Vitamin B New Research
The B vitamins are eight water-soluble vitamins that play important roles in cell
metabolism. Historically, the B vitamins were once thought to be a single vitamin, referred to
as Vitamin B (much like how people refer to Vitamin C or Vitamin D). Later research
showed that they are chemically distinct vitamins that often coexist in the same foods.
Supplements containing all eight B vitamins are generally referred to as a vitamin B complex.
Individual B vitamin supplements are referred to by the specific name of each vitamin (e.g.
B1, B2, B3). The B vitamins often work together to deliver...
VITAMIN B: NEW RESEARCH
VITAMIN B: NEW RESEARCH
CHARLYN M. ELLIOT
EDITOR
Nova Biomedical Books
New York
Copyright © 2008 by Nova Science Publishers, Inc.
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LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA
Vitamin B : new research / Charlyn M. Elliot, editor.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-60692-697-0
1. Vitamin B in human nutrition. I. Elliot, Charlyn M.
[DNLM: 1. Vitamin B Complex--pharmacology. 2. Vitamin B 12--therapeutic use. 3. Vitamin B
Complex--therapeutic use. QU 187 V837 2007]
QP772.V52V58 2007
612.3'99--dc22 2007021180
Published by Nova Science Publishers, Inc. New York
CONTENTS
Preface vii
Expert Commentary
Commentary Cobalamin Communication Current State
of Oral Vitamin B12 Treatment 1
Karin Björkegren
Research and Review Articles
Chapter I Inhibitory Effect of Vitamin B6 Compounds on DNA Polymerase,
DNA Topoisomerase and Human Cancer Cell Proliferation 5
Yoshiyuki Mizushina,, Norihisa Kato,
Hiromi Yoshida and Kiminori Matsubara
Chapter II The Causes and Consequences of Vitamin B-3 Deficiency:
Insights from Five Thousand Cases 21
Harold D. Foster and Abram Hoffer
Chapter III Folic Acid and Health: An Overview 39
Rossana Salerno-Kennedy
Chapter IV Nutritional Issues in Inflammatory Bowel Disease: Focus on
the Vitamin B Complex Deficiencies and their Clinical Impact 57
Petros Zezos and Georgios Kouklakis
Chapter V New Bacterial Cobalamin-Dependent CoA-Carbonyl
Mutases Involved in Degradation Pathways 81
Thore Rohwerder and Roland H. Müller
Chapter VI Cystalysin: An Example of the Catalytic Versatility
of Pyridoxal 5’-Phosphate Dependent Enzymes 99
Barbara Cellini, Riccardo Montioli
and Carla Borri Voltattorni
vi Contents
Chapter VII Vitamin B Treatment and Cardiovascular Events in
Hyperhomocysteinemic Patients 121
Marco Righetti
Chapter VIII Vitamin B12, Folate Depletion and Homocysteine:
What Do They Mean for Cognition ? 139
Rita Moretti, Paola Torre and Rodolfo M. Antonello
Chapter IX Vitamin B6 as Liver-targeting Group in Drug Delivery 153
Guo-Ping Yan, Xiao-Yan Wang and Li-Li Mei
Chapter X The Role and Status of Vitamin B12:
Need for Clinical Reevaluation and Change 175
Ilia Volkov, Inna Rudoy and Yan Press
Index 193
PREFACE
The B vitamins are eight water-soluble vitamins that play important roles in cell
metabolism. Historically, the B vitamins were once thought to be a single vitamin, referred to
as Vitamin B (much like how people refer to Vitamin C or Vitamin D). Later research
showed that they are chemically distinct vitamins that often coexist in the same foods.
Supplements containing all eight B vitamins are generally referred to as a vitamin B complex.
Individual B vitamin supplements are referred to by the specific name of each vitamin (e.g.
B1, B2, B3). The B vitamins often work together to deliver a number of health benefits to the
body. B vitamins have been shown to:Support and increase the rate of metabolism; Maintain
healthy skin and muscle tone; Enhance immune and nervous system function; Promote cell
growth and division — including that of the red blood cells that help prevent anemia;
Together, they also help combat the symptoms and causes of stress, depression, and
cardiovascular disease.
All B vitamins are water soluble, and are dispersed throughout the body. They must be
replenished daily with any excess excreted in the urine.Vitamin B deficiency can lead to an
enormous group of health problems.
This book presents new and important research in the field.
Expert Commentary - Background: In contrast to global traditions, most patients in
Sweden with vitamin B12 deficiency are treated with oral vitamin B12, 1 mg daily.
Objective: Analysis of current state of oral therapy with vitamin B12 in clinical research
and routine.
Material and Methods: Review of basic documentation of oral vitamin B12 therapy in
the period 1950-2005.
Results: In the period 1950-1960, various doses of vitamin B12 below 1 mg daily were
tested and mainly rejected. During the period 1960-1968, the leading research groups agreed
that oral cyanocobalamin, 1 mg daily, is the optimal dose for oral vitamin B12 prophylaxis
and treatment of deficiency states. The efficacy of such regimens varies between 80-100% in
different studies. The regimen has gained widespread clinical use in Sweden, comprising 2.5
million patient years in the period 1964-2005. Lower doses of oral vitamin B12 still lack
documentation of clinical efficacy and long-term clinical safety and reliability.
Conclusions: Oral cyanocobalamin, 1 mg daily, is a safe and reliable therapy for most
patients with vitamin B12 deficiency. It is suggested that this regimen is compared with a
viii Charlyn M. Elliot
generally accepted parenteral regimen in a prospective, randomized, open-labeled study of
adequate size in conclusive patients.
Chapter I - Vitamin B6 compounds such as pyridoxal 5'-phosphate (PLP), pyridoxal
(PL), pyridoxine (PN) and pyridoxamine (PM), which reportedly have anti-angiogenic and
anti-cancer effects, were thought to be selective inhibitors of some types of eukaryotic DNA
polymerases (pols) and human DNA topoisomerases (topos). PL moderately inhibited only
the activities of calf pol α, while PN and PM had no inhibitory effects on any of the pols
tested. On the other hand, PLP, a phosphated form of PL, was potentially a strong inhibitor of
pols α and ε from phylogenetic-wide organisms including mammals, fish, insects, plants and
protists. PLP also inhibited the activities of human topos I and II. PLP did not suppress the
activities of prokaryotic pols such as E. coli pol I, T4 pol and Taq pol, or DNA metabolic
enzymes such as HIV reverse transcriptase, RNA polymerase and deoxyribonuclease I. For
pols α and ε, PLP acted non-competitively with the DNA template-primer, and competitively
with the nucleotide substrate. To clarify how vitamin B6 inhibits angiogenesis, this review
was performed to examine the effect on human umbilical vein endothelial cell (HUVEC)
proliferation and HUVEC tube formation. Consistent with the result of an ex vivo
angiogenesis assay, PLP and PL markedly suppressed the proliferation of HUVEC, while PN
and PM were inactive. Suppression of HUVEC proliferation by PLP and PL was evident in a
dose-dependent manner with LD50 values of 112 and 53.9 μM, respectively; however,
HUVEC tube formation was unaffected by PLP and PL. On the other hand, PL inhibited the
growth of human epitheloid carcinoma of the cervix (HeLa), but PLP, PN and PM had no
influence. Since PL was converted to PLP in vivo after being incorporated into human cancer
cells, the anti-angiogenic and anti-cancer effects leading to PL must have been caused by the
inhibition of pol and topo activities after conversion to PLP. These results suggest that
vitamin B6 suppresses cell proliferation and angiogenesis at least in part by inhibiting pols α
and ε, and topos I and II.
Chapter II - Inadequacies of vitamin B-3 (niacin) can occur in at least six distinct, but
overlapping ways. Even when diet contains adequate niacin and there are no absorption or
storage problems, intake may be inadequate. This is because some individuals, for genetic
reasons, have abnormally high vitamin B-3 requirements that cannot be met by the typical
diet. As many as one-third of gene mutations result in the corresponding enzyme having a
decreased binding affinity for its coenzyme, producing a lower rate of reaction. About fifty
human genetic illnesses, caused by such defective enzymes, therefore, can best be treated by
very high doses of their corresponding coenzyme. Several such genetic disorders have been
linked to enzymes that have vitamin B-3 as their coenzyme. These include elevated
alcoholism and cancer risk, caused by defective binding in aldehyde dehydrogenase and
phenylketonuria II and hyperpharylalaninemia that are associated with inadequate binding in
dihydropteridine reductase.
There are two recently discovered types of niacin-responsive receptors, HM74A and
HM74B. HM74A is a high affinity receptor that mediates the stimulation of the synthesis of
prostaglandin by niacin. In parts of schizophrenics' brains, the protein for HM74A is
significantly decreased, confirming a niacin-related abnormality that results in very elevated
vitamin B-3 requirements. The simplest cases of niacin deficiency is caused by diets that
contain little or no vitamin B-3. Pellagra, for example, has traditionally been diagnosed in
Preface ix
patients who have been eating excessive quantities of maize, a food that lacks easily available
niacin. Vitamin B-3 deficiencies are also present in patients with absorption and storage
problems. Excessive consumption of sugars and starches, for example, will deplete the body's
supply of this vitamin, as will some antibiotics.
Addiction typically leads to niacin deficiency and can often be treated by taking high
doses of this vitamin. The breakdown of alcohol, for example, is vitamin B-3 dependent
because niacin is required as a coenzyme for one of the main enzymes involved, aldehyde
dehydrogenase. Since niacin is chemically similar to nicotine, the latter may occupy niacin
receptor sites. Certainly, high dose vitamin B-3 has helped many people shed their addiction
to nicotine.
Niacin deficiency also may be the result of excess oxidative stress, which causes an
abnormally high biochemical demand for this nutrient. It appears that multiple sclerosis,
amyotrophic lateral sclerosis, and Parkinson's disease involve the excessive breakdown of
dopamine, generating neurotoxins such as dopachrome. Vitamin B-3 can mitigate this
process but body stores are typically depleted by it. Similarly schizophrenics overproduce
adrenaline and its neurotoxic byproduct adrenochrome and other chrome indoles. As a
consequence, they become niacin depleted, a characteristic that is now being used as a
diagnostic symptom of this illness.
The ability to absorb nutrients typically declines with age. As a result, many vitamin
deficiencies, including niacin, are commonest in the elderly. These inadequacies are reflected
in cholesterol imbalances, cardiovascular disorders, stroke and arthritis, all of which respond
well to high dose niacin.
While optimum dosages vary, the literature, and Dr. Abram Hoffer's experience with
over 5,000 patients, suggest that required daily therapeutic intervention range from 10 mg in
newly diagnosed cases of pellagra to 6 to 10 grams for cholesterol normalization, and the
treatment of cardiovascular disease and stroke.
Chapter III - The review summarizes current thinking on the relationship between folate
and health with an emphasis on the potential benefits and risks associated with folic acid
supplements and fortification of food.
For decades, folate has been known to produce a form of anemia called “megaloblastica”,
there is now evidence that it is also essential to the development of the central nervous
system and that insufficient folate activity, at the time of conception and early pregnancy, can
result in congenital neural tube defects. More recently, degrees of folate inadequacy have
been found to be associated with high blood levels of the amino-acid homocysteine (Hcy).
Hcy is a well known risk factor for cardiovascular and neurodegerative diseases, dementia
and Alzheimer’s disease, osteoporotic fractures and complications during pregnancy.
Moreover, folate has been implicated in modulating the risk of several cancers. For instance,
recent epidemiological studies support an inverse association between folate status and the
rate of colorectal adenomas and carcinomas, suggesting that maintaining adequate folate
levels may be important in reducing this risk.
On the other hand, several studies suggest that a high intake, generally attributable to
supplemental folic acid, may increase the risk of breast cancer in postmenopausal women,
particularly those with moderate alcohol consumption.
x Charlyn M. Elliot
There is also the risk that widespread folate fortification, may mask B12 deficiency,
which in turn may lead to neurological damage. Vitamin B12 deficiency produces an anemia
that is identical to that of folate deficiency and also causes irreversible damage to the central
and peripheral nervous systems. Folate fortification may also affect antiepileptic drug seizure
control, and influence the genetic selection of a potentially deleterious genotype, albeit over a
number of generations.
As folic acid is now under consideration worldwide as an important functional food
component, there is great interest in finding whether dietary supplements and food
fortification with folic acid can improve health or be harmful. These and other aspects of this
matter will be explored in this review.
Chapter IV - Inflammatory bowel disease (IBD) is a chronic relapsing and remitting
inflammatory condition of unknown cause, which manifests with two major forms: as
Crohn’s disease (CD), affecting any part of the gastrointestinal tract and as ulcerative colitis
(UC), affecting the colon. Medical management with aminosalicylates (5-ASA), steroids, and
immunomodulating or immunosuppressive agents is the mainstay of therapy for most IBD
patients. Surgery is reserved for patients with severe disease refractory to medical
management or for patients with complications.
Nutrition plays an important role in pathogenesis, management and treatment of IBD.
Malnutrition is a common problem in patients with IBD, especially in those suffering from
Crohn’s disease (CD). A wide array of vitamin and mineral deficiencies has been described
in patients with IBD. Nutritional abnormalities are often overlooked in the management of
IBD patients, despite their pathogenic role in clinical manifestations and complications of
IBD. The causes of malnutrition in IBD are multiple, including decreased oral nutrient intake,
malabsorption, excessive nutrient losses, increased nutrient requirements, and iatrogenic due
to surgery or medications.
Thiamin (B1), riboflavin (B2), niacin, pyridoxine (B6), pantothenic acid, biotin, folic acid
(B9) and vitamin B12 are referred to as members of the “vitamin B complex”. These are
water-soluble factors, playing an essential role in the metabolic processes of living cells,
functioning as coenzymes or as prosthetic groups bound to apoenzymes. These vitamins are
closely interrelated and impaired intake of one may impair the utilization of others.
Folate and vitamin B12 deficiencies are frequently described in IBD patients and are
implicated in anemia, thrombophilia and carcinogenesis associated with IBD. Low serum
concentrations of other members of the “vitamin B complex” have also been described in
IBD patients, producing the syndromes due to their deficiency.
This article focuses on the recent research for the aetiology, the clinical consequences
and the management of the vitamin B complex deficiencies in patients with inflammatory
bowel disease.
Chapter V - The adenosylcobalamin-dependent CoA-carbonyl mutases catalyze the 1,2-
rearrangement of carbonyl groups reversibly converting branched-chain carbonic acids into
straight-chain ones. Currently, this enzyme group comprises of only two known mutases, the
extensively studied methylmalonyl-CoA mutase (MCM, EC 5.4.99.2) and isobutyryl-CoA
mutase (ICM, EC 5.4.99.13). Whereas MCM is widespread among bacteria and animals ICM
seems to be restricted to bacteria and has thus far only been characterized in Streptomyces
spp. Both enzymes have a rather limited substrate spectrum and function effectively merely
Preface xi
with their natural substrates methylmalonyl-CoA and isobutyryl-CoA, respectively.
Interestingly, we have recently discovered a novel bacterial CoA-carbonyl mutase catalyzing
the conversion of 2-hydroxyisobutyryl-CoA into 3-hydroxybutyryl-CoA (Rohwerder et al.
2006, Appl. Environ. Microbiol. 72:4128). This enzyme plays a central role in the productive
degradation of compounds containing a tert-butyl group such as the common fuel additives
methyl and ethyl tert-butyl ether. Similar enzymes are proposed to be involved in the
conversion of pivalic acid and in the degradation of alkanes and alkylated aromatic
hydrocarbons via anaerobic pathways employing addition to fumarate. Since all these
compounds are important pollutants of water and soil, cobalamin and the new CoA-carbonyl
mutases play a thus far not realized role in natural as well as induced bioremediation
processes. Therefore, the authors summarize in this chapter the known reactions and also
speculate about further pathways which have not yet been associated with CoA-carbonyl
mutase activity. In addition, the enzyme structure and the herewith possibly associated
evolution of substrate specificity are outlined. Finally, energetic and kinetic consequences are
discussed which may result from employing a cobalamin-dependent enzyme for dissimilatory
pathways.
Chapter VI - Pyridoxal 5’-phosphate (PLP) is the catalitically active form of the water-
soluble vitamin B6, and hence the cofactor of a number of enzymes essential to the human
body. PLP-dependent enzymes are unique for the variety of reactions on amino acids that
they are able to catalyze (transamination, decarboxylation, racemization, β- or γ-
replacement/elimination). In the absence of the apoenzyme, different reactions would occur
simultaneously, but the protein moiety drives the catalytic power of the coenzyme toward a
specific reaction. However, this specificity is not absolute; most PLP-enzymes catalyze
indeed side-reactions which can have physiological significance and provide interesting
mechanistic and stereochemical information about the structure of the enzyme active site.
Cystalysin is a PLP-dependent Cβ-Sγ lyase present in Treponema denticola, and its main
reaction is the α,β-elimination of L-cysteine to produce pyruvate, ammonia and H2S. The
latter is probably responsible for the hemolytic and hemoxidative activity associated with the
enzyme catalysis. Cystalysin is one of the most representative examples of the high catalytic
versatility of PLP-dependent enzymes. Recently, indeed, it has been shown that cystalysin is
also able to catalyze the racemization of both enantiomers of alanine, the β-desulfination of
L-cysteine sulfinic acid, and the β-decarboxylation of L-aspartate and oxalacetate with
turnover numbers measured in seconds, and the transamination of L- and D-alanine with
turnover numbers measured in minutes.
Extensive biochemical investigations have uncovered several interesting features of
cystalysin, including the binding mode of the cofactor, its substrate specificity, the formation
of reaction intermediates characteristic of most PLP-enzymes, and the involvement of some
active-site residues in the primary and secondary catalytic reactions.
Chapter VII - High total plasma homocysteine levels are detected not only in patients
with homocystinuria, a recessively inherited disease, but also in patients with renal failure,
hypothyroidism, and methyltetrahydrofolate reductase polymorphism. The most important
clinical signs of high plasma homocysteine values are thromboembolic vascular occlusions of
arteries and veins, cerebral impairment, osteoporosis, and displacement of the lens.
Cardiovascular disease is the primary reason of morbidity and mortality in the general
xii Charlyn M. Elliot
population, and it represents about 50% of the causes of mortality of the patients with chronic
renal failure. Folic acid, vitamin B6 and vitamin B12, lower hyperhomocysteinemia acting on
remethylation and transsulphuration pathway. Vitamin B treatments don't often normalize
plasma homocysteine levels, but long-term effects of vitamin B therapy are effective in
reducing the life-threatening vascular risk of homocystinuric patients.
Hyperhomocysteinemia is detected in patients with chronic renal failure, and especially in
patients with stage 5 of chronic kidney disease. Clinical observational studies have shown
different results about the effects of high plasma homocysteine levels on cardiovascular
disease in dialysis patients. In fact, cardiovascular mortality has been associated not only with
hyperhomocysteinemia, but also in some studies with hypohomocysteinemia. These
contrasting data are probably due to the strict relationship between homocysteine and
malnutrition-inflammation markers. Dialysis patients are frequently affected by malnutrition-
inflammation-atherosclerosis syndrome, and consequently this severe clinical condition can
interfere with homocysteine levels. I and my coworkers recently observed in a prospective
clinical trial that hemodialysis patients, submitted to vitamin B treatment, with low
homocysteine levels and high protein catabolic rate show a significantly higher survival rate
as compared with the other three subgroups. Prospective clinical studies, evaluating
homocysteine-lowering vitamin B therapy on cardiovascular events in patients with mild
hyperhomocysteinemia, have recently shown no clinical benefits. These results could be
misleading because a part of patients had normal homocysteine levels, follow-up time may
have been too short, and confounding factors has not been considered. To summarize, this
paper shows the hottest news regarding the effects of homocysteine-lowering vitamin B
therapy on cardiovascular events, exploring the intriguing puzzle of homocysteine.
Chapter VIII - Vitamin B12 exerts its physiological effect on two major enzymatic
pathways: the conversion of homocysteine to methionine and the conversion of
methylmalonyl coenzyme A to succinyl coenzyme A. Disruption of either of these pathways
due to vitamin B12 deficiency results in an elevation of both serum homocysteine and
methylmalonic acid. Homocysteine levels are also elevated in the case of folate deficiency.
Serum homocysteine is proposed to be more sensitive for functional intracellular vitamin B12
deficiency than analysis of vitamin B12 in serum. Hence, homocysteine, vitamin B12, and
folate are closely linked together in the so-called one-carbon cycle. The proposed mechanism
relates to the methylation reactions involving homocysteine metabolism in the nervous
system. Vitamin B12 is the necessary co-enzyme, adequate for the correct functioning of the
methyl donation from 5 Methyltethrahydrofolate in tetrhahydrofolate, necessary for
methionine synthetase. On the other hand, folate is a cofactor in one-carbon metabolism,
during which it promotes the remethylation of homocysteine- a cytotoxic sulfur-containing
amino acid that can induce DNA strand breakage, oxidative stress and apoptosis. What
clearly merges from Literature is the general conviction that vitamin B12 and folate, directly
through the maintenance of two functions, nucleic acid synthesis and the methylation
reactions, or indirectly, due to their lack which cause SAM mediated methylation reactions
inhibition by its product SAH, and through the related toxic effects of homcystein which
cause direct damage to the vascular endothelium and inhibition of N-methyl-D-Aspartate
receptors, can cause neuropsychiatric disturbances.
Preface xiii
Chapter IX - Vitamin B6 includes a series of compounds containing the pyridoxal
structure, such as pyridoxol, pyridoxamine, pyridoxaldehyde and their derivatives. The
pyridoxal structure，the catalytically active form of vitamin B6, possesses specific
hepatocyte uptake by the pyridoxine transporter at the sinusoidal pole because the pyridoxine
transporters that exist in hepatocytes can selectively recognize and bind to the pyridoxal
structure, and transport it into the cells via a member transport system. Thus pyridoxine can
be adopted as a liver-targeting group and be incorporated into the low molecular weight
compounds and macromolecules for the use as magnetic resonance imaging (MRI) contrast
agents and anticancer conjugates. The research progress of liver-targeting drug delivery
system is discussed briefly. Previous researches have demonstrated that the incorporation of
pyridoxine into these molecules can increase their uptake by the liver, and that these
molecules containing pyridoxine groups exhibit liver-targeting properties.
Chapter X - Vitamin B12 plays a functional role in a variety of organs and body systems
and the list of these organs and body systems is growing. It affects the peripheral and central
nervous systems, bone marrow, skin and mucous membranes, bones, and vessels, as well as
the normal development of children. Vitamin B12 (cobalamin) is unique among all the
vitamins in that it contains not only a complex organic molecule but also an essential trace
element, cobalt. Vitamin B12 plays an important role in DNA synthesis and has important
immunomodulatory and neurotrophic effects. According to our “working hypothesis” a
vitamin B12 has some unique, but still unrecognized functions.
Multifunctional systems in the human body need to maintain homeostasis. Man is an
ideal example of a system that constantly aspires to attain optimal regulation, even under the
stress of severe pathology. We assume that there are universal, interchangeable (as required)
propose that one of these substances is vitamin B12.Why vitamin B12? It is possible that even
when the serum cobalamin level is normal, treatment with vitamin B12 can correct defects
caused by other biologically active substances. In the authors studies this has been proved
successful in the treatment of recurrent aphthous stomatitis with vitamin B12 (irrespective of
its blood level!). We call this phenomenon the “Master Key” effect.
Vitamin B12 deficiency is a common problem that affects the general population. Early
detection of vitamin B12 deficiency is clinically important, and there is evidence that such
deficiency occurs more frequently than would be expected. Vitamin B12 deficiency can
occur in individuals with dietary patterns that exclude animal foods and patients who are
unable to absorb vitamin B12 in food. In addition there is an overall tendency to avoid eating
those foods which are high in Vitamin B12, such as beef, because of the relationship between
meat, cholesterol and cardiovascular diseases. Also there is a tendency, particularly among
the younger generation, to be vegetarians for ideological motives. Changes in life style
among segments of the population with high socioeconomic level, on one hand, and the
existence of poverty, on the other, are two main factors in the decreasing consumption of
animal products, particularly red meat. Thus, there is a decrease in the level of vitamin B12 in
general population, and as a consequence, an increase in pathology due to vitamin B12
deficiency (such as neurological and hematological disorders). If future research will
corroborate the relationship between vitamin B12 and homocystein, the authors may observe
an increase in cardiovascular disease as well. In lieu of these developments and in order to
xiv Charlyn M. Elliot
prevent serious health problems, vitamin B12 fortification should be seriously considered and
discussed.
In: Vitamin B: New Research ISBN 978-1-60021-782-1
Editor: Charlyn M. Elliot, pp. 1-4 © 2008 Nova Science Publishers, Inc.
Expert Commentary
COBALAMIN COMMUNICATION
CURRENT STATE OF ORAL VITAMIN B12
TREATMENT
Karin Björkegren∗
Department of Public Health and Caring Science, Family Medicine Uppsala Science
Park, SE-751 85 Uppsala, Sweden.
ABSTRACT
Background: In contrast to global traditions, most patients in Sweden with vitamin
B12 deficiency are treated with oral vitamin B12, 1 mg daily.
Objective: Analysis of current state of oral therapy with vitamin B12 in clinical
research and routine.
Material and Methods: Review of basic documentation of oral vitamin B12 therapy
in the period 1950-2005.
Results: In the period 1950-1960, various doses of vitamin B12 below 1 mg daily
were tested and mainly rejected. During the period 1960-1968, the leading research
groups agreed that oral cyanocobalamin, 1 mg daily, is the optimal dose for oral vitamin
B12 prophylaxis and treatment of deficiency states. The efficacy of such regimens varies
between 80-100% in different studies. The regimen has gained widespread clinical use in
Sweden, comprising 2.5 million patient years in the period 1964-2005. Lower doses of
oral vitamin B12 still lack documentation of clinical efficacy and long-term clinical
safety and reliability.
Conclusions: Oral cyanocobalamin, 1 mg daily, is a safe and reliable therapy for
most patients with vitamin B12 deficiency. It is suggested that this regimen is compared
with a generally accepted parenteral regimen in a prospective, randomized, open-labeled
study of adequate size in conclusive patients.
∗
Correspondence concerning this article should be addressed to: Dr. Karin Björkegren Department of Public
Health and Caring Science, Family Medicine Uppsala Science Park, SE-751 85 Uppsala, Sweden. e-mail:
[email protected].
2 Karin Björkegren
Keywords: Vitamin B12, deficiency, homocysteine, oral therapy.
Treatment of vitamin B12 deficiency with oral high-dose cyanocobalamin is a medical
tradition more or less unique to Sweden [1,2]. The regimen was introduced by Berlin and co-
workers in 1964 [3]. By 1990, as many patients were treated with tablets as with injections.
In the period 1990-2000, the Swedish experience with oral vitamin B12 comprised about one
million patient years [1,2]. The total experience in the period 1964-2005 comprises more than
three million patient years (Mats Nilsson, personal communication).
The reason for the success of oral vitamin B12 in Sweden is thought to lie in the seven-
crown reform of 1970, which made the cost of oral or parenteral B12 therapy equivalent for
physician and patient [1,2]. Thus, oral vitamin B12 for deficiency treatment steadily gained
confidence by experience in Swedish health care in the period 1964-2000.
The most comprehensive documentation of oral vitamin B12 therapy was performed by
the Berlin group (3). It should, however, be emphasized that the Berlin group worked within
an international network of about a hundred scientists, as deemed from the reference list of
the Berlins [3]. During the period 1950-1965, the basic mechanisms of vitamin B12
absorption and metabolism had been discovered. Due to the introduction of the Schilling test
for B12 malabsorption, the possibility for oral treatment of B12 deficiency had come into
focus.
In the period 1950-1965, oral treatment with vitamin B12 was distinguished by current
relapses in cases of B12 deficiency. Indeed, the clinical model of “pernicious anemia in
relapse” was a favorite tool of documentation. A few micrograms of cobalamin could trigger
a shift of iron parameters as a sign of revived erythroblast maturation, reticulocytosis,
maximal hemoglobin rise. However, body stores of vitamin B12 were still exhausted. Thus,
relapses were more rule than exception. The contribution of the Berlin group was a
comprehensive documentation of how to avoid relapses in oral B12 treatment in deficiency
states [3,4,5].
Although lucid to contemporary scientists, the concise final report of the Berlin group
has been subject to misunderstandings by modern medicine [3,4,6,7]. Their experimental
studies of vitamin B12 pharmaco-kinetics started about 1955 in Eskilstuna and Falköping.
The dose of radioactive cyanocobalamin was 0.5 mg. The results on 10 healthy probands and
64 patients with B12 malabsorption were presented at an international congress in Hamburg
in August 1961 [3].
The experimental data of the Berlin group, as well as of other scientists, were analyzed
by GBJ Glass in a major review in 1963 [5]. He concluded: “The daily oral administration of
1 mg cyanocobalamin thus not only provides safe maintenance therapy, without danger of
refractoriness or relapse for patients with pernicious anemia, but also maintains normal
concentrations of B12 in blood serum”.
The clinical studies of oral vitamin B12 appear to have started in the beginning of 1961,
when Ragnar Berlin returned to Linköping from a one-year appointment at the Swedish
education hospital in South Korea. The dose was 0.5 mg cyanocobalamin daily, in
accordance with the pharmaco-kinetic studies of the group. Furthermore, it took some time
for the message from Glass to sink in [3,5].
Commentary 3
During 1962, the first patients appear to have been switched from 0.5 mg daily to 1 mg
daily – “a dose of 1 mg daily has not caused any untoward reaction during five years´ study”
[3]. Before registration of the first commercial brand of oral cyanocobalamin in 1964, tablet
Behepan, 1 mg, all patients had been recruited (n=64). However, only 5-12 patients seem to
have been switched to 1 mg daily [cf 6,7]. From 1965 and forth, all patients were treated with
1 mg daily throughout the study [3].
Subsequent studies confirmed the documentation of the Berlin group of safe and reliable
oral vitamin B12 treatment for deficiency [8-11]. However, two teams noted a failure rate of
10-20% [9,11]; “failure” in this context is serum cobalamin concentrations below 300
pmol/L.
A recent dose-finding study verified that an efficient oral B12 dose should lie above 0.6
mg daily [12]. The calculations are consistent with clinical findings that treatment with 0.5
mg of oral cyanocobalamin daily did not improve movement and cognition in healthy elderly
citizens [13], whereas 1 mg daily improved cognition in demented patients [14].
It is reasonable to conclude that oral cyanocobalamin, 1 mg daily, is safe and reliable
deficiency treatment in most patients. Lower doses are not documented hitherto and appear
risky from a historical point of view. Doses above 1 mg daily bear a limited advantage, since
urinary excretion of vitamin B12 increases for doses above 0.5 mg [3,4,12].
An alarming token of time is that suboptimal doses of oral vitamin B12 are tried again
[13,15,16], as if the lessons from the period 1950-1965 were in vain. Such regimens lack
documentation in adequate long-term studies and could explain the poor clinical results
hitherto of homocysteine lowering [6,7,13,17]; homocysteine is a sensitive marker of vitamin
B12 and folate deficiency.
The old controversy about oral or parenteral vitamin B12 therapy for maintenance
treatment of vitamin B12 malabsorption still remains unsolved. However, there are plenty of
patients on parenteral maintenance treatment of B12 malabsorption in most post-industrial
countries. It is possible to define those patients who have a severe atrophic gastritis by serum
pepsinogen A and serum gastrin (18). Such patients constitute conclusive cases of
“pernicious anemia in maintenance therapy”.
The classical model of “pernicious anemia in relapse” (8) in its latest English version
(10) could be applied to patients with severe atrophic gastritis on parenteral maintenance with
vitamin B12. When the serum B12 approaches 300 pmol/L, the patient is randomized to
continued parenteral maintenance or oral cyanocobalamin, 1 mg daily. Thus, it would be
possible to compare efficacy, benefits, and costs of oral and parenteral maintenance with
vitamin B12 in a group of conclusive patients.
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