Vitamin B-Complex Injection

Vitamin B complex is essential for a wide variety of functions in the human body, Its deficiency can also lead to several disorders including chronic neurological ones. Biochemically, different structures are grouped together under B complex on the basis of their natural occurrence in same type of food and solubility in water. Since humans are not able to synthesize vitamins in B complex on their own and these vitamins are easily excreted from the body through urine, their regular intake is essential to maintain energy production, DNA/RNA synthesis/repair, genomic and non-genomic methylation as well as synthesis of numerous neurochemicals and signalling molecules. B complex deficiency is normally caused due to four possible reasons; high consumption of processed and refined food, with lack of dairy and meat-based food in diet, excessive consumption of alcohol, impaired absorption from the gastrointestinal tract or impaired storage and use by liver.^[1]

According to clinical research parenteral administration (intramuscular or intravenous) is preferred over other drug administration routes in case of emergency situations as it provides first-pass metabolism avoidance, reliable therapeutic concentrations and better bioavailability of dosage.^[2] It can also be used in situations when oral route is not feasible.

Pharmaceutical preparation:
Each 30 mL vial contains: 100 mg of vitamin B1 in form of thiamine hydrochloride, 2 mg of vitamin B2 in form riboflavin-5-Phosphate Sodium, 100 mg of B3 in form niacinamide, 2 mg of vitamin B5 in form of dexpanthenol and 2 mg of vitamin B6 in form of pyridoxine hydrochloride.

B vitamins are necessary for the proper functioning of the methylation cycle, DNA synthesis, repair and maintenance of phospholipids and generally essential for healthy skin, muscles, brain, and nerve functionality.^[3] The individual functions are described below but more often than not they work together to achieve the required effect.

Vitamin B1 (Thiamine)

It plays an important role in energy metabolism, immunity boosting and functioning of nervous system. It can help avoid type 2 diabetes, several cardiovascular diseases, some vision and kidney disorders and neurodegenerative diseases like Alzheimer’s disease.

Vitamin B2 (Riboflavin)

It is a powerful antioxidant and plays a vital role in maintaining healthy blood cells and boosts metabolism.

Vitamin B3 (Niacin)

Niacin plays a critical role in proper functioning of the nervous and digestive systems. Like other vitamins from the family it is necessary for energy production and metabolism of fatty acids. It also provides healthy skin, nails, and hair.

Vitamin B5 (Dexpanthenol)

Dexpanthenol is a derivative of pantothenic acid (vitamin B5) and is essential for various biological functions. Pantothenic acid supports the health of the central nervous system, aids in energy production, and is involved in the synthesis of important molecules such as amino acids, blood cells, vitamin D, and fatty acids.

Vitamin B6 (Pyridoxine)

Vitamin B6 has a very influential role in synthesis of neurotransmitters and is essential for good mental health. It also has a direct effect on immune function. It plays a role in metabolism of amino acids and is a necessary co-factor in the folate cycle, lack of which can lead to anaemia.
Epidemiological evidence in some cases hints that the accepted dosages of vitamin B helps only to avoid their marginal deficiency and further benefits could accrue from higher dosages than those provided by RDA.^[4][5]

B vitamins play different roles but their functions are inter-related and complementary. They work as coenzyme in several biochemical reactions to activate enzyme reaction of corresponding protein by creating holoenzyme. As holoenzyme they participate in the majority of cellular processes.^[6]

Although vitamin B1 and B6 participate more actively in the methionine cycle and citric acid cycle, which is the mitochondrial energy production process, the entire vitamin B group is involved in its successful execution.^[1] B vitamins also help to maintain the health of nervous system by playing a crucial role in the central nervous system and the peripheral nervous system functions.

Vitamin B1 (thiamine) serves as a coenzyme with transketolase enzyme in the pentose phosphate pathway of glycolysis. This pathway generates pentose sugar for synthesis of amino acid and nucleic acid and converts glucose to ribulose-5-phosphate via retrieving the carbon from the pentose phosphate shunt.^[7][8] Vitamin B2 (Riboflavin) plays an important role in many biologically important redox reactions such as energy producing, biosynthetic, detoxifying and electron scavenging pathways as a precursor of coenzyme flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD).^[9][10] Riboflavin is also essential for the metabolism of homocysteine, as a cofactor for methylenetetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR).^[11]

In the citric acid cycle, Vitamin B3 (Niacin) is involved in the formation of acetyl-CoA while conversion of its co-enzyme takes places from NAD+ (nicotinamide adenine dinucleotide) to NADH.^[12] In the anabolic methionine cycle, niacin, in the form of NAD, is a necessary co-factor for the enzymes dihydrofolate reductase in the folate/tetrahydrobiopterin cycle and S-adenosylhomocysteine hydrolase.^[1] Vitamin B5 (Dexpanthenol) is a component of coenzyme A. At least 70 enzymes utilize coenzyme A for the metabolism of fat, protein, carbohydrates and proper functioning of citric acid cycle.^[13] It is also involved in synthesis of several neural transmitters.^[12]

Vitamin B6 (Pyridoxine) acts as a necessary cofactor in the folate cycle and combines with serine hydroxymethyl transferase to effect the conversion of tetrahydrofolate(THF) to 5,10 methylene THF.^[14] B6 is a rate limiting cofactor in the synthesis of several neurotransmitters such as dopamine, serotonin, γ-aminobutyric acid (GABA), noradrenaline and the hormone melatonin.[/footnote]1^{[ Even a minor deficiency of B6 can cause a substantial down-regulation of these neurotransmitters. B6 also plays an important role in immune functions and is also a bio-marker of inflammation with its down-regulation being associated with severe inflammation.[footnote]15]}

Intravenous administration of Vitamin B preparations should be done slowly and if necessary, the preparation should be diluted to avoid speed reaction. The patient should be questioned closely about any symptoms from previous doses to prevent severe reactions. A skin sensitivity test prior to administration is advised. For the older patients (60+ years) specially with arteriosclerosis, possibility of circulatory collapse after administration should be kept in mind.^[16]

Vitamin B6 has been reported to have an adverse interaction with Vitamin K in presence of folic acid with an increase in INR (International normalized ratio). Some anti-depressants when used vitamin B complex can cause panic which could be a potential effect of these vitamins on central nervous system. When used with oral contraceptives B6 may reduce their effectiveness and cause nausea.^[17]

As a co-therapy like in case of combined collagen crosslinking (CXL) and intrastromal corneal ring segment (ICRS) implantation to treat keratoconic eyes, no adverse effect from the riboflavin injections were reported.^[18]

Anaphylactic shock due to intravenous administration of vitamin B complex has been reported earlier.^[16]

Thiamine hydrochloride (vitamin B1) in the formulation is known to cause life threatening anaphylaxis especially on multiple administrations if patient is allergic to it. Less threatening reaction to B1 include anxiety, pruritus, respiratory distress, nausea, abdominal pain. Vomiting, anorexia, headache, irritability, tremors, and palpitations, can be overdose syndromes.^[19][20]

Side effects from vitamin B2 in the preparation are rare but skin test or when necessary the more sensitive intradermal skin test may be advised to diagnose anaphylactic sensitivity.^[21]

Larger doses of niacin tend to cause nausea and vomiting. In the blood stream as nicotinic acid, it can cause skin flush and this reaction is actually responsible for the tolerable upper limit (UL) for niacin at 35 mg/d for adults in US.^[20]

Vitamins B5 and H have reported to cause life-threatening adverse reaction of eosinophilic pleuropericarditis and patient history for such allergy should be checked before administration.^[22]

Prolonged overdose of B6 (150-200 mg/day) over weeks can cause severe sensory-nervous-system dysfunction and ataxia.^{[23 ]}With normal usage serious adverse effects are not reported for pyridoxine (vitamin B6), however, diarrhea, emesis, and rosacea-like dermatitis may be observed in some cases.^[24]

Vitamins from the B group are generally recommended during pregnancy as per individual requirements. No specific safety data could be identified. Physician’s advice before use is recommended.

Vitamins from the B group are generally recommended during breastfeeding as per individual requirements. These vitamins pass through the breast milk to the infant. No specific safety data could be identified. Physician’s advice before use is recommended.

Store this medication in a refrigerator at 36°F to 46°F (2°C to 8°C). Keep all medicines out of the reach of children. Throw away any unused medicine after the beyond use date. Do not flush unused medications or pour down a sink or drain.

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3. K. Mikkelsen and V. Apostolopoulos, “Vitamin B1, B2, B3, B5, and B6 and the Immune System,” in Nutrition and Immunity, Cham: Springer International Publishing, 2019, pp. 115–125.
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9. N. S. Ross and T. P. Hansen, “Riboflavin deficiency is associated with selective preservation of critical flavoenzyme-dependent metabolic pathways.,” Biofactors, vol. 3, no. 3, pp. 185–90, Jan. 1992.
10. M. Ashoori and A. Saedisomeolia, “Riboflavin (vitamin B 2 ) and oxidative stress: a review,” Br. J. Nutr., vol. 111, no. 11, pp. 1985–1991, Jun. 2014.
11. C. J. García-Minguillán et al., “Riboflavin status modifies the effects of methylenetetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) polymorphisms on homocysteine,” Genes Nutr., vol. 9, no. 6, p. 435, Nov. 2014.
12. G. Wolf, “Handbook of Vitamins , 4th ed, edited by Janos Zempleni, Robert B Rucker, Donald B McCormick, and John W Suttie, 2007, 593 pages, hardcover, $107.96. CRC Press, New York,” Am. J. Clin. Nutr., vol. 88, no. 6, pp. 1708–1708, Dec. 2008.
13. G. Litwack, Human Biochemistry. Elsevier, 2018.
14. J. Selhub, “Folate, vitamin B12 and vitamin B6 and one carbon metabolism.,” J. Nutr. Health Aging, vol. 6, no. 1, pp. 39–42, 2002.
15. L. Sakakeeny et al., “Plasma Pyridoxal-5-Phosphate Is Inversely Associated with Systemic Markers of Inflammation in a Population of U.S. Adults,” J. Nutr., vol. 142, no. 7, pp. 1280–1285, Jul. 2012.
16. W. R. Chitwood, “ANAPHYLACTIC SHOCK FOLLOWING INTRAVENOUS ADMINISTRATION OF VITAMIN B COMPLEX,” JAMA J. Am. Med. Assoc., vol. 148, no. 6, p. 461, Feb. 1952.
17. A. de Boer, F. van Hunsel, and A. Bast, “Adverse food–drug interactions,” Regul. Toxicol. Pharmacol., vol. 73, no. 3, pp. 859–865, Dec. 2015.
18. A. Kılıç, G. Kamburoglu, and A. Akıncı, “Riboflavin injection into the corneal channel for combined collagen crosslinking and intrastromal corneal ring segment implantation,” J. Cataract Refract. Surg., vol. 38, no. 5, pp. 878–883, May 2012.
19. J. M. Stephen, R. Grant, and C. S. Yeh, “Anaphylaxis from administration of intravenous thiamine,” Am. J. Emerg. Med., vol. 10, no. 1, pp. 61–63, Jan. 1992.
20. K. D. Wrenn, F. Murphy, and C. M. Slovis, “A toxicity study of parenteral thiamine hydrochloride,” Ann. Emerg. Med., vol. 18, no. 8, pp. 867–870, Aug. 1989.
21. L.-S. Ou, M.-L. Kuo, and J.-L. Huang, “Anaphylaxis to riboflavin (vitamin B2),” Ann. Allergy, Asthma Immunol., vol. 87, no. 5, pp. 430–433, Nov. 2001.
22. P. M. Debourdeau, S. Djezzar, J. L. F. Estival, C. M. Zammit, R. C. Richard, and A. C. Castot, “Life-Threatening Eosinophilic Pleuropericardial Effusion Related to Vitamins B 5 and H,” Ann. Pharmacother., vol. 35, no. 4, pp. 424–426, Apr. 2001.
23. H. Schaumburg et al., “Sensory Neuropathy from Pyridoxine Abuse,” N. Engl. J. Med., vol. 309, no. 8, pp. 445–448, Aug. 1983.
24. D. Patel et al., “Vitamins, Amino Acids, and Drugs and Formulations Used in Nutrition,” 2016, pp. 355–364.