Neurometrix Hits a Nerve in the Diabetes Market

With a point-of-care electrodiagnostic device for the diagnosis of neuropathies, NeuroMetrix has set out to change how primary care physicians provide patient care. That means it faces the challenge of achieving market coverage on the scale of a pharmaceutical sales force, while at the same time providing the kinds of training and support that go hand-in-hand with a device business. This is a tall order for a small company. Fortunately, NeuroMetrix's timing is great. Over the years, it has expanded its testing platform from the diagnosis of carpal tunnel syndrome and low back pain to the detection of diabetic neuropathy. It thus finds itself the sole purveyor of a technology that can, at the point of care, detect diabetic neuropathy even before symptoms develop, and it has come to market just at the time when Eli Lilly and others getting close to market with drugs that treat not only the symptoms of diabetic neuropathy, but influence its course. .

NeuroMetrix may have a compelling diagnostic opportunity in diabetic neuropathyif it can, as a small company, change standards of care in a fragmented primary care market..

By Mary Stuart

Shai Gozani, MD, PhD, president and CEO of NeuroMetrix Inc. says that his company aims to build a business of singles and doubles, not grand slams and homeruns. But Gozani's modesty is hard to take seriously. When one looks at the markets NeuroMetrix--with fewer than 100 employees--has targeted, its ambitions don't appear so modest. When it launched in 1996 with expertise in the measurement of nerve conduction, the company was reaching for the "Holy Grail" in diabetes: a non-invasive glucose monitor, a quest that has defeated many yet still tantalizes diagnostics manufacturers. And now, having put aside that goal for the time being, NeuroMetrix is focused on another enormous challenge: getting a point-of-service (POS) electrodiagnostic tool for low back pain and diabetes into the offices of 250,000 physicians.

Even more immodestly, it has set out to change how primary care physicians (PCSs)—a fragmented, diffuse group more likely to write prescriptions than do procedures such as diagnostic tests—provide patient care. That means it faces the challenge of achieving market coverage on the scale of a pharmaceutical sales force while at the same time providing the training and support that go hand-in-hand with a device business. This is a tall order for a small company.

Fortunately, NeuroMetrix's timing is great. Over the years, as it has sought applications where its nerve-conduction testing platform has compelling clinical benefits, it has expanded from the diagnosis of work-related injuries like carpal tunnel syndrome and low back pain to the detection—and quantification—of diabetic neuropathy. It thus finds itself the sole purveyor of a technology that can, at the point of care, detect diabetic neuropathy even before symptoms develop. And it has come to market just at the time when Eli Lilly & Co. and other pharmaceutical companies are getting close to market with drugs that treat not only the symptoms of diabetic neuropathy, but also influence its course. (Lilly is in phase III clinical trials with ruboxistaurin, which, if it is successful, will be the first disease-modifying drug for diabetic neuropathy to hit the market.)

Indeed, the opportunity inherent in this confluence of diagnostics and therapeutics isn't lost on NeuroMetrix, which has partnered with Lilly on a market education alliance intended to broadcast to PCPs the new message that diabetic neuropathy is a condition that can be diagnosed and treated at an early stage. That agreement means that NeuroMetrix is no longer a lone wolf in a brand new category of POS testing. The company is now widely perceived by both industry executives and investors as part of a growing number of innovative diabetes companies like TheraSense Inc. , which Abbott Laboratories Inc. acquired for $1.3 billion [See Deal].

Perhaps that's why NeuroMetrix's stock price has jumped from $9 just before the March 15 announcement of the Lilly deal to $17 in early June. For NeuroMetrix, the alliance is clearly a validation of its testing platform and a way to link a diagnostic to a therapeutic. But it's also something else: it answers the question, how can a small company educate a physician's office market about a new standard of care. Moreover, with a single testing system that can perform a variety of tests for routine conditions, the heightened recognition of NeuroMetrix's POS diagnostics for diabetic neuropathy should help expand its business, a nice fall-back should the opportunity in diabetic neuropathy intervention take time to materialize.

To be sure, NeuroMetrix faces all the challenges of a small public company with limited resources: managing growth on a number of fronts, staffing up to support new customer accrual and account management (to increase utilization of testing by existing customers), and providing training and technical support within a context of creating a new standard of care. At the same time, it must manage product development to fuel future growth. It will have to execute well too by investing to support growth without getting too far ahead of the growth spurt. But if it can do so, its modest goals could result in immodest success.

Patients' Common Complaints

Shai Gozani founded the company in 1996 to develop a non-invasive blood glucose monitor. Gozani holds a PhD in neurobiology (from the University of California, Berkeley), and an MD from Harvard Medical School and the Harvard-MIT Division of Health Sciences at the Massachusetts Institute of Technology.

It was in the course of doing a neurophysiology research fellowship at Harvard Medical School that Gozani hit upon the idea of using nerve conduction as a way to measure glucose levels in the blood. Neurophysiologists had known for years that analytes such as glucose in the blood influenced nerve response. Gozani reasoned that modifications of routine clinical nerve conduction studies, in which a nerve's status is assessed by how fast it responds to an electrical stimulus, could be used to assess blood glucose. A nerve is like an electric wire, and physicians can test its health by observing the speed and amplitude of electrical impulses that propagate along its length.

Gozani's goal was to combine microelectronics with signal processing algorithms that would correlate nerve responses with glucose levels in order to create a new standard for non-invasive glucose management. Back in 1996, NeuroMetrix was part of a whole passel of companies trying to find unique signals that could be detected by non-invasive means to monitor glucose levels. Biocontrol Technology Inc., Futrex Inc., Optiscan Biomedical Corp., SpectRx Inc., Sunshine Medical Instruments Inc. and many other companies have since tried and failed to develop a non-invasive blood glucose monitor.

Seeing the long and uncertain course of development ahead, Gozani cast about for other applications in which a non-invasive nerve conduction device at the POS would be clinically useful. He soon hit upon carpal tunnel syndrome (CTS), a condition that is a focus of occupational medicine. At the time, CTS was also gaining attention from consumers because of the increasing use of computer keyboards. In carpal tunnel syndrome, the tendons that traverse the wrist swell as a result of over-use of a computer keyboard or some other injury, compress the median nerve and result in numbness, weakness or pain in the hand and wrist.

NeuroMetrix developed its first commercial version of NC-stat, an automated nerve conduction testing system, so that physicians' offices could diagnose CTS. The standard clinical way to diagnose CTS (and other neuropathic diseases) involves a physical examination of the patient, who reports subjective symptoms like numbness and pain during the exam. Primary care physicians will refer certain patients to a neurologist for a nerve conduction study and needle electromyography (EMG), which indicate degrees of nerve or muscle damage, respectively.

Without automated technology, these tests are complicated and highly manual and must be performed by a specially trained physician. To perform an EMG, an operator sticks a fine needle into a muscle. Electrical activity of the muscle is then recorded and analyzed. For a non-invasive nerve conduction study, the operator must expertly place multiple electrodes. The physician stimulates the nerve, gets signals back and determines whether they're viable or contaminated by various artifacts. PCPs aren't necessarily familiar with these technical steps, says Gozani, and this type of study requires a great deal of detailed knowledge about the electrical behavior of the body and the instrumentation.

Because of the inconvenience of scheduling as well as the potential pain and the expense of the tests, which can amount to $1,000 or more per patient, many physicians refer only patients with the most severe conditions for testing.

An Automated Alternative

Using signal processing, NeuroMetrix created NC-stat, an automated nerve conduction testing system. Gozani explains that there are two parts to a nerve conduction study: acquiring the data and making a clinical diagnosis. NeuroMetrix has automated the process of reliably acquiring data, he says.

First, the company developed disposable mylar biosensors that incorporate embedded microelectronics. These are designed to be wrapped around various parts of the body using identifiable landmarks--like the wrist crease or the ankle bone--that operators with minimal medical background can find consistently. Signal processing algorithms in the biosensor and in a portable electronic monitor the size of a small walkie-talkie address any variability due to biosensor placement. Computer processing also automates the quality control of the signals being acquired. The monitor displays numerical results as each nerve is tested.

NC-stat has a third component, a docking station into which the monitor is placed following the procedure to transmit data to a processing center at Neurometrix. An automated report generator at Neurometrix faxes back, within minutes, a report that displays acquired waveforms and numerical values from the test, such as distal motor latency--the amount of time it takes for an impulse to travel along the nerve through the wrist--side-by-side with normal parameters that would be expected for a healthy person of the same age and height. The test is quantitative and indicates the degree of nerve damage. After two hours of training, any technician or nurse can perform the test, the company says.

In 1999 NeuroMetrix launched a dedicated system for the diagnosis of CTS with a 510(k) approval validating the equivalency of its diagnostic information with the gold standard nerve conduction tests in particular nerves. It sold its first-generation system for $1,000 and charged $25 per disposable biosensor. The service component—the report generation—comes at no extra charge. A second generation NC-stat system was launched in 2002 with additional biosensors. The company's latest system, which sells for $4,000, is able to test the nerves associated with low back pain and diabetic neuropathy in addition to those implicated in CTS--all 510(k) approved applications that have been accepted for reimbursement by most payers and Medicare, says Gozani, under existing CPT codes for nerve conduction studies.

A Patient a Day

With a small sales force of 10, (NeuroMetrix has since increased the number of reps to 30, backed by independent sales agents who generate and qualify leads), sales of the NC-stat and biosensors began to ramp up soon after FDA clearance. In 2003, NeuroMetrix had sales of $9.1 million, an increase of 117% over the previous year, mostly to orthopedists and occupational health physicians doing hand and lower back studies. A small number of systems were also sold to primary care physicians. The company's rapid growth supported an initial public offering in July 2004 in which NeuroMetrix raised $24.1 million and saw its market cap hit $96 million. [See Deal]

Since its IPO, the company's focus has been to penetrate the primary care market, a category that for NeuroMetrix includes family practices, internal medicine and physicians specializing in diabetology/endocrinology and rheumatology. These are the front line providers for the three major conditions that Neuromatrix can help diagnose: diabetic neuropathy, which gradually affects 50% of the 18 million diabetics in the US; low back pain, which accounts for 20 million adult visits to physicians each year; and carpal tunnel syndrome, which prompts 2.5 million visits to physicians annually. (See Exhibit 1.)

Insert Exhibit 1 here

NeuroMetrix's message to those PCPs: NC-stat provides physicians at the point of care with objective data to answer specific types of questions about neuropathies, avoiding delays in treatment decisions due to the referral process. For patients, in-office, POS testing helps avoid the hassle of EMG and nerve conduction studies that have to be scheduled weeks or even months ahead as well as the potential pain associated with those tests. Finally, NeuroMetrix created a business model that, company officials believe, makes economic sense for physicians who use the equipment. "The technology pays for itself," says Gozani.

Physicians buy the NC-stat system—the monitor and the docking station--for $4,000 and buy disposable biosensors as the need arises. Biosensors range from $25-$45, and typically, four or five sensors are required for each test. (See Exhibit 2.) Tests are reimbursed on a per nerve basis. "The sum total," says Gozani, "is that physicians spend about $150 on disposables and generate $300-$350 in reimbursement from payers. They net about $150-$200."

The economics of the NeuroMetrix system can be tricky, particularly when the target is PCPs. Without a clear economic incentive to do testing, PCPs simply won't bother—they have too much else to do and generally don't think in terms of add-on services. But if it looks like too many patients in PCP offices are getting the test, payers might balk. It's the traditional trade-off between a screening tool—which no reimburser will pay for—and a conventional diagnostic, which has value in identifying serious medical conditions early.

In the case of diabetic neuropathy, the debate is drawn more sharply by the fact that since nerves, like heart tissue, won't regenerate once dead, physicians can significantly improve the quality of care by diagnosing neuropathy early before nerve damage has progressed--often, in fact, before patients become symptomatic. Some payers may get nervous at the thought of testing patients who show no symptoms, but Neurometrix officials make the simple claim that early detection—and the earlier the better—significantly enhances patient care. They also point out that nerve conduction studies are not screening studies and must be performed when the physician feels there is compelling medical justification. The economic incentives for physicians to use the Neurometrix diagnostic are intended exclusively to compensate them for delivering better care.

Metrics of Progress

And indeed, the economic rewards, not just to physicians, but to NeuroMetrix itself, can be considerable. In June 2005, Neurometrix announced that its one millionth biosensor had been used and downloaded into its OnCall Information System. In its first quarter results, the company reported that 88% of its $6.8 million in first quarter revenues came from biosensor sales and that it had gross margins of 73%, margins more like those of an implantable device company than a diagnostic enterprise.

NeuroMetrix now has more than 2400 active customers delivering an average of $7,500 in annual biosensor revenue. Newer customers, who were brought in during the second half of 2004, deliver an annualized biosensor revenue rate of $13,500--due to use of the company's latest, most advanced system and a new biosensor for the sural nerve, a sensory nerve in the lower extremity that adds clinical value in the assessment of lower extremity back pain and diabetic neuropathy.

Going forward, say NeuroMetrix officials, the company's long-term goal is to achieve an NC-stat utilization rate of one patient a day for each customer, or at least $30,000 per account annually.

Gary Gregory, NeuroMetrix' COO, reports that the company has several accounts that do well above $30,000 already. But to fully realize its goal, the company recently increased the number of its regional sales managers to 30.

Adding sales reps is critical and underscores a major challenge for NeuroMetrix: targeting a PCP customer base means the company will have to have a sales force considerably larger than the small, focused forces typical of most device companies—a sales force that, as its alliance with Lilly suggests, looks more like a pharmaceutical sales force.

And NeuroMetrix can't really use a physician's office distributor sales force—the most logical path for device companies trying to get to the PCP market—because distributor reps lack the focus, attention and expertise to educate physicians about NeuroMetrix's technology and to deal with pushback and reimbursement issues.

NeuroMetrix isn't the first device company that has tried to reach primary care physicians to help promote the adoption of innovative technology to treat otherwise largely untreated conditions. In spine, Kyphon Inc. has successfully built a sales force that, in effect, recruits or enlists primary care docs to help identify patients with vertebral fractures and then to refer them to surgeons who will perform a kyphoplasty. (See "Kyphon's Move into the Mainstream," IN VIVO, November 2004 (Also see "Kyphon's Move Into the Mainstream" - In Vivo, 1 Nov, 2004.).)

Still, it's a tricky proposition, particularly for a small device company with limited resources. Alliances with Big Pharma, such as NeuroMetrix's deal with Lilly, will help; so too will the service component of the NeuroMetrix system. The same reports that the NC-stat system generates and faxes to physicians also create a kind of data base that NeuroMetrix can use to see which physicians aren't using the test in numbers proportionate to the number of diabetes patients they should have and to identify physicians whose testing volumes have fallen off. Such physicians then become logical targets for NeuroMetrix sales calls.

Harder to identify are those physicians who should, because of their patient base, be testing for diabetic neuropathy, but aren't. Those will take longer for NeuroMetrix to find and to sell.Company officials note that as the incidence and awareness of diabetes skyrocket, they need only penetrate a small percentage of their target market to be successful—hence the significance of the one-millionth biosensor: it's both an important sales milestone and a mere drop in the bucket in terms of the number of biosensors that could be sold.

Once it reaches those physicians, NeuroMetrix's current revenue goals may be conservative; Gozani believes that NeuroMetrix's potential market may be as big as $1 billion although getting to that will rest heavily on moving beyond its target specialist customers and increasing its sales to primary care markets. In the first quarter of 2005, NeuroMetrix reported some progress towards this goal: PCPs accounted for 55% of its revenues, orthopedics represented 26% and other specialty care providers shared the remaining 19%.

Parallel Standards of Care

As noted, part of NeuroMetrix's challenge lies in convincing physicians that the diagnostic information it provides has an impact on patient care. Indeed, even strong economic incentives to use the test won't make much difference if physicians, particularly primary care docs, just don't see a need for it. And it won't simply be a matter of replacing, in house, tests that are now referred out; today, many physicians underutilize nerve conduction studies because of their expense and inconvenience. Despite the tens of millions of patients that present with symptoms that could be due to neuropathies, only 2 million conventional nerve conduction tests are performed each year.

For certain diseases, physicians are unclear what impact the nerve studies will have on treatment decisions. For diabetic neuropathy, for example, many physicians rely on the physical exam and patients' reports of pain and numbness. They prescribe tricyclic antidepressants or dual reuptake inhibitors like Neurontin and Cymbalta for neuropathic pain, without assessing nerve damage.

Moreover, as NeuroMetrix targets PCPs and a limited number of specialists, it has not targeted neurologists in the past, and that has created some tension and the potential for turf battles. The experts in nerve assessment—the neurologists—aren't always in favor of "non-experts" performing nerve conduction tests, and some members of the community may feel threatened by the loss of their procedures to PCPs. NeuroMetrix has just started selling to neurologists, and it still must find ways to work with them lest their unfamiliarity with the product and technology leads them to push back against it, both from their seats on the review boards of payers and from the podiums at their society meetings. Such turf battles aren't unique to neurology. The American College of Radiology, for example, last year was lobbying Congress to limit the installation, within orthopedics practices, of MRI systems dedicated to extremity-imaging, on the basis that self-referrals by orthopedists would drive up health care costs. But the fact that this is a common tension underscores NeuroMetrix's need to address it.

Gozani knows NeuroMetrix has to satisfy both constituencies, and he believes that it won't be a question of moving procedure share from neurologists to primary care physicians. He believes two parallel standards of care will be created, each with a different need for nerve conduction information. So while the company sells directly to primary care physicians, it is simultaneously reaching out to the neurology community with the message that there is an abundance of patients and a clinical need for testing by both groups.

Gozani argues that PCPs are looking for information relative to a defined problem. If a patient presents with a hurt wrist, for example, a PCP will probably do a work up on the wrist to determine what's wrong. The internist, he goes on, is asking a specific question, within the context of a clinical exam and with foreknowledge of the patient through continuity of care: "Does the patient have median nerve injury at the level of the wrist?" In the case of back or leg pain, the question might be, "Does the patient have lumbosacral root compression?" Or, to diagnose diabetic neuropathy, the physician might want to know if there is electrophysiological evidence of nerve dysfunction affecting the legs. That is the sort of defined problem that NC-stat is designed to answer, says Gozani.

Neurologists, however, look at things differently. Morris A. Fisher, MD, a neurologist at the Veterans Administration Hospital in Hines, IL, says, "As a neurologist, I want more information because I think there are patterns of abnormalities associated with diabetes that aren't present in other types of neuropathies." Indeed, the neurologist looking at even a relatively simple disorder like carpal tunnel syndrome may look not just at the ulnar and median nerves but also at the upper extremities, on both sides of the body, to see what else is going on. Neurologists are also used to looking at patients with confounding sets of problems, patients who simultaneously have osteoarthritis, diabetes and lumbar stenosis. That's why some argue that a focused approach is inadequate.

Still, Fisher is far from an enemy of the new technology. He notes that NC-stat provides information that isn't available through conventional studies. And because it is inexpensive, readily available and easy to use, he goes on, it can be used to provide a series of measurements over time to help physicians follow patients. Also, because of its signal processing capabilities, NC-stat provides certain types of diagnostic information that's not easy to obtain from standard nerve conduction studies.

"Today, I did a study on a patient that has lumbar spinal stenosis," says Fisher. "I did a full set of the electrodiagnostic studies that I usually do, but I also did a NeuroMetrix study. NeuroMetrix has an automated way of analyzing F-waves, which relate to evidence of proximal injury, or injury close to the spinal cord. There is evidence that those studies are helpful for evaluating lumbosacral radiculopathy. To do that in the usual fashion is cumbersome and time consuming, and most clinicians don't do it," Fisher says. This is important information because mild damage to the nerve root is reversible if the mechanical or inflammatory insult to the nerve root is removed. If it's not addressed, however, nerve damage can become permanent.

Gozani insists that expanding the number of users of automated nerve conduction testing isn't a zero sum game that takes procedures away from one group of physicians and gives them to another. He draws a parallel to the introduction, into primary care practices, of the EKG, a test that was once the exclusive province of cardiologists. Once these front-line doctors had an objective tool to identify cardiovascular abnormalities early and often, cardiologists' patient volumes actually increased since primary care doctors still refer patients with certain abnormalities to the specialist. Gozani believes the same thing will happen with neuropathies. By detecting disease before clinical symptoms are evident, NC-stat will increase the volume and appropriateness of patients that go to specialists for a comprehensive work-up, he claims.

NeuroMetrix isn't, however, positioning NC-stat as a screening tool; nor is it a stripped-down version of the equipment used by neurologists. It has been designed to provide equivalent—sometimes superior—diagnostic information for select, common disorders. Generally speaking, these kinds of cases are reimbursed: the differential diagnosis of symptom-based complaints (pain in the limbs, weakness, tingling); localization of focal neuropathies or compressive lesions (for example, the kinds of nerve compression that occur in carpal tunnel syndrome or sciatica); or the diagnosis or confirmation of suspected generalized neuropathies in a patient with a history of diabetes, for example.

But Does It Impact Treatment?

The fact that physicians make enough money—but not too much—from performing automated nerve conduction tests isn't enough to justify widespread clinical use, and part of NeuroMetrix's challenge is to educate physicians, who all practice medicine differently, about the most compelling uses of electrodiagnostic testing.

Occupational medicine physician Mark Upfal, MD, the corporate medical director of the Detroit Medical Center, an early adopter of the NeuroMetrix system for CTS (also a clinical advisor to the company), says "Any time we get someone with a wrist problem where we suspect nerve compression, we can run the test. And we can do it inexpensively without waiting a couple of weeks for the referral and without waiting for the clinical information to come back." Upfal says the test may alter what he or his colleagues do in terms of treatment—if it is CTS vs. arthritis, there is a different course of treatment. It helps them assign a work status to an individual, and it allows them to provide an employer with a better idea of what to expect over time.

For diabetic neuropathy, the impact of better diagnostics on treatment has been less clear—until recently. Certainly, a POS test that allows physicians to identify neuropathy early might increase watchfulness and help diabetics lacking sensation in their feet avoid unfelt chronic wounds, subsequent gangrene and amputation. And a series of studies of diabetic neuropathy may serve as evidence of overall diabetes control. But recently, the availability of several new therapies for diabetic neuropathy has become a potentially major driver for the adoption of the NC-stat. In the past few months, several drugs have , received FDA approval specifically for neuropathic pain--Eli Lilly's Cymbalta, (duloxetine) and Pfizer Inc. 's Lyrica (pregabalin), for example--and a number of companies, with Eli Lilly at the head of the pack, are advancing drugs to stop the progression of the disease at its earliest stages. (NC-stat was used to measure nerve conduction in the Cymbalta clinical trial). Thus, Lilly's education alliance with NeuroMetrix appears to address two of the diagnostic company's major challenges: linking diagnostics to therapy and educating primary care physicians on the scale of a pharmaceutical sales effort.

A Disease-Modifying Drug Changes Everything

Until now, NeuroMetrix's challenge was the traditional one that faces all diagnostic companies: who wants to do a diagnostic test if there's no therapy for the condition defined? Without clear-cut treatment options for neuropathies, the value of a diagnostic tool becomes questionable at best. Because of a lack of pharmacological therapies, apart from palliative pain mediation, the typical treatment regimens for neuropathy in the past have ranged from tightening blood glucose control and other measures to reduce hyperglycemia, watchful waiting, to physical rehabilitation to surgery. But Lilly's disease-modifying phase III drug ruboxistaurin, an oral protein kinase C beta inhibitor, will be the first drug to treat the underlying process of microvascular damage associated with diabetic neuropathy, and if it succeeds, it creates a compelling reason to test all diabetic patients at early stages of the disease before neuropathic complications occur.

The partnership between NeuroMetrix and Lilly is, at this stage, an education alliance. It isn't revenue-generating per se, but at the same time, NeuroMetrix will benefit from working with the leading insulin company in the US without any royalty or other strings attached.

More formal partnerships that link diabetes diagnostics and therapeutics may arise in the future, similar to the types of alliances that occurred before the launch of a new generation of osteoporosis drugs. Merck & Co. Inc. , for example, joined forces with diagnostics firm Ostex International Inc. just before the launch of Fosamax (alendronate). [See Deal] In osteoporosis, these alliances ultimately failed to substantially increase sales of the diagnostic after an initial burst of enthusiasm at drug launch. But in diabetic neuropathy, since it's not known which 50% of diabetes patients will develop the disease, it will likely become important to test all diabetics, even before symptoms develop, to identify patients that could benefit from a therapy that halts disease progression, and for now, NeuroMetrix has the only point-of-care test that can do that.

Today, NeuroMetrix has its work cut out for it as it attempts to manage growth while managing its cash. So far, it has spent it wisely. CFO Brad Smith reports that first quarter cash burn was only $150,000 and that the company has $30 million on the balance sheet today in cash and investments.

At the same time, NeuroMetrix also has to manage product development for future growth. It aims to use computing power to help NC-stat extract even more diagnostic information from the signals it acquires. The company is also developing a related therapeutic system, a drug delivery device with a guidance system that allows a drug to be injected close to a nerve without hitting it.

Indeed, NeuroMetrix does appear to have hit a nerve; once the classic story of an innovative technology looking for the right application, it's the right time and place to serve a new and growing market for the diagnosis and treatment of diabetic neuropathy.