Management of Methylsulfonylmethane (MSM) Related Neuropathy
The first-line approach for MSM-related neuropathy is discontinuation of the supplement, followed by symptomatic treatment with gabapentin (300-1200 mg/day) or pregabalin (75-300 mg/day) for persistent neuropathic symptoms.
Initial Management
Discontinuation of MSM
- Immediately stop MSM supplementation
- Monitor for symptom improvement after discontinuation
- Symptoms may begin to resolve within days to weeks after stopping the supplement
Assess severity and characteristics of neuropathy
- Evaluate distribution (symmetric vs asymmetric)
- Determine predominant symptoms (pain, numbness, tingling, weakness)
- Document baseline severity using a validated scale (e.g., Visual Analog Scale for pain)
Pharmacological Management
For persistent symptoms after MSM discontinuation:
First-line medications:
- Gabapentin: Start at 300 mg daily, titrate up to 300-1200 mg three times daily 1
- Pregabalin: Start at 75 mg twice daily, titrate up to 300 mg daily 1
Alternative options:
- Tricyclic antidepressants:
- Amitriptyline: 10-75 mg at bedtime 1
- Nortriptyline: 25-75 mg at bedtime (better tolerated than amitriptyline)
- Duloxetine: 60-120 mg daily 1
Topical treatments:
- Capsaicin cream: 0.025-0.075% applied 3-4 times daily 1
- Lidocaine patches: Apply to painful areas for 12 hours daily
Non-Pharmacological Approaches
- Physical therapy: To maintain function and prevent deconditioning
- Nutritional intervention: Increase omega-3 fatty acids (1000 mg 2-3 times daily) 1
- Acupuncture: Consider twice weekly sessions for pain relief 1
- TENS (Transcutaneous Electrical Nerve Stimulation): For pain management
Monitoring and Follow-up
- Reassess symptoms every 2-4 weeks initially
- Monitor for medication side effects:
- Gabapentin/pregabalin: somnolence, dizziness, peripheral edema
- TCAs: dry mouth, constipation, urinary retention, blurred vision
- Adjust medication dosing based on symptom improvement and side effects
- Consider referral to neurology if symptoms persist beyond 8-12 weeks despite treatment
Special Considerations
Avoid medications that may worsen neuropathy, including:
- Certain chemotherapeutic agents
- Statins in susceptible individuals
- Excessive alcohol consumption
Caution with MSM-containing combination supplements:
- Some supplements combine MSM with alpha-lipoic acid and bromelain 2
- While these combinations have been studied for chemotherapy-induced neuropathy, they should be avoided in patients with MSM-related neuropathy
Pitfalls to Avoid
Delayed recognition of MSM as the causative agent
- Many patients may not report supplement use unless specifically asked
- MSM is found in many joint health and beauty supplements
Inadequate trial periods for neuropathic pain medications
- Allow 2-4 weeks at therapeutic doses before determining efficacy
- Titrate doses gradually to minimize side effects
Overlooking other potential causes of neuropathy
- Consider screening for diabetes, vitamin B12 deficiency, thyroid dysfunction
- Evaluate for other neurotoxic medications or supplements
The prognosis for MSM-related neuropathy is generally favorable with prompt discontinuation of the supplement and appropriate symptomatic management. Most patients should experience gradual improvement over weeks to months after stopping MSM.