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Dwyre DM, Reddy J, Fernando LP, Donnelly JM, Miller JW, Green R. Microangiopathic thrombocytopenia caused by vitamin B12 deficiency responding to plasma exchange. Br J Haematol 2024. [PMID: 39030927 DOI: 10.1111/bjh.19625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/24/2024] [Indexed: 07/22/2024]
Abstract
A young adult African American female presented with normocytic microangiopathic haemolytic anaemia, elevated lactate dehydrogenase and thrombocytopenia. The patient responded to therapeutic plasma exchanges (TPE) for presumed thrombotic microangiopathy caused by thrombotic thrombocytopenic purpura (TTP). After relapsing, the patient was found to have pancytopenia, megaloblastic bone marrow and low vitamin B12 consistent with pernicious anaemia, which improved with intramuscular B12 and discontinuation of TPE. B12-deficient macrocytosis was not seen at presentation due to concomitant alpha-thalassaemia. Initial clinical/laboratory improvement is attributed to B12 present in TPE plasma. B12 deficiency can mimic TTP. Vigilance is needed regarding atypical presentations of pernicious anaemia.
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Affiliation(s)
- Denis M Dwyre
- Department of Medical Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Jyotsna Reddy
- Kaiser Permanente Medical Group, Sacramento, California, USA
| | - Leonor P Fernando
- Department of Medical Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, California, USA
| | - Jacob M Donnelly
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Ralph Green
- Department of Medical Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, California, USA
- Department of Internal Medicine (Hematology-Oncology), University of California Davis Medical Center, Sacramento, California, USA
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2
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Wolffenbuttel BHR, McCaddon A, Ahmadi KR, Green R. A Brief Overview of the Diagnosis and Treatment of Cobalamin (B12) Deficiency. Food Nutr Bull 2024; 45:S40-S49. [PMID: 38987879 DOI: 10.1177/03795721241229500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND An increasing number of adult individuals are at risk of vitamin B12 deficiency, either from reduced nutritional intake or impaired gastrointestinal B12 absorption. OBJECTIVE This study aims to review the current best practices for the diagnosis and treatment of individuals with vitamin B12 deficiency. METHODS A narrative literature review of the diagnosis and treatment of vitamin B12 deficiency. RESULTS Prevention and early treatment of B12 deficiency is essential to avoid irreversible neurological consequences. Diagnosis is often difficult due to diverse symptoms, marked differences in diagnostic assays' performance and the unreliability of second-line biomarkers, including holo-transcobalamin, methylmalonic acid and total homocysteine. Reduced dietary intake of B12 requires oral supplementation. In B12 malabsorption, oral supplementation is likely insufficient, and parenteral (i.e. intramuscular) supplementation is preferred. There is no consensus on the optimal long-term management of B12 deficiency with intramuscular therapy. According to the British National Formulary guidelines, many individuals with B12 deficiency due to malabsorption can be managed with 1000 µg intramuscular hydroxocobalamin once every two months after the initial loading. Long-term B12 supplementation is effective and safe, but responses to treatment may vary considerably. Clinical and patient experience strongly suggests that up to 50% of individuals require individualized injection regimens with more frequent administration, ranging from daily or twice weekly to every 2-4 weeks, to remain symptom-free and maintain a normal quality of life. 'Titration' of injection frequency based on measuring biomarkers such as serum B12 or MMA should not be practiced. There is currently no evidence to support that oral/sublingual supplementation can safely and effectively replace injections. CONCLUSIONS This study highlights the interindividual differences in symptomatology and treatment of people with B12 deficiency. Treatment follows an individualized approach, based on the cause of the deficiency, and tailored to help someone to become and remain symptom-free.
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Affiliation(s)
| | - Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham University, Wrexham, United Kingdom
| | - Kourosh R Ahmadi
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Ralph Green
- University of California Davis, Sacramento, CA, USA
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3
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Miller JW, Smith A, Troen AM, Mason JB, Jacques PF, Selhub J. Excess Folic Acid and Vitamin B12 Deficiency: Clinical Implications? Food Nutr Bull 2024; 45:S67-S72. [PMID: 38987872 DOI: 10.1177/03795721241229503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND In the 1940s to 1950s, high-dose folic acid supplements (>5 mg/d) were used clinically to reverse the megaloblastic anemia of vitamin B12 deficiency caused by pernicious anemia. However, this treatment strategy masked the underlying B12 deficiency and possibly exacerbated its neuropathological progression. The issue of masking and exacerbating B12 deficiency has recently been rekindled with the institution of folic acid fortification and the wide-spread use of folic acid supplements. OBJECTIVES The objectives of this review are to describe clinical and epidemiological evidence that excess folic acid exacerbates B12 deficiency, to summarize a hypothesis to explain this phenomenon, and to provide guidance for clinicians. RESULTS Cognitive function test scores are lower and blood homocysteine and methylmalonic acid concentrations are higher in people with low B12 and elevated folate than in those with low B12 and nonelevated folate. High-dose folic acid supplementation in patients with pernicious anemia or epilepsy cause significant reductions in serum B12. It is hypothesized that high-dose folic acid supplements cause depletion of serum holotranscobalamin and thus exacerbate B12 deficiency. CONCLUSION The evidence for excess folic acid exacerbating B12 deficiency is primarily correlative or from uncontrolled clinical observations, and the hypothesis to explain the phenomenon has not yet been tested. Nonetheless, the evidence is sufficiently compelling to warrant increased vigilance for identifying B12 deficiency in at risk individuals, including older adults and others with low B12 intake or conditions that are associated with B12 malabsorption, who also ingest excessive folic acid or are prescribed folic acid in high doses.
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Affiliation(s)
| | | | | | - Joel B Mason
- Tufts-USDA Human Nutrition Research Center on Aging, Boston, MA, USA
| | - Paul F Jacques
- Tufts-USDA Human Nutrition Research Center on Aging, Boston, MA, USA
| | - Jacob Selhub
- Tufts-USDA Human Nutrition Research Center on Aging, Boston, MA, USA
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Zou X, Yi F, Zhou W, Dong Y, Alhaskawi A, Zhou H, Ezzi SHA, Kota VG, Abdulla MHAH, Alenikova O, Abdalbary SA, Lu H, Wang C. Mechanisms and recent advances in the diagnosis and treatment of nitrous oxide-induced peripheral neuropathy: a narrative review. Front Neurol 2024; 15:1381938. [PMID: 38854969 PMCID: PMC11158622 DOI: 10.3389/fneur.2024.1381938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Under standard conditions, nitrous oxide (N2O) manifests as a colorless, odorless gas with a mildly sweet taste. The compound finds applications in various fields, including its use as an aerosol propellants, an accelerant in motor racing, and an anesthetic in surgical procedures and dentistry. Unfortunately, the recreational misuse of N2O has become prevalent among young individuals due to its euphoric and hallucinogenic effects. Compounding this issue is the fact that nitrous oxide can be easily obtained from over-the-counter household items, facilitating its non-medical use. The global community has witnessed a surge in the recreational utilization of nitrous oxide gas in recent years. Despite the widespread non-medical abuse of N2O, there remains inadequate understanding of the potential adverse effects resulting from exposure to it. This paper provides an overview of management findings, laboratory and electrodiagnostic characteristics, as well as clinical presentations associated with neurological disorders induced by nitrous oxide usage.
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Affiliation(s)
- Xiaodi Zou
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fangyu Yi
- The First School of Clinical of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Weijie Zhou
- Department of Orthopedics, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Yanzhao Dong
- Department of Orthopedics, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Ahmad Alhaskawi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haiying Zhou
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | | | | | - Olga Alenikova
- Department of Neurology, Republican Research and Clinical Center of Neurology and Neurosurgery, Minsk, Belarus
| | - Sahar Ahmed Abdalbary
- Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Nahda University in Beni Suef, Beni Suef, Egypt
| | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Changxin Wang
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Ioakeim-Skoufa I, González-Rubio F, Aza-Pascual-Salcedo M, Laguna-Berna C, Poblador-Plou B, Vicente-Romero J, Coelho H, Santos-Mejías A, Prados-Torres A, Moreno-Juste A, Gimeno-Miguel A. Multimorbidity patterns and trajectories in young and middle-aged adults: a large-scale population-based cohort study. Front Public Health 2024; 12:1349723. [PMID: 38818448 PMCID: PMC11137269 DOI: 10.3389/fpubh.2024.1349723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/06/2024] [Indexed: 06/01/2024] Open
Abstract
Introduction The presence of multiple chronic conditions, also referred to as multimorbidity, is a common finding in adults. Epidemiologic research can help identify groups of individuals with similar clinical profiles who could benefit from similar interventions. Many cross-sectional studies have revealed the existence of different multimorbidity patterns. Most of these studies were focused on the older population. However, multimorbidity patterns begin to form at a young age and can evolve over time following distinct multimorbidity trajectories with different impact on health. In this study, we aimed to identify multimorbidity patterns and trajectories in adults 18-65 years old. Methods We conducted a retrospective longitudinal epidemiologic study in the EpiChron Cohort, which includes all inhabitants of Aragón (Spain) registered as users of the Spanish National Health System, linking, at the patient level, information from electronic health records from both primary and specialised care. We included all 293,923 patients 18-65 years old with multimorbidity in 2011. We used cluster analysis at baseline (2011) and in 2015 and 2019 to identify multimorbidity patterns at four and eight years of follow-up, and we then created alluvial plots to visualise multimorbidity trajectories. We performed age- and sex-adjusted logistic regression analysis to study the association of each pattern with four- and eight-year mortality. Results We identified three multimorbidity patterns at baseline, named dyslipidaemia & endocrine-metabolic, hypertension & obesity, and unspecific. The hypertension & obesity pattern, found in one out of every four patients was associated with a higher likelihood of four- and eight-year mortality (age- and sex-adjusted odds ratio 1.11 and 1.16, respectively) compared to the unspecific pattern. Baseline patterns evolved into different patterns during the follow-up. Discussion Well-known preventable cardiovascular risk factors were key elements in most patterns, highlighting the role of hypertension and obesity as risk factors for higher mortality. Two out of every three patients had a cardiovascular profile with chronic conditions like diabetes and obesity that are linked to low-grade systemic chronic inflammation. More studies are encouraged to better characterise the relatively large portion of the population with an unspecific disease pattern and to help design and implement effective and comprehensive strategies towards healthier ageing.
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Affiliation(s)
- Ignatios Ioakeim-Skoufa
- Department of Drug Statistics, Division of Health Data and Digitalisation, Norwegian Institute of Public Health, Oslo, Norway
- Emerging Technologies Advisory Group, ISACA, Chicago, IL, United States
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Drug Utilisation Work Group, Spanish Society of Family and Community Medicine (semFYC), Barcelona, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), Madrid, Spain
- Department of Pharmacology, Physiology, and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
| | - Francisca González-Rubio
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Drug Utilisation Work Group, Spanish Society of Family and Community Medicine (semFYC), Barcelona, Spain
| | - Mercedes Aza-Pascual-Salcedo
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), Madrid, Spain
- Primary Care Pharmacy Service Zaragoza III, Aragon Health Service (SALUD), Zaragoza, Spain
| | - Clara Laguna-Berna
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
| | - Beatriz Poblador-Plou
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Jorge Vicente-Romero
- Department of Pharmacology, Physiology, and Legal and Forensic Medicine, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
| | - Helena Coelho
- Tondela-Viseu Hospital Centre, Viseu, Portugal
- Specialised Section for Regulatory Affairs & Quality, Portuguese Society of Health Care Pharmacists (SPFCS), Coimbra, Portugal
| | - Alejandro Santos-Mejías
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
| | - Alexandra Prados-Torres
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Aida Moreno-Juste
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), Madrid, Spain
- Aragon Health Service (SALUD), Zaragoza, Spain
| | - Antonio Gimeno-Miguel
- EpiChron Research Group on Chronic Diseases, Aragon Health Sciences Institute (IACS), Aragon Health Research Institute (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Research Network on Chronicity, Primary Care, and Health Promotion (RICAPPS), Institute of Health Carlos III (ISCIII), Madrid, Spain
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Davis TME, Chubb SAP, Peters KE, Davis WA. Serum vitamin B12, distal symmetrical polyneuropathy and anaemia in type 2 diabetes: the Fremantle Diabetes Study Phase 2. Intern Med J 2024; 54:575-581. [PMID: 37665691 DOI: 10.1111/imj.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND There are limited data relating to the effects of metformin-associated vitamin B12 deficiency on the risk of distal symmetrical polyneuropathy (DSPN) and megaloblastic anaemia in well-characterised community-based cohorts. AIMS To assess inter-relationships between metformin therapy, vitamin B12 deficiency assessed using serum active B12 concentrations, and DSPN and anaemia in 1492 Fremantle Diabetes Study Phase 2 (FDS2) participants with type 2 diabetes. METHODS Prevalence rates of vitamin B12 deficiency (total <80 pmol/L, active <23 pmol/L) and borderline deficiency (total ≥80 and ≤200 pmol/L, active ≥23 and ≤35 pmol/L) were determined using baseline sera. The relationship between vitamin B12 status and both DSPN and anaemia was assessed using multivariable analyses. RESULTS Most FDS2 participants (94.4%) were vitamin B12 replete (total serum concentration >200 pmol/L, active >35 pmol/L), 2.0% were deficient (total <80 pmol/L, active <23 pmol/L) and the remainder (3.6%) borderline. Although metformin treatment increased the odds of deficiency (4.2%, 3.1% borderline) in a dose-dependent fashion (odds ratio (95% confidence interval) 39.4 (4.90-316) for >2000 mg daily compared with no treatment; P < 0.001), there was no significant association between vitamin B12 status and DSPN, anaemia (haemoglobin ≤130 g/L males, ≤120 g/L females), haemoglobin concentration or mean corpuscular volume (P ≥ 0.147). Metformin increased the likelihood of anaemia, especially at high doses, independent of vitamin B12 deficiency. CONCLUSIONS Since nutritional sources likely attenuate metformin-associated vitamin B12 malabsorption and its clinical sequelae in developed countries such as Australia, there is no need for routine/opportunistic serum vitamin B12 screening in metformin-treated patients.
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Affiliation(s)
- Timothy M E Davis
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Stephen A P Chubb
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Kirsten E Peters
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
- Proteomics International, QEII Medical Centre, Perth, Western Australia, Australia
| | - Wendy A Davis
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
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Al Zoubi MS, Al Kreasha R, Aqel S, Saeed A, Al-Qudimat AR, Al-Zoubi RM. Vitamin B 12 deficiency in diabetic patients treated with metformin: A narrative review. Ir J Med Sci 2024:10.1007/s11845-024-03634-4. [PMID: 38381379 DOI: 10.1007/s11845-024-03634-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
Metformin is the most prescribed oral hypoglycemic drug and is considered by many health practitioners as the first-line treatment for non-insulin-dependent diabetes mellitus (T2DM). It is used either as a monotherapy or adjuvant to other anti-hyperglycemic agents. Most of its side effects are usually mild and self-limiting. However, several studies have shown an association between the use of metformin and low vitamin B12 levels in diabetic patients. The current review aimed to provide a literature review of the current published reports on the association, the possible mechanisms, and the related individualized risk factors that might lead to this incidence. The most accepted mechanism of the effect of metformin on vitamin B12 level is related to the absorption process where metformin antagonism of the calcium cation and interference with the calcium-dependent IF-vitamin B12 complex binding to the ileal cubilin receptor. In addition, many risk factors have been associated with the impact of metformin on vitamin B12 levels in diabetic patients such as dose and duration where longer durations showed a greater prevalence of developing vitamin B12 deficiency. Male patients showed lower levels of vitamin B12 compared to females. Black race showed a lower prevalence of vitamin B12 deficiency in metformin-treated patients. Moreover, chronic diseases including T2DM, hyperlipidemia, coronary artery disease, polycystic ovary disease (PCOD), obesity, and metformin therapy were significantly associated with increased risk of vitamin B12 deficiency.
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Affiliation(s)
- Mazhar Salim Al Zoubi
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Rasha Al Kreasha
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Sarah Aqel
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Ahmad Saeed
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Ahmad R Al-Qudimat
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Raed M Al-Zoubi
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, 3050, Doha, Qatar.
- Department of Biomedical Sciences, College of Health Sciences, QU-Health, Qatar University, Doha, 2713, Qatar.
- Department of Chemistry, Jordan University of Science and Technology, P.O.Box 3030, Irbid, 22110, Jordan.
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Sathienluckana T, Palapinyo S, Yotsombut K, Wanothayaroj E, Sithinamsuwan P, Suksomboon N. Expert consensus guidelines for community pharmacists in the management of diabetic peripheral neuropathy with a combination of neurotropic B vitamins. J Pharm Policy Pract 2024; 17:2306866. [PMID: 38333576 PMCID: PMC10851824 DOI: 10.1080/20523211.2024.2306866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
This consensus guidance is for community pharmacists in diabetic peripheral neuropathy (DPN) management with a combination of neurotropic B vitamins. A multidisciplinary team including endocrinology, neurology, and pharmacy from Thailand discussed and aligned the practical scheme of DPN management in the community pharmacy setting, using the literature review and having face-to-face meeting. Five major statements have been endorsed as consensus recommendations for DPN care with strong acknowledgment. The aims of DPN management included reducing symptoms and the risk of complications, minimising adverse reactions from treatment regimens, and improving patients' knowledge and adherence to the treatment strategies. An initial screening process using a 7 items interview of Douleur Neuropathique 4 (DN4) questionnaire should be implemented to identify patients at risk of developing DPN. Subsequently, pharmacologic, and non-pharmacologic treatment should be employed based on patient-centered care. An interesting approach is combination of neurotropic B vitamins, which may be used as monotherapy or combination therapy to control DPN symptoms. The combined therapy potentially exhibits a synergistic effect and improves patient adherence. The consensus would be further considered in context of harmonisation of routine practice and country requirements.
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Affiliation(s)
| | - Sirinoot Palapinyo
- Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Kitiyot Yotsombut
- Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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Zhu J, Hu Z, Luo Y, Liu Y, Luo W, Du X, Luo Z, Hu J, Peng S. Diabetic peripheral neuropathy: pathogenetic mechanisms and treatment. Front Endocrinol (Lausanne) 2024; 14:1265372. [PMID: 38264279 PMCID: PMC10803883 DOI: 10.3389/fendo.2023.1265372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 12/14/2023] [Indexed: 01/25/2024] Open
Abstract
Diabetic peripheral neuropathy (DPN) refers to the development of peripheral nerve dysfunction in patients with diabetes when other causes are excluded. Diabetic distal symmetric polyneuropathy (DSPN) is the most representative form of DPN. As one of the most common complications of diabetes, its prevalence increases with the duration of diabetes. 10-15% of newly diagnosed T2DM patients have DSPN, and the prevalence can exceed 50% in patients with diabetes for more than 10 years. Bilateral limb pain, numbness, and paresthesia are the most common clinical manifestations in patients with DPN, and in severe cases, foot ulcers can occur, even leading to amputation. The etiology and pathogenesis of diabetic neuropathy are not yet completely clarified, but hyperglycemia, disorders of lipid metabolism, and abnormalities in insulin signaling pathways are currently considered to be the initiating factors for a range of pathophysiological changes in DPN. In the presence of abnormal metabolic factors, the normal structure and function of the entire peripheral nervous system are disrupted, including myelinated and unmyelinated nerve axons, perikaryon, neurovascular, and glial cells. In addition, abnormalities in the insulin signaling pathway will inhibit neural axon repair and promote apoptosis of damaged cells. Here, we will discuss recent advances in the study of DPN mechanisms, including oxidative stress pathways, mechanisms of microvascular damage, mechanisms of damage to insulin receptor signaling pathways, and other potential mechanisms associated with neuroinflammation, mitochondrial dysfunction, and cellular oxidative damage. Identifying the contributions from each pathway to neuropathy and the associations between them may help us to further explore more targeted screening and treatment interventions.
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Affiliation(s)
- Jinxi Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ziyan Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- The Second Clinical Medical College of Nanchang University, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yifan Luo
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yinuo Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wei Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Du
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhenzhong Luo
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jialing Hu
- Department of Emergency Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Shengliang Peng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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10
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Khan Z, Mehan S, Saifi MA, Das Gupta G, Narula AS, Kalfin R. Proton Pump Inhibitors and Cognitive Health: Review on Unraveling the Dementia Connection and Co-morbid Risks. Curr Alzheimer Res 2024; 20:739-757. [PMID: 38424433 PMCID: PMC11107432 DOI: 10.2174/0115672050289946240223050737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 03/02/2024]
Abstract
Dementia, an international health issue distinguished by the impairment of daily functioning due to cognitive decline, currently affects more than 55 million people worldwide, with the majority residing in low-income and middle-income countries. Globally, dementia entails significant economic burdens in 2019, amounting to a cost of 1.3 trillion US dollars. Informal caregivers devote considerable hours to providing care for those affected. Dementia imposes a greater caregiving and disability-adjusted life-year burden on women. A recent study has established a correlation between prolonged Proton Pump Inhibitor (PPI) usage and dementia, in addition to other neurodegenerative conditions. PPIs are frequently prescribed to treat peptic ulcers and GERD (gastroesophageal reflux disease) by decreasing stomach acid secretion. They alleviate acid-related symptoms through the inhibition of acid-secreting H+-K+ ATPase. In a number of observational studies, cognitive decline and dementia in the elderly have been linked to the use of PPIs. The precise mechanism underlying this relationship is unknown. These drugs might also alter the pH of brain cells, resulting in the accumulation of amyloid-beta (Aβ) peptides and the development of Alzheimer's disease (AD). Despite the compelling evidence supporting the association of PPIs with dementia, the results of studies remain inconsistent. The absence of a correlation between PPI use and cognitive decline in some studies emphasizes the need for additional research. Chronic PPI use can conceal underlying conditions, including cancer, celiac disease, vitamin B12 deficiency, and renal injury, highlighting dementia risk and the need for further investigations on cognitive health.
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Affiliation(s)
- Zuber Khan
- Division of Neuroscience, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India (Affiliated to IK Gujral Punjab Technical University), Jalandhar, Punjab, 144603, India;
| | - Sidharth Mehan
- Division of Neuroscience, Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India (Affiliated to IK Gujral Punjab Technical University), Jalandhar, Punjab, 144603, India;
| | - Mohd. Anas Saifi
- Department of Medical Elementology and Toxicology, School of Chemical and Life Sciences, Jamia Hamdard, New Delhi-110062, India;
| | - Ghanshyam Das Gupta
- Department of Pharmaceutics, ISF College of Pharmacy, Moga, Punjab, India (Affiliated to IK Gujral Punjab Technical University), Jalandhar, Punjab, 144603, India;
| | - Acharan S. Narula
- Narula Research, LLC, 107 Boulder Bluff, Chapel Hill, NC 27516, USA;
| | - Reni Kalfin
- Institute of Neurobiology, Bulgarian Academy of Sciences, Acad. G. Bonchev St., Block 23, Sofia 1113, Bulgaria;
- Department of Healthcare, South-West University “NeofitRilski”, Ivan Mihailov St. 66, Blagoevgrad 2700, Bulgaria
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11
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Bhatnagar MS, Choudhari S, Pawar D, Sharma A. Long-Term Use of Proton-Pump Inhibitors: Unravelling the Safety Puzzle. Cureus 2024; 16:e52773. [PMID: 38389608 PMCID: PMC10882567 DOI: 10.7759/cureus.52773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
Globally, over 25% of the population suffers from acid-related disorders such as dyspepsia or gastroesophageal reflux disease (GERD), and around 7.6% of Indians report having GERD symptoms on a frequent enough basis to warrant a diagnosis. Over the past three decades, proton-pump inhibitors (PPIs) have been the mainstay of medical therapy for acid-peptic diseases like GERD, etc. Additionally, they are frequently prescribed for prophylactic purposes and in conjunction with non-steroidal anti-inflammatory drugs. PPIs are generally prescribed for four to eight weeks. However, it may be prescribed for patients with comorbidities and multiple medications for a longer period of time. While this remains true in terms of effectiveness, concerns have been raised about the safety of long-term PPI use and the serious adverse effects that may result. Some of the observational and population-based cohort studies have shown an association between long-term use of PPIs and an increased risk of pneumonia, major cardiovascular events, dementia, vitamin B12 deficiency, bone fractures, gastric cancer, and kidney injury, among others. This review analyzes the clinical data supporting the long-term use of PPIs and takes a deep dive into whether these several emerging long-term concerns apply to the currently available PPIs in India. We have summarized a vast array of studies, including randomized trials, cohort studies, and meta-analyses, that report low or high incidences of major health risks linked with PPIs and have assessed their appropriateness over a given period.
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Marchesi N, Fahmideh F, Pascale A, Allegri M, Govoni S. Neuropathic Pain in Aged People: An Unresolved Issue Open to Novel Drug Approaches, Focusing on Painful Diabetic Neuropathy. Curr Neuropharmacol 2024; 22:53-64. [PMID: 37550909 DOI: 10.2174/1570159x21666230807103642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 08/09/2023] Open
Abstract
A majority of older patients suffer from neuropathic pain (NP) that significantly alters their daily activities and imposes a significant burden on health care. Multiple comorbidities and the risk of polypharmacy in the elderly make it challenging to determine the appropriate drug, dosage, and maintenance of therapy. Age-dependent processes play a contributing role in neuropathy given that diabetic neuropathy (DN) is the most common form of neuropathy. This narrative review is mainly focused on the drug treatment approach for neuropathy-associated pain in aged people including both drugs and dietary supplements, considering the latter as add-on mechanism-based treatments to increase the effectiveness of usual treatments by implementing their activity or activating other analgesic pathways. On one hand, the limited clinical studies assessing the effectiveness and the adverse effects of existing pain management options in this age segment of the population (> 65), on the other hand, the expanding global demographics of the elderly contribute to building up an unresolved pain management problem that needs the attention of healthcare providers, researchers, and health authorities as well as the expansion of the current therapeutic options.
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Affiliation(s)
- Nicoletta Marchesi
- Department of Drug Sciences, Section of Pharmacology, University of Pavia, Pavia, Italy
| | - Foroogh Fahmideh
- Department of Drug Sciences, Section of Pharmacology, University of Pavia, Pavia, Italy
| | - Alessia Pascale
- Department of Drug Sciences, Section of Pharmacology, University of Pavia, Pavia, Italy
| | - Massimo Allegri
- Ensemble Hospitalier de la Cote - Centre Lemanique d'antalgie et Neuromodulation, Morges, Switzerland
| | - Stefano Govoni
- Department of Drug Sciences, Section of Pharmacology, University of Pavia, Pavia, Italy
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Lee I, Jo JW, Woo HJ, Suk KT, Lee SS, Kim BS. Proton pump inhibitors increase the risk of carbapenem-resistant Enterobacteriaceae colonization by facilitating the transfer of antibiotic resistance genes among bacteria in the gut microbiome. Gut Microbes 2024; 16:2341635. [PMID: 38634770 PMCID: PMC11028007 DOI: 10.1080/19490976.2024.2341635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) pose a global health threat; however, there is still limited understanding of the risk factors and underlying mechanisms of CRE colonization in the gut microbiome. We conducted a matched case-control study involving 282 intensive care unit patients to analyze influencing covariates on CRE colonization. Subsequently, their effects on the gut microbiome were analyzed in a subset of 98 patients (47 CRE carriers and 51 non-CRE carriers) using whole metagenome sequences. The concomitant use of proton pump inhibitors (PPIs) and antibiotics was a significant risk factor for CRE colonization. The gut microbiome differed according to PPI administration, even within the CRE and non-CRE groups. Moreover, the transfer of mobile genetic elements (MGEs) harboring carbapenem resistance genes (CRGs) between bacteria was higher in the PPI-treated group than in the PPI-not-treated group among CRE carriers. The concomitant use of PPIs and antibiotics significantly alters the gut microbiome and increases the risk of CRE colonization by facilitating the transfer of CRGs among bacteria of the gut microbiome. Based on these findings, improved stewardship of PPIs as well as antibiotics can provide strategies to reduce the risk of CRE colonization, thereby potentially improving patient prognosis.
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Affiliation(s)
- Imchang Lee
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, Republic of Korea
- The Korean Institute of Nutrition, Hallym University, Chuncheon, Republic of Korea
| | - Jae-Won Jo
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, Republic of Korea
- The Korean Institute of Nutrition, Hallym University, Chuncheon, Republic of Korea
| | - Heung-Jeong Woo
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
| | - Ki Tae Suk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Republic of Korea
| | - Seung Soon Lee
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Bong-Soo Kim
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, Republic of Korea
- The Korean Institute of Nutrition, Hallym University, Chuncheon, Republic of Korea
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14
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Eduin B, Roubille C, Badiou S, Cristol JP, Fesler P. Association between Elevated Plasma Vitamin B12 and Short-Term Mortality in Elderly Patients Hospitalized in an Internal Medicine Unit. Int J Clin Pract 2023; 2023:6652671. [PMID: 38146346 PMCID: PMC10749720 DOI: 10.1155/2023/6652671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/14/2023] [Accepted: 11/25/2023] [Indexed: 12/27/2023] Open
Abstract
Background The prognostic value of vitamin B12 blood levels remains controversial. An association between elevated vitamin B12 and mortality has been reported, particularly among elderly patients with cancers and liver or blood diseases. The present study explored the relationship between mortality and elevated vitamin B12 levels in a population of unscheduled inpatients in an internal medicine unit. Methods This retrospective observational analysis was conducted between August 2014 and December 2018. We compared 165 patients with elevated plasma vitamin B12 levels (>600 pmol/l) with a random sample of 165 patients with normal B12 levels who were hospitalized during the same period. Demographic, clinical, and biological characteristics were assessed during hospitalization. The primary endpoint was all-cause death at 1 year. Results Patients with elevated B12 were younger, with a lower body mass index and lower plasma albumin than those with normal B12 (75 ± 16 years vs 79 ± 13 years, p = 0.047; 23 ± 5 vs 26 ± 7 kg/m2, p < 0.001; and 33 ± 5 vs 35 ± 5 g/l, p < 0.001, respectively). The prevalence of auto-immune disease and referral from an intensive care unit was higher among patients with elevated B12 (11% vs 5%, p = 0.043 and 36% vs 10%, p < 0.001, respectively). After 1 year of follow-up, 64 (39%) patients with elevated B12 had died compared to 43 (26%) patients with normal B12 (p = 0.018). Multivariate analysis using the Cox proportional hazards regression model adjusted for age, gender, body mass index, intensive care unit hospitalization, albumin level, and the presence of solid cancer or autoimmune disease revealed elevated B12 to be associated with a significant risk of death in the first year of follow-up (hazard ratio: 1.71 [1.08-2.7], p = 0.022). Conclusion Elevated B12 is an early warning indicator of increased short-term mortality, such as independently of age, cancer, or comorbidities, in patients hospitalized in an internal medicine department.
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Affiliation(s)
- Benjamin Eduin
- Department of Internal Medicine, University Hospital of Montpellier, Montpellier, France
| | - Camille Roubille
- Department of Internal Medicine, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital of Montpellier, Montpellier, France
| | - Stéphanie Badiou
- PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital of Montpellier, Montpellier, France
- Department of Biochemistry and Hormonology, University Hospital of Montpellier, Montpellier, France
| | - Jean Paul Cristol
- PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital of Montpellier, Montpellier, France
- Department of Biochemistry and Hormonology, University Hospital of Montpellier, Montpellier, France
| | - Pierre Fesler
- Department of Internal Medicine, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, University Hospital of Montpellier, Montpellier, France
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15
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Fekete M, Lehoczki A, Tarantini S, Fazekas-Pongor V, Csípő T, Csizmadia Z, Varga JT. Improving Cognitive Function with Nutritional Supplements in Aging: A Comprehensive Narrative Review of Clinical Studies Investigating the Effects of Vitamins, Minerals, Antioxidants, and Other Dietary Supplements. Nutrients 2023; 15:5116. [PMID: 38140375 PMCID: PMC10746024 DOI: 10.3390/nu15245116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Cognitive impairment and dementia are burgeoning public health concerns, especially given the increasing longevity of the global population. These conditions not only affect the quality of life of individuals and their families, but also pose significant economic burdens on healthcare systems. In this context, our comprehensive narrative review critically examines the role of nutritional supplements in mitigating cognitive decline. Amidst growing interest in non-pharmacological interventions for cognitive enhancement, this review delves into the efficacy of vitamins, minerals, antioxidants, and other dietary supplements. Through a systematic evaluation of randomized controlled trials, observational studies, and meta-analysis, this review focuses on outcomes such as memory enhancement, attention improvement, executive function support, and neuroprotection. The findings suggest a complex interplay between nutritional supplementation and cognitive health, with some supplements showing promising results and others displaying limited or context-dependent effectiveness. The review highlights the importance of dosage, bioavailability, and individual differences in response to supplementation. Additionally, it addresses safety concerns and potential interactions with conventional treatments. By providing a clear overview of current scientific knowledge, this review aims to guide healthcare professionals and researchers in making informed decisions about the use of nutritional supplements for cognitive health.
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Affiliation(s)
- Mónika Fekete
- Department of Public Health, Faculty of Medicine, Semmelweis University, 1089 Budapest, Hungary; (M.F.); (S.T.)
| | - Andrea Lehoczki
- National Institute for Haematology and Infectious Diseases, Department of Haematology and Stem Cell Transplantation, South Pest Central Hospital, 1097 Budapest, Hungary;
| | - Stefano Tarantini
- Department of Public Health, Faculty of Medicine, Semmelweis University, 1089 Budapest, Hungary; (M.F.); (S.T.)
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Department of Health Promotion Sciences, College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Peggy and Charles Stephenson Oklahoma Cancer Center, Oklahoma City, OK 73104, USA
| | - Vince Fazekas-Pongor
- Department of Public Health, Faculty of Medicine, Semmelweis University, 1089 Budapest, Hungary; (M.F.); (S.T.)
| | - Tamás Csípő
- Department of Public Health, Faculty of Medicine, Semmelweis University, 1089 Budapest, Hungary; (M.F.); (S.T.)
| | - Zoltán Csizmadia
- Faculty of Health Sciences, University of Pécs, 7621 Pécs, Hungary;
| | - János Tamás Varga
- Department of Pulmonology, Semmelweis University, 1083 Budapest, Hungary
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16
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Djukic M, Krull J, Urbanczyk P, Nau R. [Geriatric traumatological rounds in a primary care hospital]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:821-825. [PMID: 37270729 PMCID: PMC10239549 DOI: 10.1007/s00113-023-01338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/05/2023]
Abstract
Geriatric traumatological rounds (GTR) with representatives of several disciplines are a challenge in the setting of primary care hospitals with limited resources. The GTR were started with only an experienced traumatologist and a geriatrician in 2019. Routine quality control data showed a reduction of the frequency of cardiac failure and mortality after the start of the GTR. Therefore, even the minimum variant of GTR with the focus on the differential diagnosis of falls and adequate drug treatment appears to be beneficial for the patient. Special attention is given to the medical treatment of cardiac failure, pulmonary diseases, osteoporosis, psychiatric disorders and anemia. Vitamin B12 and folate deficiency are substituted. When anticoagulants or platelet aggregation inhibitors are indicated, they are resumed early. Potentially inadequate drugs for older patients are avoided. Doses of many drugs used in geriatric patients must be adjusted to a reduced renal function often present in old age. Frequent electrolyte abnormalities are diagnosed and adequately treated.
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Affiliation(s)
- Marija Djukic
- Klinik für Geriatrie, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Deutschland
- Institut für Neuropathologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Julia Krull
- Klinik für Unfallchirurgie und Orthopädie, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Deutschland
| | - Philipp Urbanczyk
- Klinik für Unfallchirurgie und Orthopädie, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Deutschland
| | - Roland Nau
- Klinik für Geriatrie, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Deutschland.
- Institut für Neuropathologie, Universitätsmedizin Göttingen, Göttingen, Deutschland.
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17
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Tayal R, Yasmin S, Chauhan S, Singh TG, Saini M, Shorog E, Althubyani MM, Alsaadi BH, Aljohani F, Alenazi MA, Abutaily SA, Ansari MY. Are Proton Pump Inhibitors Contributing in Emerging New Hypertensive Population? Pharmaceuticals (Basel) 2023; 16:1387. [PMID: 37895858 PMCID: PMC10609986 DOI: 10.3390/ph16101387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Balancing the therapeutic advantages of a medicine with its possible risks and side effects is an important part of medical practice and drug regulation. When a drug is designed to treat a particular disease or medical condition ends up causing additional risks or side effects that lead to the development of other serious health problems, it can have detrimental consequences for patients. This article explores the correlation between persistent proton pump inhibitor (PPI) use and hypertension, a common cardiovascular ailment. While PPIs are beneficial in treating various gastrointestinal problems, their availability without a prescription has resulted in self-medication and long-term use without medical monitoring. Recent findings have revealed a link between long-term PPI usage and increased cardiovascular risks, particularly hypertension. This study investigates the intricate mechanisms underlying PPI's effects, focusing on potential pathways contributing to hypertension, such as endothelial dysfunction, disruption of nitric oxide bioavailability, vitamin B deficiency, hypocalcemia, and hypomagnesemia. The discussion explains how long-term PPI use can disrupt normal endothelial function, vascular control, and mineral balance, eventually leading to hypertension. The article emphasizes the significance of using PPIs with caution and ongoing research to better understand the implications of these medications on cardiovascular health.
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Affiliation(s)
- Rohit Tayal
- Chitkara College of Pharmacy, Chitkara University, Rajpura 140401, Punjab, India; (R.T.); (T.G.S.)
| | - Sabina Yasmin
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia;
| | - Samrat Chauhan
- Chitkara College of Pharmacy, Chitkara University, Rajpura 140401, Punjab, India; (R.T.); (T.G.S.)
| | - Thakur Gurjeet Singh
- Chitkara College of Pharmacy, Chitkara University, Rajpura 140401, Punjab, India; (R.T.); (T.G.S.)
| | - Monika Saini
- M.M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be) University, Mullana, Ambala 133207, Haryana, India;
- Swami Vivekanand College of Pharmacy, Ramnagar, Banur 140601, Punjab, India
| | - Eman Shorog
- Clinical Pharmacy Department, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia;
| | - Maryam M. Althubyani
- Department of Clinical Services, Pharmaceutical Care Services, King Salman Medical City, Ministry of Health MOH, Al Madinah Al Munawwarah 11176, Saudi Arabia; (M.M.A.); (B.H.A.)
| | - Baiaan H. Alsaadi
- Department of Clinical Services, Pharmaceutical Care Services, King Salman Medical City, Ministry of Health MOH, Al Madinah Al Munawwarah 11176, Saudi Arabia; (M.M.A.); (B.H.A.)
| | - Fatimah Aljohani
- Prince Sultan Armed Forces Hospital, Al Madenah Al Monwarah 42375, Saudi Arabia;
| | - Maram A. Alenazi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Ministry of Health (MOH), Hail 55471, Saudi Arabia;
| | - Sarah A. Abutaily
- Ambulatory Care Clinical, Prince Sultan Military Medical City, Riyadh 12233, Saudi Arabia;
| | - Mohammad Yousuf Ansari
- M.M. College of Pharmacy, Maharishi Markandeshwar (Deemed to be) University, Mullana, Ambala 133207, Haryana, India;
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18
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Dinesh D, Lee JS, Scott TM, Tucker KL, Palacios N. Association between Acid-Lowering Agents, Metformin, and Vitamin B12 among Boston-Area Puerto Ricans. J Nutr 2023; 153:2380-2388. [PMID: 37302714 PMCID: PMC10447618 DOI: 10.1016/j.tjnut.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Vitamin B12 involves several physiological functions, and malabsorption is reported with medication use. OBJECTIVES Studies have reported an inverse association between the use of metformin or acid-lowering agents (ALAs), such as proton pump inhibitors, histamine 2 receptor antagonists, and blood vitamin B12 concentration, because of malabsorption. The concomitant use of these medications is underreported. We sought to examine these associations in a cohort of Boston-area Puerto Rican adults. METHODS This analysis was conducted within the Boston Puerto Rican Health Study (BPRHS), an ongoing longitudinal cohort that enrolled 1499 Puerto Rican adults aged 45-75 y at baseline. Our study comprised 1428, 1155, and 782 participants at baseline, wave2 (2.2 y from baseline), and wave3 (6.2 y from baseline), respectively. Covariate-adjusted linear and logistic regression was used to examine the association between baseline medication use and vitamin B12 concentration or deficiency (vitamin B12 <148 pmol/L or methylmalonic acid >271 nmol/L), and long-term medication use (continuous use for ∼6.2 y) and wave3 vitamin B12 concentration and deficiency. Sensitivity analyses were done to examine these associations in vitamin B12 supplement users. RESULTS At baseline, we observed an association between metformin use (β = -0.069; P = 0.03) and concomitant ALA and metformin use (β = -0.112; P = 0.02) and vitamin B12 concentration, but not a deficiency. We did not observe associations between ALA, proton pump inhibitors, or histamine 2 receptor antagonists, individually, with vitamin B12 concentration or deficiency. CONCLUSIONS These results suggest an inverse relationship between metformin, concomitant ALA, metformin use, and serum vitamin B12 concentration.
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Affiliation(s)
- Deepika Dinesh
- Center for Population Health, University of Massachusetts Lowell, Lowell, MA, United States; Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell, Lowell, MA, United States.
| | - Jong Soo Lee
- Center for Population Health, University of Massachusetts Lowell, Lowell, MA, United States; Department of Mathematics and Statistics, University of Massachusetts Lowell, Lowell, MA, United States
| | - Tammy M Scott
- Center for Population Health, University of Massachusetts Lowell, Lowell, MA, United States; Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States; Department of Psychiatry, School of Medicine, Tufts University, Boston, MA, United States
| | - Katherine L Tucker
- Center for Population Health, University of Massachusetts Lowell, Lowell, MA, United States; Department of Biomedical and Nutritional Sciences, University of Massachusetts Lowell, Lowell, MA, United States
| | - Natalia Palacios
- Center for Population Health, University of Massachusetts Lowell, Lowell, MA, United States; Department of Public Health, University of Massachusetts Lowell, Lowell, MA, United States; Department of Nutrition, Harvard University School of Public Health, Boston, MA, United States; Department of Veterans Affairs, Geriatric Research Education Clinical Center, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, United States.
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19
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Chen M, Shu Y, Li Q, Kang Z, Liu T, Zhou H, Huang W, Zhang W. Bacteroides ovatus accelerates metformin-induced vitamin B12 deficiency in type 2 diabetes patients by accumulating cobalamin. NPJ Biofilms Microbiomes 2023; 9:51. [PMID: 37488134 PMCID: PMC10366088 DOI: 10.1038/s41522-023-00419-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023] Open
Abstract
Vitamin B12 (VB12) deficiency, which may lead to hematologic and neurologic symptoms, has been associated with metformin use, but the underlying mechanism is unclear. Here we report the B. ovatus as an effective VB12 catcher which was enriched in the type 2 diabetes patients suffered from VB12 deficiency after 3 to 6 months of metformin treatment. Colonization of B. ovatus increased the plasma levels of methylmalonic acid and homocysteine in high-fat diet (HFD)-fed mice treated with metformin, and compromised the efficacy of metformin against the HFD-induced metabolic disorders. Mechanistically, metformin increased the intracellular accumulation of VB12 in B. ovatus via btuB upregulation and promoted ATP production for energy-dependent translocation of VB12 transporters at the inner membrane, leading to an enhanced colonization of B. ovatus to compete for VB12 with hosts and subsequently an aggravated VB12 deficiency in the host. Our findings illustrate a previously unappreciated mechanism of metformin leads to host VB12 deficiency by acting directly on gut bacteria to increase their VB12 uptake and consumption, and suggest that inter-host-microbe competition for nutrients may broadly impact human health and drug safety.
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Affiliation(s)
- Manyun Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, P. R. China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, P. R. China
- National Clinical Research Center for Geriatric Disorders, Changsha, P. R. China
| | - Yan Shu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, P. R. China
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland at Baltimore, Baltimore, MD, USA
| | - Qing Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, P. R. China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, P. R. China
- National Clinical Research Center for Geriatric Disorders, Changsha, P. R. China
| | - Zhiqiang Kang
- Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou University, Zhengzhou, P. R. China
| | - Tao Liu
- Shenzhen Center for Chronic Disease Control and Prevention, Shenzhen, P. R. China
| | - Honghao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, P. R. China
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, P. R. China
- National Clinical Research Center for Geriatric Disorders, Changsha, P. R. China
| | - Weihua Huang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, P. R. China.
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, P. R. China.
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, P. R. China.
- National Clinical Research Center for Geriatric Disorders, Changsha, P. R. China.
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, P. R. China.
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, Changsha, P. R. China.
- Engineering Research Center of Applied Technology of Pharmacogenomics, Ministry of Education, Changsha, P. R. China.
- National Clinical Research Center for Geriatric Disorders, Changsha, P. R. China.
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20
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Liu Z, Jia X, Wu P, Wu B, Pan Y, Zhong S, Xiao L, Song Y, Hu J, Zhou K. PMAT variant rs3889348 is associated with metformin-induced gastrointestinal among Chinese Type 2 diabetes patients. Pharmacogenomics 2023; 24:551-560. [PMID: 37458617 DOI: 10.2217/pgs-2023-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Abstract
Aim: This study examined intronic gene variants for their association with metformin intolerance in a Chinese population, focusing on the plasma monoamine transporter (PMAT) cis-protein expression quantitative trait loci (cis-eQTL) variant rs3889348. Methods: We recruited Type 2 diabetes patients from two hospitals and identified 111 metformin-intolerant patients using a questionnaire, and selected 206 metformin-tolerant patients from 2180 Type 2 diabetes mellitus patients. Genetic testing revealed an association between adverse gastrointestinal (GI) effects and SLC22A1 and PMAT. Results: The single-nucleotide polymorphism rs3889348 is associated with metformin-induced adverse GI effects. Each additional copy of the G allele increases the score by 5.23 (95% CI: 1.82-8.64; p = 0.003). Patients taking more transporter inhibitors were more likely to respond to metformin-induced GI intolerance (p = 0.042). Conclusion: PMAT cis-eQTL rs3889348 was significantly associated with metformin-induced adverse GI effects.
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Affiliation(s)
- Ziqing Liu
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 10140, China
| | - Xiao Jia
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy & Tianjin Key Laboratory of Molecular Drug Research, Nankai University, Tianjin, 300000, China
| | - Peng Wu
- Guangzhou Laboratory, Guangdong Province, China
| | - Benrui Wu
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 10140, China
- National Laboratory of Biomacromolecules, Institute of Biophysics Chinese Academy of Sciences, Beijing, 100101, China
| | - Ying Pan
- The first people's hospital of Kunshan, Jiangsu Province, China
| | - Shao Zhong
- The first people's hospital of Kunshan, Jiangsu Province, China
| | - Luhua Xiao
- Kunshan community health service center in Bailu, Jiangsu Province, China
| | - Yuehong Song
- Kunshan community health service center in Zhenchuan, Jiangsu Province, China
| | - Jinbo Hu
- Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kaixin Zhou
- Guangzhou Laboratory, Guangdong Province, China
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21
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Schleicher E, Didangelos T, Kotzakioulafi E, Cegan A, Peter A, Kantartzis K. Clinical Pathobiochemistry of Vitamin B 12 Deficiency: Improving Our Understanding by Exploring Novel Mechanisms with a Focus on Diabetic Neuropathy. Nutrients 2023; 15:nu15112597. [PMID: 37299560 DOI: 10.3390/nu15112597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/27/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
Vitamin B12 (B12) is an essential cofactor of two important biochemical pathways, the degradation of methylmalonic acid and the synthesis of methionine from homocysteine. Methionine is an important donor of methyl groups for numerous biochemical reactions, including DNA synthesis and gene regulation. Besides hematological abnormalities (megaloblastic anemia or even pancytopenia), a deficiency in B12 may cause neurological symptoms, including symptoms resembling diabetic neuropathy. Although extensively studied, the underlining molecular mechanism for the development of diabetic peripheral neuropathy (DPN) is still unclear. Most studies have found a contribution of oxidative stress in the development of DPN. Detailed immunohistochemical investigations in sural nerve biopsies obtained from diabetic patients with DPN point to an activation of inflammatory pathways induced via elevated advanced glycation end products (AGE), ultimately resulting in increased oxidative stress. Similar results have been found in patients with B12 deficiency, indicating that the observed neural changes in patients with DPN might be caused by cellular B12 deficiency. Since novel results show that B12 exerts intrinsic antioxidative activity in vitro and in vivo, B12 may act as an intracellular, particularly as an intramitochondrial, antioxidant, independent from its classical, well-known cofactor function. These novel findings may provide a rationale for the use of B12 for the treatment of DPN, even in subclinical early states.
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Affiliation(s)
- Erwin Schleicher
- Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, University Hospital of Tübingen, 72076 Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich, German Center for Diabetes Research (DZD), 72076 Tübingen, Germany
- German Center for Diabetes Research (DZD e.V.), 85764 Neuherberg, Germany
| | - Triantafyllos Didangelos
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, "AHEPA" Hospital, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece
| | - Evangelia Kotzakioulafi
- Diabetes Center, 1st Propaedeutic Department of Internal Medicine, Medical School, "AHEPA" Hospital, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece
| | - Alexander Cegan
- Department of Biological and Biochemical Sciences, Faculty of Chemical Technology, University of Pardubice, 53210 Pardubice, Czech Republic
| | - Andreas Peter
- Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, University Hospital of Tübingen, 72076 Tübingen, Germany
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich, German Center for Diabetes Research (DZD), 72076 Tübingen, Germany
- German Center for Diabetes Research (DZD e.V.), 85764 Neuherberg, Germany
| | - Konstantinos Kantartzis
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich, German Center for Diabetes Research (DZD), 72076 Tübingen, Germany
- German Center for Diabetes Research (DZD e.V.), 85764 Neuherberg, Germany
- Department of Internal Medicine IV, Division of Endocrinology, Diabetology and Nephrology, University of Tübingen, 72076 Tübingen, Germany
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22
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Wu HHL, McDonnell T, Chinnadurai R. Physiological Associations between Vitamin B Deficiency and Diabetic Kidney Disease. Biomedicines 2023; 11:biomedicines11041153. [PMID: 37189771 DOI: 10.3390/biomedicines11041153] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/24/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
The number of people living with chronic kidney disease (CKD) is growing as our global population continues to expand. With aging, diabetes, and cardiovascular disease being major harbingers of kidney disease, the number of people diagnosed with diabetic kidney disease (DKD) has grown concurrently. Poor clinical outcomes in DKD could be influenced by an array of factors-inadequate glycemic control, obesity, metabolic acidosis, anemia, cellular senescence, infection and inflammation, cognitive impairment, reduced physical exercise threshold, and, importantly, malnutrition contributing to protein-energy wasting, sarcopenia, and frailty. Amongst the various causes of malnutrition in DKD, the metabolic mechanisms of vitamin B (B1 (Thiamine), B2 (Riboflavin), B3 (Niacin/Nicotinamide), B5 (Pantothenic Acid), B6 (Pyridoxine), B8 (Biotin), B9 (Folate), and B12 (Cobalamin)) deficiency and its clinical impact has garnered greater scientific interest over the past decade. There remains extensive debate on the biochemical intricacies of vitamin B metabolic pathways and how their deficiencies may affect the development of CKD, diabetes, and subsequently DKD, and vice-versa. Our article provides a review of updated evidence on the biochemical and physiological properties of the vitamin B sub-forms in normal states, and how vitamin B deficiency and defects in their metabolic pathways may influence CKD/DKD pathophysiology, and in reverse how CKD/DKD progression may affect vitamin B metabolism. We hope our article increases awareness of vitamin B deficiency in DKD and the complex physiological associations that exist between vitamin B deficiency, diabetes, and CKD. Further research efforts are needed going forward to address the knowledge gaps on this topic.
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Affiliation(s)
- Henry H L Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia
| | - Thomas McDonnell
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
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23
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Rossokha Z, Fishchuk L, Vorobei L, Medvedieva N, Popova O, Vershyhora V, Sheyko L, Brisevac L, Stroy D, Gorovenko N. Hyperhomocysteinemia in men and women of married couples with reproductive disorders. What is the difference? Syst Biol Reprod Med 2023; 69:75-85. [PMID: 36308028 DOI: 10.1080/19396368.2022.2124896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Hyperhomocysteinemia (HHcy) is an autosomal recessive inherited metabolic disease caused by variations in folate metabolism genes, characterized by impaired methionine metabolism and accumulation of homocysteine (Hcy) in the blood serum. It was shown that men usually have higher plasma Hcy levels than women, but have not yet assessed the leading factors of these differences, which is important for the development of personalized protocols for the prevention of folate metabolism disorders in couples with reproductive disorders. This study aimed to analyze the effect of intergenic and gene-factor interactions on the risk of developing HHcy in men and women of married couples with reproductive disorders. In our study were involved 206 married Caucasian couples (206 males and 206 females) from central regions of Ukraine with early pregnancy losses in the anamnesis. We found that the incidence of HHcy in men was significantly higher than in women. Gender differences in folic acid and vitamin B12 levels were identified. The best predictors of HHcy in men (MTRR (A66G), MTHFR (C677T), MTR (A2756G), vitamin B12 level) and in women (MTHFR (C677T), MTR (A2756G), vitamin B12 level) were selected by binary logistic regression. There was no significant difference in the distribution of genotypes by the studied gene variants when comparing men and women with HHcy. Our findings demonstrate that there is a gender difference in the development of HHcy. This difference is caused by intergenic interaction and by environmental factors, in particular, nutrition and vitamins consumption.
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Affiliation(s)
- Zoia Rossokha
- Department of genetic diagnostics, State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine.,State Institution "Reference-Centre for Molecular Diagnostic of Public Health Ministry of Ukraine", Kyiv, Ukraine
| | - Liliya Fishchuk
- Department of genetic diagnostics, State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine.,State Institution "Reference-Centre for Molecular Diagnostic of Public Health Ministry of Ukraine", Kyiv, Ukraine
| | | | - Nataliia Medvedieva
- State Institution "Reference-Centre for Molecular Diagnostic of Public Health Ministry of Ukraine", Kyiv, Ukraine
| | - Olena Popova
- State Institution "Reference-Centre for Molecular Diagnostic of Public Health Ministry of Ukraine", Kyiv, Ukraine
| | - Viktoriia Vershyhora
- State Institution "Reference-Centre for Molecular Diagnostic of Public Health Ministry of Ukraine", Kyiv, Ukraine
| | - Larysa Sheyko
- Department of genetic diagnostics, State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine.,Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Ljudmila Brisevac
- Department of genetic diagnostics, State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine.,Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Dmytro Stroy
- Department of genetic diagnostics, State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - Nataliia Gorovenko
- Department of genetic diagnostics, State Institute of Genetic and Regenerative Medicine National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine.,Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
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24
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Haines KL, Gorenshtein L, Lumpkin S, Grisel B, Gallagher S. Optimal Nutrition in the Older Adult: Beneficial Versus Ineffective Supplements. Curr Nutr Rep 2023:10.1007/s13668-023-00459-y. [PMID: 36689099 DOI: 10.1007/s13668-023-00459-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Proper nutrition in older adults is essential, as nutritional deficiencies are common in this population. This review aims to summarize the benefits and risks of nutritional supplementation in the older adult population including the efficacy of various supplements, their risks, and common drug interactions with frequently prescribed medications. RECENT FINDINGS In recent years, a growing percentage of older adults have been found to take multiple daily nutritional supplements. This population has complex nutritional needs due to the physiology of aging and the presence of comorbidities. However, many primary care providers are unaware of the benefits and drawbacks of nutritional supplementation in the elderly. This review summarizes the current literature to provide more clarity to providers on how to support this population's nutritional needs. Nutritional supplementation is essential for elderly populations who may not be able to obtain adequate nutrition from dietary sources. Supplements vary widely in efficacy and safety. As such, supplementation should be individualized and guided by a qualified healthcare provider to ensure patients receive effective, beneficial nutrition.
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Affiliation(s)
- Krista L Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | | | - Stephanie Lumpkin
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Scott Gallagher
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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25
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Yang X, Hu R, Zhu Y, Wang Z, Hou Y, Su K, He X, Song G. Meta-analysis of Serum Vitamin B12 Levels and Diabetic Retinopathy in Type 2 Diabetes. Arch Med Res 2023; 54:64-73. [PMID: 36549948 DOI: 10.1016/j.arcmed.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/19/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Previous studies have shown an association between low serum vitamin B12 levels and the risk of diabetic retinopathy (DR) in type 2 diabetes, but the conclusions from various studies were inconsistent. Therefore, we collected relevant data from various databases to perform a meta-analysis and address the inconsistencies in these studies. METHODS We searched PubMed, Embase, Cochrane Library, CNKI, Wanfang and CQVIP for eligible studies published up to April 10, 2022, and performed a meta-analysis using Stata software to assess the association between serum vitamin B12 levels and DR. RESULTS A total of 15 studies were included in this meta-analysis. Statistical analysis showed that serum vitamin B12 levels were significantly reduced in patients with type 2 diabetic retinopathy ,WMD 95% CI = -68.91 (-76.76, -61.06) (p <0.00001, I2 = 88.30%). In subgroup analyses by ethnicity, an association between low serum vitamin B12 levels and DR risk was found in East Asian, South Asian and mixed populations, but not in Caucasian populations. CONCLUSIONS This meta-analysis analyzed vitamin B12 in patients with type 2 diabetic retinopathy and emphasized the importance of monitoring serum vitamin B12 levels in patients with type 2 diabetic retinopathy, but this meta-analysis still has deficiencies and limitations, and more clinical studies are needed to confirm this conclusion in the future.
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Affiliation(s)
- Xiaoyue Yang
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Rui Hu
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Yajun Zhu
- Endocrinology Department, Hebei General Hospital, Shijiazhuang, Hebei, PR China
| | - Zhen Wang
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Yilin Hou
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Kangkang Su
- Graduate School of Hebei North University, Zhangjiakou, Hebei, PR China
| | - Xiaoyu He
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Guangyao Song
- Department of Internal Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China; Endocrinology Department, Hebei General Hospital, Shijiazhuang, Hebei, PR China; Graduate School of Hebei North University, Zhangjiakou, Hebei, PR China.
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26
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Muacevic A, Adler JR, Manoharan MP, Raja R, Jamil A, Csendes D, Gutlapalli SD, Prakash K, Desai DM, Desai A, Khan S. The Effects of Proton Pump Inhibitors in Acid Hypersecretion-Induced Vitamin B12 Deficiency: A Systematic Review (2022). Cureus 2022; 14:e31672. [PMID: 36545170 PMCID: PMC9762528 DOI: 10.7759/cureus.31672] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/19/2022] [Indexed: 11/20/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is the most common disease, for which proton pump inhibitors (PPIs) are a widely used class of drugs. Due to their efficacy and relative safety profile, PPIs are used chronically by GERD patients. Although it is a safe drug, particular attention focuses on the long-term adverse effects of PPI. The association with vitamin deficiencies has received additional focus since chronic PPI treatment increases the incidence of vitamin B12 deficiency, especially in the elderly. However, numerous studies regarding the establishment of an association between PPI and vitamin B12 status revealed conflicting results. In this systematic review, we systematically examined observational studies that focused on the impact of chronic PPI effects on vitamin B12 absorption and diagnostic biomarkers of vitamin B12 deficiency. Our review showed significant changes in diagnostic biomarkers of vitamin B12 status in long-term PPI users, including elevated homocysteine and methylmalonic acid (MMA) concentration levels defining cellular vitamin B12 deficiency. Although there is uncertainty regarding the exact mechanism, it supports the concept that long-term intake of PPI can have clinical implications for vitamins.
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27
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Achenbach P, Block F, Dafotakis M. Medikamentös-induzierte Polyneuropathien jenseits von
Chemotherapeutika und Antiinfektiva. KLIN NEUROPHYSIOL 2022. [DOI: 10.1055/a-1869-3563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Zahlreiche in der klinischen Routine eingesetzte Wirkstoffe jenseits von
Chemotherapeutika und Antiinfektiva können eine Polyneuropathie
verstärken oder hervorrufen. Kenntnis darüber, welche
Medikamente mit Polyneuropathien assoziiert sind sowie über
Risikofaktoren seitens der Patienten können die Häufigkeit
reduzieren. Bei entsprechendem Risiko sollten alternative Präparate
eingesetzt oder die Indikation zur Therapie generell überdacht
werden.
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28
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Bell DSH. Metformin-induced vitamin B12 deficiency can cause or worsen distal symmetrical, autonomic and cardiac neuropathy in the patient with diabetes. Diabetes Obes Metab 2022; 24:1423-1428. [PMID: 35491956 DOI: 10.1111/dom.14734] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/15/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Abstract
Metformin blocks the absorption of vitamin B12 through a mechanism that has not been established but could be because of interference with the calcium-dependent binding of the intrinsic factor vitamin B12 complex to the cubam receptor in the terminal ileum. The subsequent deficiency of vitamin B12 may cause or accelerate distal symmetrical and autonomic neuropathy in the patient with diabetes. Several observational studies and meta-analyses have reported a significant association between metformin utilization and vitamin B12 deficiency. Prospective studies have shown that not only do metformin utilizers have lower vitamin B12 levels but they also have higher frequencies of distal symmetrical polyneuropathy and autonomic neuropathy (including cardiac denervation, which is associated with increased incidences of cardiac arrhythmias, cardiac events and mortality). Therefore, periodic monitoring of vitamin B12 is recommended in all patients who utilize metformin, particularly if metformin has been used for over 5 years at which stage hepatic stores of vitamin B12 would probably be depleted. Factors that accelerate the loss of hepatic vitamin B12 stores are proton pump inhibitors, bariatric surgery, being elderly and having an increased turnover of red blood cells. If serum vitamin B12 levels are borderline, measurement of methylmalonic acid and homocysteine levels can detect vitamin B12 deficiency at its earliest stage. Therapies include prophylactic calcium and vitamin B12 supplements, metformin withdrawal, replenishing vitamin B12 stores with intramuscular or oral vitamin B12 therapy and regular monitoring of vitamin B12 levels and vitamin B12 supplements if metformin continues to be utilized. With adequate vitamin B12 replacement, while symptoms of neuropathy may or may not improve, objective findings of neuropathy stabilize but do not improve.
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29
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Exploration of Microneedle-assisted Skin Delivery of Cyanocobalamin formulated in Ultraflexible Lipid Vesicles. Eur J Pharm Biopharm 2022; 177:184-198. [PMID: 35787430 DOI: 10.1016/j.ejpb.2022.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/26/2022] [Accepted: 06/29/2022] [Indexed: 11/22/2022]
Abstract
Vitamin B12 (cyanocobalamin) deficiency is a widespread condition because of its different aetiologies, like malabsorption syndrome or lifestyles as strict veganism that is increasing its incidence and prevalence in developed countries. It has important haematological consequences that require pharmacological treatment. Current therapy consists of oral or parenteral supplements of cyanocobalamin; however, the oral route is discarded for malabsorption syndrome patients and the parenteral route is not well accepted generally. Topical treatments have been suggested as an alternative, but the molecular weight and hydrophilicity of cyanocobalamin limits its diffusion through the skin. Lipid vesicles can allow the transdermal absorption of molecules >500 Da. The aim of this work was to use different ultraflexible lipid vesicles (transfersomes and ethosomes) to enhance cyanocobalamin transdermal delivery. Vesicles were characterized and lyophilised for long-term stability. The ability to deliver cyanocobalamin through the skin was assessed in vitro using full-thickness porcine skin in Franz diffusion cells. As expected, the best transdermal fluxes were provided by ultraflexible vesicles, in comparison to a drug solution. Moreover, the pre-treatment of the skin with a solid microneedle array boosts the amount of drug that could potentially reach the systemic circulation.
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30
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Yu Z, Wang A, Hu C, Yu T, Chen J. Type-1 Grade 2 Multi-Focal Gastric Neuroendocrine Tumors Secondary to Chronic Autoimmune Gastritis. Front Med (Lausanne) 2022; 9:856125. [PMID: 35783638 PMCID: PMC9247202 DOI: 10.3389/fmed.2022.856125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundChronic autoimmune gastritis (CAG) refers to chronic atrophic gastritis due to autoimmunity. Loss of gastric glands in CAG results in hypergastrinemia and achlorhydria leading to Vitamin B12 deficiency and hyperplasia of G cells and enterochromaffin-like (ECL) cells. Vitamin B12 deficiency could cause pernicious anemia and subacute combined degeneration, while G cells and ECL cells hyperplasia might develop gastric neuroendocrine tumor (G-NET).Case PresentationA 35-year-old Chinese female presented with multi-focal type-1 Grade 2 (G2) NETs with a 14-year history of pernicious anemia and subacute combined degeneration.ConclusionHere, we report a rare case of a Chinese patient presenting G-NET combined with pernicious anemia and subacute combined degeneration, which are secondary to chronic autoimmune gastritis. This case also illustrates the importance of routine gastroscopy in patients with Vitamin B12 deficiency.
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Affiliation(s)
- Ziqi Yu
- Munich Medical Research School, Ludwig Maximilian University (LMU) of Munich, Munich, Germany
| | - Aiyao Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang Medical College, Jiangxi Provincial People’s Hospital, Nanchang, China
| | - Chong Hu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang Medical College, Jiangxi Provincial People’s Hospital, Nanchang, China
| | - Tao Yu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang Medical College, Jiangxi Provincial People’s Hospital, Nanchang, China
| | - Jianyong Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Nanchang Medical College, Jiangxi Provincial People’s Hospital, Nanchang, China
- *Correspondence: Jianyong Chen,
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31
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Abstract
Of the water-soluble vitamins, vitamin B12 (B12) has the lowest daily requirement. It also has several unique properties including a complex pathway for its absorption and assimilation requiring intact gastric and terminal small intestinal function, an enterohepatic pathway, and several dedicated binding proteins and chaperons. The many causes of B12 deficiency include malabsorption and defects in cellular delivery and uptake, as well as limited dietary intake. B12 is required as a cofactor for only two reactions in humans, the cytosolic methionine synthase reaction and the mitochondrial methymalonyl CoA mutase reaction. Disruption of either of these reactions gives rise to B12 deficiency. Although more common with advancing age, because of the higher prevalence of malabsorptive disorders in the elderly, B12 deficiency is widely distributed across all age groups particularly where food insecurity occurs. The consequences and severity of B12 deficiency are variable depending on the degree of deficiency and its duration. Major organ systems affected include the blood, bone marrow and nervous system. Megaloblastic anemia results from a defect in thymidine and therefore DNA synthesis in rapidly dividing cells. Nervous system involvement is varied, some of which results from defective myelin synthesis and repair. Cognitive impairment and psychosis may also occur. Diagnosis of B12 deficiency rests on clinical suspicion followed by laboratory testing, which consists of a panel of tests, that together provide clinically reliable predictive indices. B12 metabolism and deficiency is closely intertwined with folate, another B-vitamin. This chapter explores the various aspects of a unique and fascinating micronutrient.
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Affiliation(s)
- Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA, United States.
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ, United States
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32
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Guéant JL, Guéant-Rodriguez RM, Alpers DH. Vitamin B12 absorption and malabsorption. VITAMINS AND HORMONES 2022; 119:241-274. [PMID: 35337622 DOI: 10.1016/bs.vh.2022.01.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Vitamin B12 is assimilated and transported by complex mechanisms that involve three transport proteins, intrinsic factor (IF), haptocorrin (HC) and transcobalamin (TC) and their respective membrane receptors. Vitamin deficiency is mainly due to inadequate dietary intake in vegans, and B12 malabsorption is related to digestive diseases. This review explores the physiology of vitamin B12 absorption and the mechanisms and diseases that produce malabsorption. In the stomach, B12 is released from food carrier proteins and binds to HC. The degradation of HC by pancreatic proteases and the pH change trigger the transfer of B12 to IF in the duodenum. Cubilin and amnionless are the two components of the receptor that mediates the uptake of B12 in the distal ileum. Part of liver B12 is excreted in bile, and undergoes an enterohepatic circulation. The main causes of B12 malabsorption include inherited disorders (Intrinsic factor deficiency, Imerslund-Gräsbeck disease, Addison's pernicious anemia, obesity, bariatric surgery and gastrectomies. Other causes include pancreatic insufficiency, obstructive Jaundice, tropical sprue and celiac disease, bacterial overgrowth, parasitic infestations, Zollinger-Ellison syndrome, inflammatory bowel diseases, chronic radiation enteritis of the distal ileum and short bowel. The assessment of B12 deficit is recommended in the follow-up of subjects with bariatric surgery. The genetic causes of B12 malabsorption are probably underestimated in adult cases with B12 deficit. Despite its high prevalence in the general population and in the elderly, B12 malabsorption cannot be anymore assessed by the Schilling test, pointing out the urgent need for an equivalent reliable test.
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Affiliation(s)
- Jean-Louis Guéant
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France; Department of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France; Department of Hepato-Gastroenterology, University Hospital of Nancy, Nancy, France.
| | - Rosa-Maria Guéant-Rodriguez
- University of Lorraine, INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France; Department of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, Nancy, France
| | - David H Alpers
- Department of Internal Medicine, Division of Gastroenterology, Washington University School of Medicine, St Louis, MO, United States.
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Kapitonova M, Gupalo S, Alyautdin R, Ibrahim IAA, Salim N, Ahmad A, Talip SB, Nwe TM, Morokhina S. Gastroprotective effect of Berberis vulgaris on ethanol-induced gastric mucosal injury: Histopathological evaluations. AVICENNA JOURNAL OF PHYTOMEDICINE 2022; 12:30-41. [PMID: 35145893 PMCID: PMC8801213 DOI: 10.22038/ajp.2021.18113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/13/2020] [Accepted: 01/20/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Modern treatment of peptic ulcers includes antibacterial and gastroprotective medications. However, current anti-ulcer drugs possess severe side effects. Therefore, all attempts to find new effective medications free from side effects are justified. Though Berberis vulgaris is a medicinal plant commonly used for the treatment of numerous disorders, gastroprotective effect of its leaf extract was not investigated before. MATERIALS AND METHODS Gastric ulcer was modelled in Sprague-Dawley rats after treatment with B. vulgaris leaf extract containing 0.07% of alkaloids, 0.48% of flavonoids and 8.05% of tanning substances, 10 or 50 mg of dry extract/kg, changes in the stomach mucosa were assessed semi-quantitatively, and the gastric wall was evaluated for prostaglandin E2 level using ELISA and assessed histologically by calculation of the lesion index. RESULTS B. vulgaris leaf extract at the dose of 50 mg/kg reduced the macroscopic ulcer score and the microscopic lesion index, increased prostaglandin E2 concentration in the gastric wall significantly higher than atropine and B. vulgaris leaf extract 10 mg/kg. CONCLUSION The gastroprotective effect of the high dose of B. vulgaris leaf extract may be due to stimulation of prostaglandin E2 secretion in the stomach, and anti-oxidative and anti-inflammatory properties of polyphenolic complex of flavonoids and tannins present in the leaves of this plant.
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Affiliation(s)
- Marina Kapitonova
- Faculty of Medicine and Health Sciences, UNIMAS, Kota Samarahan, Sarawak, Malaysia
| | - Sergey Gupalo
- Faculty of Medicine MAHSA University, Bandar Saujana Putra, Jenjarom, Selangor, Malaysia
| | - Renad Alyautdin
- Medicinal Products Safety, Scientific Centre for Expert Evaluation of Medicinal Products, Moscow, Russia
- Department of Pharmacology, Sechenov University, Moscow, Russia
| | - Ibrahim Abdel Aziz Ibrahim
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Norita Salim
- Institute of Medical Molecular Biotechnology, and Faculty of Medicine, UiTM, Sungai Buloh, Selangor, Malaysia
| | - Azhar Ahmad
- Institute of Medical Molecular Biotechnology, and Faculty of Medicine, UiTM, Sungai Buloh, Selangor, Malaysia
| | - Saiful Bahri Talip
- Faculty of Medicine and Health Sciences, UNIMAS, Kota Samarahan, Sarawak, Malaysia
| | - Tin Moe Nwe
- Faculty of Medicine and Health Sciences, UNIMAS, Kota Samarahan, Sarawak, Malaysia
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Nutritional Management in Bariatric Surgery Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212049. [PMID: 34831805 PMCID: PMC8618972 DOI: 10.3390/ijerph182212049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 02/08/2023]
Abstract
The obesity epidemic, mainly due to lifestyle changes in recent decades, leads to serious comorbidities that reduce life expectancy. This situation is affecting the health policies of many nations around the world. Traditional measures such as diet, physical activity, and drugs are often not enough to achieve weight loss goals and to maintain the results over time. Bariatric surgery (BS) includes various techniques, which favor rapid and sustained weight loss. BS is a useful and, in most cases, the best treatment in severe and complicated obesity. In addition, it has a greater benefit/risk ratio than non-surgical traditional therapies. BS can allow the obese patient to lose weight quickly compared with traditional lifestyle changes, and with a greater probability of maintaining the results. Moreover, BS promotes improvements in metabolic parameters, even diabetes remission, and in the quality of life. These changes can lead to an increase of life expectancy by over 6 years on average. The nutrition of people before and after BS must be the subject of indications from a trained staff, and patients must be followed in the subsequent years to reduce the risk of malnutrition and the associated problems. In particular, it is still debated whether it is necessary to lose weight prior to surgery, a procedure that can facilitate the surgeon's work reducing the surgical risk, but at the same time, lengthens preparation times increasing the risks associated with concomitant pathologies. Furthermore, preventing nutritional deficiencies prior to the intervention can improve the results and reduce short- and long-term mortality.
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Selhub J, Miller JW, Troen AM, Mason JB, Jacques PF. Perspective: The High-Folate-Low-Vitamin B-12 Interaction Is a Novel Cause of Vitamin B-12 Depletion with a Specific Etiology-A Hypothesis. Adv Nutr 2021; 13:16-33. [PMID: 34634124 PMCID: PMC8803489 DOI: 10.1093/advances/nmab106] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/12/2022] Open
Abstract
Vitamin B-12 is a water-soluble vitamin that plays important roles in intermediary metabolism. Vitamin B-12 deficiency has many identifiable causes, including autoimmune and other gastrointestinal malabsorption disorders, dietary deficiency, and congenital defects in genes that are involved in vitamin B-12 trafficking and functions. Another putative cause of vitamin B-12 deficiency is the high-folate-low vitamin B-12 interaction, first suspected as the cause for observed relapse and exacerbation of the neurological symptoms in patients with pernicious anemia who were prescribed high oral doses of folic acid. We propose that this interaction is real and represents a novel cause of vitamin B-12 depletion with specific etiology. We hypothesize that excessive intake of folic acid depletes serum holotranscobalamin (holoTC), thereby decreasing active vitamin B-12 in the circulation and limiting its availability for tissues. This effect is specific for holoTC and does not affect holohaptocorrin, the inert form of serum vitamin B-12. Depletion of holoTC by folic acid in individuals with already low vitamin B-12 status further compromises the availability of vitamin B-12 coenzymes to their respective enzymes, and consequently a more pronounced state of biochemical deficiency. This hypothesis is drawn from evidence of observational and intervention studies of vitamin B-12-deficient patients and epidemiological cohorts. The evidence also suggests that, in a depleted state, vitamin B-12 is diverted to the hematopoietic system or the kidney. This most likely reflects a selective response of tissues expressing folate receptors with high affinity for unmetabolized folic acid (UMFA; e.g., hematopoietic progenitors and renal tubules) compared with those tissues (e.g., liver) that only express the reduced folate carrier, which is universally expressed but has poor affinity for UMFA. The biochemical and physiological mechanisms underlying this interaction require elucidation to clarify its potential public health significance.
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Affiliation(s)
| | | | - Aron M Troen
- School of Nutritional Sciences and Institute of Biochemistry Food Science and Nutrition, The Robert H Smith Faculty of Agriculture Food and Environment, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joel B Mason
- Tufts–USDA Human Nutrition Research Center on Aging, Boston, MA, USA
| | - Paul F Jacques
- Tufts–USDA Human Nutrition Research Center on Aging, Boston, MA, USA
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Gana W, De Luca A, Debacq C, Poitau F, Poupin P, Aidoud A, Fougère B. Analysis of the Impact of Selected Vitamins Deficiencies on the Risk of Disability in Older People. Nutrients 2021; 13:3163. [PMID: 34579039 PMCID: PMC8469089 DOI: 10.3390/nu13093163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/03/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023] Open
Abstract
Vitamin deficiencies have a serious impact on healthy aging in older people. Many age-related disorders have a direct or indirect impact on nutrition, both in terms of nutrient assimilation and food access, which may result in vitamin deficiencies and may lead to or worsen disabilities. Frailty is characterized by reduced functional abilities, with a key role of malnutrition in its pathogenesis. Aging is associated with various changes in body composition that lead to sarcopenia. Frailty, aging, and sarcopenia all favor malnutrition, and poor nutritional status is a major cause of geriatric morbidity and mortality. In the present narrative review, we focused on vitamins with a significant risk of deficiency in high-income countries: D, C, and B (B6/B9/B12). We also focused on vitamin E as the main lipophilic antioxidant, synergistic to vitamin C. We first discuss the role and needs of these vitamins, the prevalence of deficiencies, and their causes and consequences. We then look at how these vitamins are involved in the biological pathways associated with sarcopenia and frailty. Lastly, we discuss the critical early diagnosis and management of these deficiencies and summarize potential ways of screening malnutrition. A focused nutritional approach might improve the diagnosis of nutritional deficiencies and the initiation of appropriate clinical interventions for reducing the risk of frailty. Further comprehensive research programs on nutritional interventions are needed, with a view to lowering deficiencies in older people and thus decreasing the risk of frailty and sarcopenia.
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Affiliation(s)
- Wassim Gana
- Division of Geriatric Medicine, Regional University Hospital Centre, 37000 Tours, France; (F.P.); (A.A.); (B.F.)
- Geriatrics Mobile Units, Regional University Hospital Centre, 37000 Tours, France; (C.D.); (P.P.)
| | - Arnaud De Luca
- Nutrition Mobile Unit, Regional University Hospital Centre, 37000 Tours, France;
- Inserm UMR 1069, Nutrition, Croissance et Cancer, 37032 Tours, France
| | - Camille Debacq
- Geriatrics Mobile Units, Regional University Hospital Centre, 37000 Tours, France; (C.D.); (P.P.)
| | - Fanny Poitau
- Division of Geriatric Medicine, Regional University Hospital Centre, 37000 Tours, France; (F.P.); (A.A.); (B.F.)
| | - Pierre Poupin
- Geriatrics Mobile Units, Regional University Hospital Centre, 37000 Tours, France; (C.D.); (P.P.)
| | - Amal Aidoud
- Division of Geriatric Medicine, Regional University Hospital Centre, 37000 Tours, France; (F.P.); (A.A.); (B.F.)
- Geriatrics Mobile Units, Regional University Hospital Centre, 37000 Tours, France; (C.D.); (P.P.)
| | - Bertrand Fougère
- Division of Geriatric Medicine, Regional University Hospital Centre, 37000 Tours, France; (F.P.); (A.A.); (B.F.)
- Education, Ethics, Health (EA 7505), Tours University, 37000 Tours, France
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Khairan P, Sobue T, Eshak ES, Zha L, Kitamura T, Sawada N, Iwasaki M, Inoue M, Yamaji T, Shimazu T, Iso H, Tsugane S. Association of dietary intakes of vitamin B12, vitamin B6, folate, and methionine with the risk of esophageal cancer: the Japan Public Health Center-based (JPHC) prospective study. BMC Cancer 2021; 21:982. [PMID: 34470601 PMCID: PMC8411535 DOI: 10.1186/s12885-021-08721-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/18/2021] [Indexed: 01/12/2023] Open
Abstract
Background B vitamins and methionine are essential substrates in the one-carbon metabolism pathway involved in DNA synthesis and methylation. They may have essential roles in cancer development. We aimed to evaluate the associations of dietary intakes of vitamin B12, vitamin B6, folate, and methionine with the risk of esophageal cancer (EC) using data from the Japan Public Health Center-based Prospective Study. Methods We included 87,053 Japanese individuals who completed a food frequency questionnaire and were followed up from 1995–1998 to 2013 and 2015. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated by Cox proportional-hazard regression across quintiles of dietary intakes of B vitamins and methionine. Results After 1,456,678 person-years of follow-up, 427 EC cases were documented. The multivariable HR (95% CI) of incident EC in the highest versus lowest quintile of dietary intake of vitamin B12 was 1.75 (1.13–2.71; p-trend=0.01). Stratification analysis based on alcohol consumption showed that higher dietary intakes of vitamin B12 and methionine were associated with an increased risk of EC among never-drinkers; HRs (95% CIs) were 2.82 (1.18–6.74; p-trend=0.009; p-interaction=0.18) and 3.45 (1.32–9.06; p-trend=0.003; p-interaction 0.02) for vitamin B12 and methionine, respectively. Meanwhile, there was no association between vitamin B12 and methionine intake with the risk of EC among drinkers. There were no associations between dietary intake of folate or vitamin B6 and the risk of EC. Conclusion Dietary intake of vitamin B12 was positively associated with the risk of EC in the Japanese population. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08721-8.
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Affiliation(s)
- Paramita Khairan
- Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.,Department of Internal Medicine, Faculty of Medicine, University of Muhammadiyah, Jakarta, Indonesia
| | - Tomotaka Sobue
- Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Ehab Salah Eshak
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.,Department of Public Health and Preventive Medicine, Faculty of Medicine, Minia University, Minya, Egypt
| | - Ling Zha
- Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Norie Sawada
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Chuo-ku Tokyo, 104-0045, Japan
| | - Motoki Iwasaki
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Chuo-ku Tokyo, 104-0045, Japan
| | - Manami Inoue
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Chuo-ku Tokyo, 104-0045, Japan
| | - Taiki Yamaji
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Chuo-ku Tokyo, 104-0045, Japan
| | - Taichi Shimazu
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Chuo-ku Tokyo, 104-0045, Japan
| | - Hiroyasu Iso
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Shoichiro Tsugane
- Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Chuo-ku Tokyo, 104-0045, Japan
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Buda V, Prelipcean A, Cristescu C, Roja A, Dalleur O, Andor M, Danciu C, Ledeti A, Dehelean CA, Cretu O. Prescription Habits Related to Chronic Pathologies of Elderly People in Primary Care in the Western Part of Romania: Current Practices, International Recommendations, and Future Perspectives Regarding the Overuse and Misuse of Medicines. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137043. [PMID: 34280980 PMCID: PMC8297022 DOI: 10.3390/ijerph18137043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022]
Abstract
The European Commission’s 2019 report regarding the state of health profiles highlighted the fact that Romania is among the countries with the lowest life expectancy in the European Union. Therefore, the objectives of the present study were to assess the current prescription habits of general physicians in Romania related to medicines taken by the elderly population for chronic conditions in both urban and rural setting and to discuss/compare these practices with the current international recommendations for the elderly (American—Beers 2019 criteria and European—STOPP/START v.2, 2015 criteria). A total of 2790 electronic prescriptions for chronic pathologies collected from 18 community pharmacies in the western part of Romania (urban and rural zones) were included. All medicines had been prescribed by general physicians. We identified the following situations of medicine overuse: 15% of the analyzed prescriptions involved the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for >2 weeks, 12% involved the use of a proton-pump inhibitor (PPI) for >8 weeks, theophylline was the bronchodilator used as a monotherapy in 3.17% of chronic obstructive pulmonary disease cases, and zopiclone was the hypnotic drug of choice for 2.31% of cases. Regarding the misuse of medicines, 2.33% of analyzed prescriptions contained an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin II receptor blocker (ARB) for patients with renal failure in addition to vitamin K antagonists (AVKs) and NSAIDs in 0.43% of cases. Prescriptions for COX2 NSAIDs for periods longer than 2 weeks for patients with cardiovascular disorders accounted for 1.33% of prescriptions, and trihexyphenidyl was used as a monotherapy for patients with Parkinson’s disease in 0.18% of cases. From the included medical prescriptions, 32.40% (the major percent of 2383 prescriptions) had two potentially inappropriate medications (PIMs). Rural zones were found to be risk factor for PIMs. Decreasing the chronic prescription of NSAIDs and PPIs, discontinuing the use of hypnotic drugs, and avoiding potentially harmful drug–drug associations will have long term beneficial effects for Romanian elderly patients.
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Affiliation(s)
- Valentina Buda
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (A.P.); (C.C.); (C.D.); (A.L.); (C.A.D.)
- Research Centre for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
- Correspondence: ; Tel.: +40-755-100-408
| | - Andreea Prelipcean
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (A.P.); (C.C.); (C.D.); (A.L.); (C.A.D.)
| | - Carmen Cristescu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (A.P.); (C.C.); (C.D.); (A.L.); (C.A.D.)
| | - Alexandru Roja
- Faculty of Economics and Business Administration, West University of Timisoara, Vasile Parvan Boulevard, No.4, 300223 Timisoara, Romania;
| | - Olivia Dalleur
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Universite Catholique de Louvain, E. Mounier Street, No. 81, 1200 Woluwe-Saint-Lambert, Belgium;
| | - Minodora Andor
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (M.A.); (O.C.)
| | - Corina Danciu
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (A.P.); (C.C.); (C.D.); (A.L.); (C.A.D.)
- Research Centre for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Adriana Ledeti
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (A.P.); (C.C.); (C.D.); (A.L.); (C.A.D.)
- Advanced Instrumental Screening Center, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Cristina Adriana Dehelean
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (A.P.); (C.C.); (C.D.); (A.L.); (C.A.D.)
- Research Centre for Pharmaco-Toxicological Evaluation, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Octavian Cretu
- Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (M.A.); (O.C.)
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Systematic Review and Meta-analysis: The Effects of Prophylactic Proton Pump Inhibitor Treatment in Patients With Coronary Heart Disease Receiving Dual Antiplatelet Therapy. J Cardiovasc Pharmacol 2021; 77:835-861. [PMID: 34057160 DOI: 10.1097/fjc.0000000000001014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/28/2021] [Indexed: 12/24/2022]
Abstract
Dual antiplatelet therapy (DAPT) and proton pump inhibitors (PPIs) are widely used in clinical treatment. However, the pharmacokinetic interaction between PPIs and DAPT is still unclear in patients with cardiovascular disease. This systematic review and meta-analysis aimed to evaluate the risks and benefits of the combination of PPI and DAPT in patients with coronary heart disease. The PubMed, EMBASE, Cochrane, and Web of Science databases were systematically searched from inception to April 1, 2020, for eligible studies. The outcomes investigated in this study included major adverse cardiovascular events, myocardial infarction, all-cause death, gastrointestinal complications, and platelet function testing. Studies were excluded from the review if other gastrointestinal medication or aspirin or P2Y12 receptor inhibitor monotherapy was administered. The review included 52 studies, and data from 40 studies were extracted for meta-analysis. No association was found between the risk of adverse clinical outcomes and the combination of PPI and DAPT based on the randomized controlled trial data (risk ratio: 0.98; 95% confidence interval: 0.87-1.09; P = 0.877; I2 = 0%). However, an increased risk of adverse clinical outcomes due to the use of PPIs was observed in patients treated with DAPT based on the data from observational studies (risk ratio: 1.259; 95% confidence interval: 1.079-1.468; P = 0.003; I2 = 67.8%), although the heterogeneity of these studies was high. In conclusion, this systematic review and meta-analysis demonstrated that pharmacokinetic interactions between PPI and DAPT do not lead to adverse clinical outcomes.
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O'Logbon J, Crook M, Steed D, Harrington DJ, Sobczyńska-Malefora A. Ethnicity influences total serum vitamin B 12 concentration: a study of Black, Asian and White patients in a primary care setting. J Clin Pathol 2021; 75:598-604. [PMID: 33952588 DOI: 10.1136/jclinpath-2021-207519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/21/2021] [Accepted: 04/06/2021] [Indexed: 11/03/2022]
Abstract
AIMS A growing body of evidence suggests that ethnicity and race influence vitamin B12 metabolism and status yet clinical awareness of this is poor, causing doubts regarding diagnosis and treatment. Moreover, deficiency and insufficiency cut-offs are universally applied for this test in most diagnostic settings. The objective of this study was to assess serum vitamin B12 concentrations in Black, Asian and White primary care patients in London, UK, particularly in patients of Black or Black British ethnic origin and establish if there is a need for specific reference ranges. METHODS Serum B12 results from 49 414 patients were processed between January 2018 and November 2019 using the Architect assay (Abbott Diagnostics) at St. Thomas' Hospital, London, UK. Age, sex and ethnicity data were collected from the laboratory Health Informatics Team. RESULTS Black patients (n=13 806) were found to have significantly higher serum vitamin B12 concentration across all age groups and both sexes, especially Nigerian patients (median B12 505 pmol/L,IQR: 362-727, n=891), compared with Asian and White ethnic groups (p<0.001). Binary logistic regression analysis revealed that the Black or Black British ethnic group had the strongest association with elevated serum B12 (>652 pmol/L) (adjusted OR 3.38, 95% CI 3.17 to 3.61, p<0.0001). CONCLUSIONS It is likely that a combination of genetic and acquired/environmental factors are responsible for the ethnic differences in serum B12. This suggests that there is a need for ethnic-specific reference ranges with indications for the incorporation of age and sex too.
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Affiliation(s)
- Jessica O'Logbon
- GKT School of Medicine, King's College London Faculty of Life Sciences and Medicine, London, UK jessica.o'
| | - Martin Crook
- Clinical Biochemistry and Metabolic Medicine, Guy's, St Thomas' Trust, London, UK.,Clinical Biochemistry and Metabolic Medicine, Lewisham and Greenwich Trust, London, UK.,Hon Professor in Biochemical Medicine, King's College London, London, UK
| | - David Steed
- Viapath Informatics, Viapath, Francis House, St Thomas' Hospital, London, UK
| | - Dominic Jon Harrington
- Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK
| | - Agata Sobczyńska-Malefora
- Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK
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Sobczyńska-Malefora A, Delvin E, McCaddon A, Ahmadi KR, Harrington DJ. Vitamin B 12 status in health and disease: a critical review. Diagnosis of deficiency and insufficiency - clinical and laboratory pitfalls. Crit Rev Clin Lab Sci 2021; 58:399-429. [PMID: 33881359 DOI: 10.1080/10408363.2021.1885339] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vitamin B12 (cobalamin) is an essential cofactor for two metabolic pathways. It is obtained principally from food of animal origin. Cobalamin becomes bioavailable through a series of steps pertaining to its release from dietary protein, intrinsic factor-mediated absorption, haptocorrin or transcobalamin-mediated transport, cellular uptake, and two enzymatic conversions (via methionine synthase and methylmalonyl-CoA-mutase) into cofactor forms: methylcobalamin and adenosylcobalamin. Vitamin B12 deficiency can masquerade as a multitude of illnesses, presenting different perspectives from the point of view of the hematologist, neurologist, gastroenterologist, general physician, or dietician. Increased physician vigilance and heightened patient awareness often account for its early presentation, and testing sometimes occurs during a phase of vitamin B12 insufficiency before the main onset of the disease. The chosen test often depends on its availability rather than on the diagnostic performance and sensitivity to irrelevant factors interfering with vitamin B12 markers. Although serum B12 is still the most commonly used and widely available test, diagnostics by holotranscobalamin, serum methylmalonic acid, and plasma homocysteine measurements have grown in the last several years in routine practice. The lack of a robust absorption test, coupled with compromised sensitivity and specificity of other tests (intrinsic factor and gastric parietal cell antibodies), hinders determination of the cause for depleted B12 status. This can lead to incorrect supplementation regimes and uncertainty regarding later treatment. This review discusses currently available knowledge on vitamin B12, informs the reader about the pitfalls of tests for assessing its deficiency, reviews B12 status in various populations at different disease stages, and provides recommendations for interpretation, treatment, and associated risks. Future directions for diagnostics of B12 status and health interventions are also discussed.
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Affiliation(s)
- Agata Sobczyńska-Malefora
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Edgard Delvin
- Sainte-Justine UHC Research Centre, Montreal, Canada.,Department of Biochemistry and Molecular Medicine, University of Montreal, Montreal, Canada
| | | | - Kourosh R Ahmadi
- Department of Nutrition & Metabolism, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Dominic J Harrington
- The Nutristasis Unit, Viapath, St. Thomas' Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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B12 Deficiency and Clinical Presentation in the Setting of Nitric Oxide Use. Case Rep Neurol Med 2021; 2021:5590948. [PMID: 33927908 PMCID: PMC8049814 DOI: 10.1155/2021/5590948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/07/2021] [Accepted: 03/29/2021] [Indexed: 12/16/2022] Open
Abstract
B12 deficiency can arise symptomatically from an array of varying pathologies including frank deficiency from strict vegan diets. Other high-risk contributing pathological conditions include chronic alcoholism, autoimmune disease, and chronic gastrointestinal inflammatory disorders, and it is also seen in those with a history of gastric surgery. Additionally, the elderly are at an increased risk as are patients prescribed certain medications. Uncommonly suspected causes of B12 deficiency include the abuse of recreational nitrous oxide (NO) given its interference with cobalt oxidation. Here, we report two cases of hypovitaminosis B12 in association with NO abuse in an effort to highlight an increasingly dangerous trend with recreational use. Importantly, we aim to increase visibility of this malady given that improperly diagnosed neurologic deterioration following NO anesthesia has been shown to become irreversible and may even result in death.
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D'Agostino S, Limongelli L, Favia G, Dolci M. Oral manifestation of vitamin B12 associated with metformin and proton pump inhibitors: oral signs of drug related hypovitaminosis. Minerva Dent Oral Sci 2021; 70:95-96. [PMID: 33205923 DOI: 10.23736/s2724-6329.20.04447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Silvia D'Agostino
- Department of Medical, Oral and Biotechnological Science, University G. D'Annunzio, Chieti, Italy -
| | - Luisa Limongelli
- Interdisciplinary Department of Medicine, University Aldo Moro, Bari, Italy
| | - Gianfranco Favia
- Interdisciplinary Department of Medicine, University Aldo Moro, Bari, Italy
| | - Marco Dolci
- Department of Medical, Oral and Biotechnological Science, University G. D'Annunzio, Chieti, Italy
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Bailey RL, Jun S, Murphy L, Green R, Gahche JJ, Dwyer JT, Potischman N, McCabe GP, Miller JW. High folic acid or folate combined with low vitamin B-12 status: potential but inconsistent association with cognitive function in a nationally representative cross-sectional sample of US older adults participating in the NHANES. Am J Clin Nutr 2020; 112:1547-1557. [PMID: 32860400 PMCID: PMC8184300 DOI: 10.1093/ajcn/nqaa239] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Potential safety concerns relative to impaired cognitive function may exist when high folic acid exposures are combined with low vitamin B-12 status. OBJECTIVES We aimed to examine the relation of the coexistence of high folate and low vitamin B-12 status with cognitive function, utilizing various definitions of "high" folate status. METHODS Cross-sectional data from older adults (≥60 y; n = 2420) from the 2011-2014 NHANES were analyzed. High folate status was defined as unmetabolized serum folic acid (UMFA) > 1 nmol/L or serum total folate > 74.1 nmol/L, and low vitamin B-12 status as methylmalonic acid > 271 nmol/L or serum vitamin B-12 < 150 pmol/L. Logistic regression models estimated ORs of scoring low on 1 of 4 cognitive tests: the Digit Symbol Substitution Test (DSST), the Consortium to Establish a Registry for Alzheimer's Disease Delayed Recall (CERAD-DR) and Word Learning tests, and the Animal Fluency test (AF). RESULTS A significant interaction was observed relative to scoring low on the DSST (<34; UMFA; P-interaction = 0.0071) and AF (serum folate; P-interaction = 0.0078) for low vitamin B-12 and high folate status. Among those with low vitamin B-12, high UMFA or high serum total folate was associated with higher risk of scoring low on the DSST (OR: 2.16; 95% CI: 1.05, 4.47) and the AF (OR: 1.93; 95% CI: 1.08, 3.45). Among those with "normal" vitamin B-12, higher UMFA or serum total folate was protective on the CERAD-DR. In noninteraction models, when high folate and normal vitamin B-12 status was the reference group, low vitamin B-12 combined with high UMFA was associated with greater risk based on the DSST (<34, OR: 2.87; 95% CI: 1.85, 4.45; <40, OR: 2.22; 95% CI: 1.31, 3.75) and AF (OR: 1.97; 95% CI: 1.30, 2.97); but low vitamin B-12 and lower UMFA (OR: 1.69; 95% CI: 1.16, 2.47) was also significantly associated for DSST < 40 risk. CONCLUSIONS Low vitamin B-12 was associated with cognitive impairment both independently and in an interactive manner with high folate for certain cognitive performance tests among older adults.
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Affiliation(s)
- Regan L Bailey
- Department of Nutrition Science, Purdue
University, West Lafayette, IN, USA
| | - Shinyoung Jun
- Department of Nutrition Science, Purdue
University, West Lafayette, IN, USA
| | - Lisa Murphy
- Department of Nutrition Science, Purdue
University, West Lafayette, IN, USA
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of
California, Davis, Davis, CA, USA
| | | | - Johanna T Dwyer
- Office of Dietary Supplements, NIH, Bethesda,
MD, USA
- Frances Stern Nutrition Center, Tufts Medical
Center, Boston, MA, USA
- Jean Mayer USDA Human Nutrition Research Center on Aging at
Tufts University School of Medicine, Boston, MA, USA
| | | | - George P McCabe
- Department of Statistics, Purdue University,
West Lafayette, IN, USA
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers
University, New Brunswick, NJ, USA
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Demaré S, Kothari A, Calcutt NA, Fernyhough P. Metformin as a potential therapeutic for neurological disease: mobilizing AMPK to repair the nervous system. Expert Rev Neurother 2020; 21:45-63. [PMID: 33161784 PMCID: PMC9482886 DOI: 10.1080/14737175.2021.1847645] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Metformin is currently first line therapy for type 2 diabetes (T2D). The mechanism of action of metformin involves activation of AMP-activated protein kinase (AMPK) to enhance mitochondrial function (for example, biogenesis, refurbishment and dynamics) and autophagy. Many neurodegenerative diseases of the central and peripheral nervous systems arise from metabolic failure and toxic protein aggregation where activated AMPK could prove protective. Areas covered: The authors review literature on metformin treatment in Parkinson’s disease, Huntington’s disease and other neurological diseases of the CNS along with neuroprotective effects of AMPK activation and suppression of the mammalian target of rapamycin (mTOR) pathway on peripheral neuropathy and neuropathic pain. The authors compare the efficacy of metformin with the actions of resveratrol. Expert opinion: Metformin, through activation of AMPK and autophagy, can enhance neuronal bioenergetics, promote nerve repair and reduce toxic protein aggregates in neurological diseases. A long history of safe use in humans should encourage development of metformin and other AMPK activators in preclinical and clinical research. Future studies in animal models of neurological disease should strive to further dissect in a mechanistic manner the pathways downstream from metformin-dependent AMPK activation, and to further investigate mTOR dependent and independent signaling pathways driving neuroprotection.
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Affiliation(s)
- Sarah Demaré
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre , Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, University of Manitoba , Winnipeg, MB, Canada
| | - Asha Kothari
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre , Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, University of Manitoba , Winnipeg, MB, Canada
| | - Nigel A Calcutt
- Department of Pathology, University of California San Diego , La Jolla, CA, USA
| | - Paul Fernyhough
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre , Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, University of Manitoba , Winnipeg, MB, Canada
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Chappell L, Brown SA, Wensel TM. Evaluation of Vitamin B12 Monitoring in Patients on Concomitant Metformin and Proton Pump Inhibitors. Innov Pharm 2020; 11. [PMID: 34007643 PMCID: PMC8127105 DOI: 10.24926/iip.v11i4.3355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Type 2 diabetes mellitus and gastroesophageal reflux disease are highly prevalent in the United States. First-line therapies for these disease states include metformin and proton pump inhibitors, respectively. Both of these medications have been associated with a decreased absorption of vitamin B12. Objective: The objective of this study was to assess the prevalence of B12 monitoring and supplementation in patients receiving concomitant metformin and PPI therapy. Methods: A retrospective data analysis was performed at a single federally qualified health center. Patients receiving concomitant metformin and PPI therapy (specifically omeprazole and pantoprazole) over the past year were included. Data collected included demographics, dosing, therapy duration, and vitamin B12 level. Data were analyzed using descriptive statistics. Results: A total of 104 patients met the inclusion criteria for this study. Metformin 1000 mg immediate release tablets was the most common dose and formulation prescribed. Omeprazole and pantoprazole were the most commonly prescribed PPIs. The most frequent duration of therapy was 1 to 4 years. Fourteen patients had a documented B12 level and no patients were categorized as deficient. Seven patients were prescribed a B12 supplement during the study period. Conclusion: In this single center, retrospective chart review of patients receiving concomitant metformin and PPI therapy, the average duration of therapy for both agents was 1-4 years. Only 13.5% of patients had a documented B12 level. Of those patients, none were categorized as deficient. Though routine monitoring of B12 levels may be important for patients on long-term therapy with both agents or who present with symptoms of B12 deficiency, this study does not support routine monitoring of B12 levels for patients with duration of therapy of 4 years or less.
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Damodharan S, Raj GM, Sakthibalan M, Dakshinamoorthy K, Muraliswaran P. Effect of long-term acid suppression therapy with proton pump inhibitors or H 2 receptor blockers on serum vitamin B 12 levels in elderly population. Ir J Med Sci 2020; 190:1213-1217. [PMID: 33085017 DOI: 10.1007/s11845-020-02399-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Long-term usage of acid suppression drugs like proton pump inhibitors (PPIs) or H2 receptor blockers in the elderly population has been found to result in vitamin B12 deficiency. However, the reports are equivocal. OBJECTIVE To determine the serum vitamin B12 levels in elderly patients under chronic acid suppression therapy. METHODS Patients aged above 60 years and on any of the PPIs or H2 blockers for at least 6 months were recruited. Out of 77 patients recruited, 60 patients were included for the final analysis. The serum vitamin B12 levels were measured using the AccuDiag™-Vitamin B12 ELISA system. RESULTS Out of 60 patients, pantoprazole (40%) and omeprazole (37%) were the commonly prescribed acid-suppressing drugs. Nearly 50% of the patients on prolonged acid suppression therapy were either "deficient" (less than 200 pg/ml) or "insufficient" (200 to 300 pg/ml) in serum vitamin B12 levels. Neither the average serum vitamin B12 levels (p = 0.994) nor the vitamin B12 status (p = 0.226) varied significantly across the drug groups of pantoprazole, omeprazole, and ranitidine. CONCLUSIONS Prolonged acid suppression therapy with PPIs or H2 blockers may result in serum vitamin B12 deficiency. However, there was no class (PPIs vs. H2 receptor blockers)- or drug (pantoprazole vs. omeprazole vs. ranitidine)-based differences found in the vitamin B12 deficiency caused.
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Affiliation(s)
- Srinivasan Damodharan
- Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Pondy-Villupuram Main Road, Ariyur, Puducherry, 605102, India
| | - Gerard Marshall Raj
- Department of Pharmacology, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Pondy-Villupuram Main Road, Ariyur, Puducherry, 605102, India.
| | - M Sakthibalan
- Department of Pharmacology, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Pondy-Villupuram Main Road, Ariyur, Puducherry, 605102, India
| | - Karthikeyan Dakshinamoorthy
- Department of General Medicine, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Pondy-Villupuram Main Road, Ariyur, Puducherry, 605102, India
| | - P Muraliswaran
- Department of Biochemistry, Sri Venkateshwaraa Medical College Hospital and Research Centre (SVMCH & RC), Pondy-Villupuram Main Road, Ariyur, Puducherry, 605102, India
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Maruvada P, Stover PJ, Mason JB, Bailey RL, Davis CD, Field MS, Finnell RH, Garza C, Green R, Gueant JL, Jacques PF, Klurfeld DM, Lamers Y, MacFarlane AJ, Miller JW, Molloy AM, O'Connor DL, Pfeiffer CM, Potischman NA, Rodricks JV, Rosenberg IH, Ross SA, Shane B, Selhub J, Stabler SP, Trasler J, Yamini S, Zappalà G. Knowledge gaps in understanding the metabolic and clinical effects of excess folates/folic acid: a summary, and perspectives, from an NIH workshop. Am J Clin Nutr 2020; 112:1390-1403. [PMID: 33022704 PMCID: PMC7657327 DOI: 10.1093/ajcn/nqaa259] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/20/2020] [Indexed: 12/21/2022] Open
Abstract
Folate, an essential nutrient found naturally in foods in a reduced form, is present in dietary supplements and fortified foods in an oxidized synthetic form (folic acid). There is widespread agreement that maintaining adequate folate status is critical to prevent diseases due to folate inadequacy (e.g., anemia, birth defects, and cancer). However, there are concerns of potential adverse effects of excess folic acid intake and/or elevated folate status, with the original concern focused on exacerbation of clinical effects of vitamin B-12 deficiency and its role in neurocognitive health. More recently, animal and observational studies have suggested potential adverse effects on cancer risk, birth outcomes, and other diseases. Observations indicating adverse effects from excess folic acid intake, elevated folate status, and unmetabolized folic acid (UMFA) remain inconclusive; the data do not provide the evidence needed to affect public health recommendations. Moreover, strong biological and mechanistic premises connecting elevated folic acid intake, UMFA, and/or high folate status to adverse health outcomes are lacking. However, the body of evidence on potential adverse health outcomes indicates the need for comprehensive research to clarify these issues and bridge knowledge gaps. Three key research questions encompass the additional research needed to establish whether high folic acid or total folate intake contributes to disease risk. 1) Does UMFA affect biological pathways leading to adverse health effects? 2) Does elevated folate status resulting from any form of folate intake affect vitamin B-12 function and its roles in sustaining health? 3) Does elevated folate intake, regardless of form, affect biological pathways leading to adverse health effects other than those linked to vitamin B-12 function? This article summarizes the proceedings of an August 2019 NIH expert workshop focused on addressing these research areas.
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Affiliation(s)
- Padma Maruvada
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - Patrick J Stover
- Texas A&M University College of Agriculture and Life Sciences, Texas A&M University AgriLife, College Station, TX, USA
| | - Joel B Mason
- Jean Mayer USDA Human Nutrition Research Center on Aging, Friedman School of Nutrition Science and Policy, and School of Medicine, Tufts University, Boston, MA, USA
| | - Regan L Bailey
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Cindy D Davis
- Office of Dietary Supplements, NIH, Bethesda, MD, USA
| | - Martha S Field
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Richard H Finnell
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Cutberto Garza
- Professor Emeritus, Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jean-Louis Gueant
- University of Lorraine and University Regional Hospital Centre of Nancy, Nancy, France
| | - Paul F Jacques
- Tufts University Friedman School of Nutritional Science and Policy and the Jean Mayer USDA Human Nutrition Research Center, Boston, MA, USA
| | - David M Klurfeld
- Department of Nutrition, Food Safety, and Quality, USDA Agricultural Research Service, Beltsville, MD, USA
| | - Yvonne Lamers
- Food, Nutrition and Health Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Anne M Molloy
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Irwin H Rosenberg
- Jean Mayer USDA Human Nutrition Research Center on Aging, Friedman School of Nutrition Science and Policy, and School of Medicine, Tufts University, Boston, MA, USA
| | | | - Barry Shane
- Department of Nutritional Sciences & Toxicology, University of California, Berkeley, Berkeley, CA, USA
| | - Jacob Selhub
- Tufts University Friedman School of Nutritional Science and Policy and the Jean Mayer USDA Human Nutrition Research Center, Boston, MA, USA
| | | | | | - Sedigheh Yamini
- Office of Nutrition and Food Labeling, Center for Food Safety and Applied Nutrition, US FDA, College Park, MD, USA
| | - Giovanna Zappalà
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
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Randomized Trial on the Clinical Utility of a Novel Biomarker Panel to Identify Treatable Determinants of Chronic Pain. Diagnostics (Basel) 2020; 10:diagnostics10080513. [PMID: 32717995 PMCID: PMC7459523 DOI: 10.3390/diagnostics10080513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/26/2023] Open
Abstract
Millions suffer daily from chronic pain diagnosed anatomically and treated with opioids. Research shows that underlying nutritional, metabolic and oxidative stressors, which drive the development or worsening of chronic pain, are not diagnosed despite the fact that treatment of these primary pain pathways relieves pain and increases function. One of the main reasons for this gap in care is the lack of a simple diagnostic assay to help clinicians make these diagnoses. We examined the clinical utility of a urine-based pain biomarker panel. Primary care physicians were randomized into the test group and compared to controls. We measured their ability to make the diagnosis and treat a total of nine standardized patients, with common but challenging cases of chronic pain, over two rounds of data collection in a pre–post design using a fixed-effects model. Intervention doctors received educational materials on a novel pain biomarker panel after the baseline round and had access to biomarker test results. Provider responses were measured against evidence-based criteria. The two study arms at baseline provided similar, poor care for three different primary pain pathways: nutritional deficiencies (5.0% control versus 9.2% intervention treated, p = 0.208), metabolic abnormalities (1.0% control versus 0% for intervention treated, p = 0.314), and oxidative stress (1.2% control versus 0% intervention treated, p = 0.152). After the introduction of the Foundation Pain Index (FPI) biomarker test, physicians in the intervention group were 41.5% more likely to make the diagnosis of a micronutrient deficiency, 29.4% more likely to identify a treatable metabolic abnormality and 26.1% more likely to identify an oxidative stressor. These diagnostic and treatment improvements were seen across all three case types, ranging from a relative +54% (p = 0.004) for chronic neuropathic pain to +35% (p = 0.007) in chronic pain from other causes to +38% (p = 0.002) in chronic pain with associated mental health issues. Intervention doctors were also 75.1% more likely to provide a non-opioid treatment to patients on chronic opioids (O.R. 1.8, 95% C.I. 0.8–3.7), 62% less likely to order unnecessary imaging for their patients with low back pain (O.R. 0.38, 95% C.I. 0.15–0.97) and 66% less likely to order an unnecessary pain referral (O.R. 0.34, 95% C.I. 0.13–0.90). This experimental study showed significant clinical utility of a validated pain biomarker panel that determines nutritional deficiencies, metabolic abnormalities and oxidative stressors that drive underlying treatable causes of pain. When integrated into routine primary care practice, this testing approach could considerably improve diagnostic accuracy and provide more targeted, non-opioid treatments for patients suffering from chronic pain.
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Cobalamin Deficiency in the Elderly. Mediterr J Hematol Infect Dis 2020; 12:e2020043. [PMID: 32670521 PMCID: PMC7340236 DOI: 10.4084/mjhid.2020.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/30/2020] [Indexed: 12/16/2022] Open
Abstract
Older people are at risk for cobalamin (vitamin B12) deficiency because of a number of common disorders (e.g., autoimmune gastritis) and drugs (e.g., antacids) that may alter its absorption and utilization. The prevalence of cobalamin deficiency increases with age, resulting, particularly elevated, in frail and institutionalized subjects. At variance with common sense, the diagnosis is far from simple. It requires a high degree of suspicion, due to heterogeneity and non-specificity of the signs and symptoms, ranging from macrocytosis (with or without anemia) to neuropsychiatric manifestations, that characterize several other aging-related disorders, like hematological malignancies, diabetes, hypothyroidism or vasculopathy. Furthermore, the detection of low levels of serum vitamin B12 appears poorly sensitive and specific. Other biomarkers, like serum homocysteine or methylmalonic acid, have improved the diagnostic possibilities but are expensive, not widely available, and may be influenced by some confounders (e.g., folate deficiency, or chronic renal failure). Early recognition and treatment are crucial since a proportion of patients develop severe complications, such as bone marrow failure and irreversible neurological impairment. High-dose oral treatment has proven to be as effective as the parenteral route, even in subjects with malabsorption, ensuring the complete resolution in the majority of cases. In this review, we trace the essential role of cobalamin in humans, the possible causes and impact of deficiency, the diagnostic challenges and the therapeutic options, between old and emerging concepts, with a particular focus on the elderly.
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