peripheral neuropathy (DPN).”*
CONCLUSION OF STUDY:
These findings suggest that LMF-MeCbl-PLP may be a safe and effective therapy nutritional management for patients with DPN.
Significant benefits with LMF-MeCbl-PLP were observed in parameters that may have a greater impact on patient’s well being.
Fonseca V. et al. Poster presented at the 20th Anniversary 2011 American Academy of Clinical Endocrinology Annual Meeting and Clinical Congress *These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

42. Summary Patients with DPN experience TOTAL Symptoms
LMF-MeCbl-PLP2-4
Patients with DPN experience TOTAL Symptoms
Current therapies may have a quick onset, but are palliative only
LMF-MeCbl-PLP has a nutritional effect on peripheral nerves
Metanx® has a nutritional effect on peripheral nerves, reduces total symptoms and may alter the natural history of the disease
Ware JE et al. SF-36 Health Survey: Manual & Interpretation Guide Obrosova IF et al. Abstracts of the Experimental Biology Meeting. Oral Presentations
2011. Jacobs AM and Cheng D Rev Neurol Dis Tanenberg RJ. Hospital Physician 2009.