Vitamin K1 ameliorates lipopolysaccharide-triggered skeletal muscle damage revealed by faecal bacteria transplantation

BACKGROUND

Sepsis-associated muscle weakness is common in patients of intensive care units (ICUs), and it is closely associated with poor outcomes. The mechanism of sepsis-induced muscle weakness is unclear. Recent studies have found that gut microbiota and metabolites are involved in the regulation of skeletal muscle mass and metabolism. This study aimed to investigate the effects of gut microbiota and metabolites on sepsis-associated muscle weakness.

METHODS

In a lipopolysaccharide (LPS)-induced inflammation mouse model, mice with different sensitivities to LPS-induced inflammation were considered as donor mice for the faecal microbiota transplantation (FMT) assay, and recipient mice were divided into sensitive (Sen) and resistant (Res) groups. Skeletal muscle mass and function, as well as colonic barrier integrity were tested and gut microbiota and metabolite composition were analysed in both groups of mice. The effect of intestinal differential metabolite vitamin K1 on LPS-triggered muscle damage was investigated, and the underlying mechanism was explored.

RESULTS

Recipients exhibited varying LPS-triggered muscle damage and intestinal barrier disruption. Tibialis anterior (TA) muscle of Sen exhibited upregulated expression levels of MuRF-1 (0.825 ± 0.063 vs. 0.304 ± 0.293, P = 0.0141) and MAFbx (1.055 ± 0.079 vs. 0.456 ± 0.3, P = 0.0092). Colonic tight junction proteins ZO-1 (0.550 ± 0.087 vs. 0.842 ± 0.094, P = 0.0492) and occludin (0.284 ± 0.057 vs. 0.664 ± 0.191, P = 0.0487) were significantly downregulated in the Sen group. Metabolomic analysis showed significantly higher vitamin K1 in the faeces (P = 0.0195) and serum of the Res group (P = 0.0079) than those of the Sen group. After vitamin K1 intervention, muscle atrophy-related protein expression downregulated (P < 0.05). Meanwhile SIRT1 protein expression were upregulated (0.320 ± 0.035 vs. 0.685 ± 0.081, P = 0.0281) and pNF-κB protein expression were downregulated (0.815 ± 0.295 vs. 0.258 ± 0.130, P = 0.0308). PI3K (0.365 ± 0.142 vs. 0.763 ± 0.013, P = 0.0475), pAKT (0.493 ± 0.159 vs. 1.183 ± 0.344, P = 0.0254) and pmTOR (0.509 ± 0.088 vs. 1.110 ± 0.190, P = 0.0368) protein expression levels were upregulated in TA muscle. Meanwhile, vitamin K1 attenuated serum inflammatory factor levels.

CONCLUSIONS

Vitamin K1 might ameliorate LPS-triggered skeletal muscle damage by antagonizing NF-κB-mediated inflammation through upregulation of SIRT1 and regulating the balance between protein synthesis and catabolism.

Observation of the neuroprotective efficacy of vitamin K in a streptozocin-induced diabetes model in chick embryos

Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia due to insulin deficiency and/or resistance. Vitamin K (VK) is a group of fat-soluble molecules, including naturally occurring vitamin K1 (phylloquinone). vitamin K2 (menaquinone), and synthetic vitamin K3 (menadione). Beyond coagulation, the health benefits of VK have been described to play different roles in both physiological and pathological processes such as inflammation, energy metabolism, neuroprotection, cellular growth, and survival. It was aimed to observe the antioxidant and/or neuroprotective activity of vitamin K1 in our model of chick embryo diabetic neuropathy (DN) induced by streptozotocin (STZ). Ninety White Leghorn, fertile and 0-day-old SPF (specific pathogen-free) eggs (57 ± 4 gr) were used in the study. Chick embryo blood brain tissues were taken for biochemical evaluation. Plasma insulin and glucose levels were measured. In addition, brain tissue total antioxidant level (TAS), total oxidant level (TOS), malondialdehyde (MDA), and vascular endothelial growth factor (VEGF) levels were measured. Plasma glucose levels were higher in the STZ-treated groups and lower in the treatment groups. Plasma insulin levels were observed to be higher in STZ groups in groups treated with high VK. Low TAS, high MDA, TOS, and VEGF levels were recorded in brain tissue STZ groups. Low VEGF, TOS, and MDA levels were recorded in the group treated with the highest VK, while high TAS levels were observed. In our STZ-induced chick embryo diabetic neuropathy model, we observed that VK1 reduced oxidant damage by showing antioxidant properties or by modulating antioxidant enzymes.

The severe adverse reaction to vitamin k1 injection is anaphylactoid reaction but not anaphylaxis

The severe adverse reaction to vitamin K₁ injection is always remarkable and is thought to result from anaphylaxis. Paradoxically, however, some patients administered vitamin K₁ injection for the first time have adverse reactions. Using beagle dogs, the present study tested the hypothesis that the response to vitamin K₁ is an anaphylactoid reaction. The results showed that serious anaphylaxis-like symptoms appeared in beagle dogs after the administration of vitamin K₁ injection for the first time. The plasma histamine concentration increased, and blood pressure decreased sharply. After sensitization, dogs were challenged with vitamin K₁ injection and displayed the same degree of symptoms as prior to sensitization. However, when the vitamin K₁ injection-sensitized dogs were challenged with a vitamin K₁-fat emulsion without solubilizers such asTween-80, the abnormal reactions did not occur. Furthermore, there was no significant change in the plasma immunoglobulin E concentration after vitamin K₁ challenge. Following treatment with vitamin K₁ injection, the release of histamine and β-hexosaminidase by rat basophilic leukemia-2H3 cells as well as the rate of apoptosis increased. The Tween-80 group displayed results similar to those observed following vitamin K₁ injection in vivo. However, the dogs in the vitamin K₁-fat emulsion group did not display any abnormal behavior or significant change in plasma histamine. Additionally, degranulation and apoptosis did not occur in rat basophilic leukemia-2H3 cells. Our results indicate that the adverse reaction induced by vitamin K₁ injection is an anaphylactoid reaction, not anaphylaxis. Vitamin K₁ injection induces the release of inflammatory factors via a non-IgE-mediated immune pathway, for which the trigger may be the solubilizer.

"Cowboy's belt with revolver" scleroderma caused by vitamin K1 injections

Vitamin K1 (phytomenadione or phytonadione) is a fat soluble vitamin used to treat certain coagulation disorders. Intra muscular injection of vitamin K1 can occasionally be complicated by different types of skin reactions: erythematous plaques, urticarial rashes or scleroderma-like lesions at the injection site. We report the case of a 52-year-old man presenting with 2 symmetrical erythematous-infiltrated scleroderma-like plaques localized on the right and left lower trunk. To correct the coagulation deficiency with hypoprothrombinemia developed as a consequence of HCV+ hepatitis, the patient was on vitamin K1 therapy, administered by i.m. injection (10 mg Vitamin K1/1 ml) once a day for 2 weeks. Three months after treatment interruption, ivory indurated morphoeiform plaques developed at the injection sites, assuming the typical appearance of a "cowboy's belt with revolver". The scleroderma-like lesions persisted 2 years after vitamin K1 withdrawal. We report this case to highlight the possibility that vitamin K1 injections can occasionally be complicated by different types of skin reactions such as sclerodermatous plaques. Due to the delay in the onset, to the variable clinical picture, to the persistence after therapy interruption, this kind of lesions can represent a tricky diagnostic challenge and in spite of different treatments can endure for years.

Intake of vitamin K1 and K2 and risk of hip fractures: The Hordaland Health Study

BACKGROUND

Evidence of the effect of vitamin K on bone health is conflicting. The aim was to investigate the association between intake of vitamins K1 and K2 and subsequent risk of hip fracture in a general population sample, as well as potential effect modification by apolipoprotein E gene (APOE) status by presence of the E4 allele.

METHODS

1238 men and 1569 women 71-75 years of age were included in the community-based Hordaland Health Study 1997-1999 in Western Norway. Information on hip fracture was obtained from hospitalizations in the region from enrolment until 31 December 2009. Information on intake of vitamins K1 and K2 collected at baseline was used as potential predictors of hip fracture in Cox proportional hazards regression analyses.

RESULTS

Participants in the lowest compared to the highest quartile of vitamin K1 intake had increased risk of suffering a hip fracture (hazard ratio (HR)=1.57 [95% CI 1.09, 2.26]). Vitamin K2 intake was not associated with hip fracture. Presence of APOE4-allele did not increase the risk of hip fracture, nor was there any effect modification with vitamin K1 in relation to risk of hip fracture.

CONCLUSIONS

A low intake of vitamin K1, but not K2, was associated with an increased risk of hip fractures.

Letter: Localized cutaneous reaction to intramuscular vitamin K in a patient with acute fatty liver of pregnancy

Vitamin K1 is frequently used in the treatment and prevention of hypoprothrombinemia and hemorrhagic disease of the newborn. It also serves as an antidote to anticoagulants. Erythematous, indurated, pruritic plaques uncommonly occur in adults after intramuscular injection with vitamin K1. We present a case of a localized cutaneous reaction to intramuscular vitamin K1 in a peripartum patient with acute fatty liver of pregnancy. The history and clinical presentation of our case is presented with a discussion of the pathogenesis pathogenesis of vitamin K1 and available treatment for this condition.

Contact dermatitis due to clarifying cream

A 45-year-old woman developed a severe eczematous reaction localized on the application site after using a clarifying cream. Patch testing showed positively to vitamin K1.

A retrospective evaluation of vitamin K1 therapy to reverse the anticoagulant effect of warfarin

STUDY OBJECTIVE

To assess compliance with the 2001 consensus guidelines of the American College of Chest Physicians (ACCP) regarding administration of vitamin K1 to reverse the anticoagulant effect of warfarin.

DESIGN

Retrospective chart review.

SETTING

University teaching hospital.

PATIENTS

Fifty-five adult inpatients who received both warfarin and vitamin K1 between September 2001 and January 2002.

MEASUREMENTS AND MAIN RESULTS

The patients' medical records were evaluated; data were collected on patient demographics and on vitamin K1 dosage and route of administration, warfarin dosage, and international normalized ratio (INR) before and after vitamin K1 administration. Administration routes and 87 doses of vitamin K1 prescribed for the 55 patients were assessed for compliance with the ACCP guidelines. Administration routes were subcutaneous (40.2% of doses), intravenous (35.6%), oral (13.8%), and intramuscular (10.3%). The most frequently prescribed dose of vitamin K1 was 10 mg (32.2%), followed by 2 mg (21.8%) and 5 mg (18.4%). Rates of compliance with the ACCP guidelines categorized by INR value were as follows: INR below 5, 12.2%; INR 5-9, 27.8%; INR between 9 and 20, 26.7%; and INR above 20, 0%. Four patients had documented episodes of bleeding and received seven doses of vitamin K1. Twenty-six patients received fresh frozen plasma with vitamin K1. Overall compliance with ACCP-recommended doses and routes of vitamin K1 was only 17.2%.

CONCLUSION

The most frequently prescribed administration routes for vitamin K1 were subcutaneous and intravenous, indicating that the oral route is often not used as recommended. The vitamin K1 doses prescribed for reversal of warfarin anticoagulation were highly variable, and for most (83%) patients, the recommended guidelines were not followed. The clinical significance of noncompliance with the ACCP guidelines for vitamin K1 administration warrants further study.

The incidence of anaphylaxis following intravenous phytonadione (vitamin K1): a 5-year retrospective review

BACKGROUND

Phytonadione (vitamin K1) administered intravenously (i.v.) has been associated with anaphylaxis, although the incidence is not known. The anaphylaxis is thought to be attributable to the solubilizing vehicle, polyethoxylated castor oil (Cremophor EL, BASF AG, Ludwingshafen, Germany).

OBJECTIVE

To estimate the incidence of anaphylaxis after i.v. administration of phytonadione.

METHODS

A retrospective review of anaphylaxis after i.v. phytonadione over a 58-month period at a large academic center was performed. During the period of the study a protocol for the administration of i.v. phytonadione was in place. A review of computerized records and survey of staff identified cases of anaphylaxis meeting predefined inclusion criteria. In addition, a literature review was performed for articles concerning anaphylaxis after i.v. phytonadione.

RESULTS

Over the 58 months of the study, a total of 6,572 doses of i.v. phytonadione were administered. Two cases of anaphylaxis after i.v. phytonadione were identified. The incidence of anaphylaxis was 3 per 10,000 doses with 95% confidence intervals of 0.04 to 11 per 10,000 doses. The literature review identified 14 cases meeting inclusion criteria with no reviews of the literature or estimates of incidence.

CONCLUSIONS

The incidence of anaphylaxis after i.v. phytonadione is overall comparable or slightly less than other drugs known to cause anaphylaxis. We do not recommend routine pretreatment with antihistamines or corticosteroids before administration of phytonadione.

Efficacy and safety of intravenous phytonadione (vitamin K1) in patients on long-term oral anticoagulant therapy

OBJECTIVES

To determine the safety and efficacy of intravenously administered phytonadione (vitamin K1) in patients on routine oral warfarin anticoagulation.

PATIENTS AND METHODS

This retrospective cohort study comprised adults who were taking warfarin, were not bleeding, and received intravenous phytonadione anticoagulation therapy before a diagnostic or therapeutic procedure between September 1, 1994, and March 31, 1996. The main outcome measures were adverse reactions to intravenously administered phytonadione, prothrombin-international normalized ratio time values, the incidence of bleeding and thrombosis after the procedure, and the time between the procedure and return to anticoagulation after resumption of warfarin treatment.

RESULTS

Two (1.9%) of the 105 patients studied had suspected adverse reactions to intravenous phytonadione (dyspnea and chest tightness during infusion in both). For the 82 patients who underwent a procedure, the median time from phytonadione to procedure onset was 27 hours (range, 0.7-147 hours), which was significantly less for patients receiving an initial phytonadione dose of more than 1 mg (P=.009). None had thromboembolism after surgery, although 2 (2.4%) of the 82 patients had procedure-associated major bleeding. For the 60 patients resuming warfarin therapy after a procedure, the median time to return to therapeutic anticoagulation was 4.1 days (range, 0.8-31.7 days) and was unaffected by the phytonadione dosage.

CONCLUSIONS

Intravenous phytonadione appears to be safe and is effective for semiurgent correction of long-term oral anticoagulation therapy before surgery. In small doses, it does not prolong the patient's time to return to therapeutic anticoagulation.

Cutaneous reactions associated with vitamin K1

BACKGROUND

Vitamin K1 (phytonadione) is a fat-soluble, naturally occurring vitamin used to treat certain coagulation disorders. A review of the adverse cutaneous reactions to Vitamin K1 is important because this diagnosis can be easily overlooked. This is due to their low incidence and because the presentation and morphology can vary considerably.

OBJECTIVE

The objective of this article is to summarize the different morphologies, the natural history, and the treatment of the cutaneous reactions reported to Vitamin K1.

METHODS

A case of a patient who developed a localized eczematous plaque at the site of a vitamin K1 injection is outlined. A review of the English medical literature focused on the adverse cutaneous reactions associated with intramuscular or subcutaneous use of vitamin K1.

RESULTS

Our patient developed a localized eczematous reaction to subcutaneous vitamin K1. The eruption developed within 7 days of her dose of vitamin K1. The eruption persisted for 18 months despite treatment with topical and intralesional steroids. There are three distinct types of cutaneous reactions to vitamin K1: localized eczematous, localized morphea-form, and, very rarely, diffuse maculopapular eruption. The eczematous type (32 cases) appears at the site of injection, and the median number of days between injection and appearance of the eruption is 13 days. The dose range required to initiate the reaction is broad (10 to 410 mg). Thirteen of 32 cases took more than 2 months to resolve. The morphea-form type (7 cases) is a localized morphea-form patch that appears at the site of injection. The average delay before presentation of morphea-form changes was 8.5 months (range: 5 weeks-1.5 years). The dose range is broad (30-2080 mg), and the prognosis for resolution very poor.

CONCLUSION

The diagnosis of an adverse cutaneous reaction to vitamin K can be made if the possibility is considered. Many of these reactions are very slow to clear up and some may persist as a chronic sclerodermoid change. Managing these reactions may be frustrating for both the patient and the clinician.

Combined effects of inhaled nitric oxide (iNO) and oxidant agents on the production of methemoglobinemia in newborn piglets

OBJECTIVE

To investigate the effects of the association of inhaled nitric oxide (iNO) and oxidant drugs (acetaminophen, phytomenadione, and EMLA cream) on methemoglobinemia during the neonatal period.

DESIGN

Prospective, randomized, experimental study.

SETTING

University Experimental Pharmacology laboratory.

SUBJECTS

Sixty newborn piglets weighing 1.5-2.0 Kg.

INTERVENTIONS

Twelve groups of five piglets were anaesthetized, mechanically ventilated, and studied for 3 hrs. Eight groups received iNO (40 ppm or 80 ppm) alone or in association with a single intravenous dose of acetaminophen (120 mg/kg propacetamol), phytomenadione (5 mg vitamin K1) or EMLA cream (2.5 g) applied to the ventral lower abdomen for 3 hrs. Three other groups received, respectively, acetaminophen, phytomenadione, or EMLA cream without iNO. The last group (control group) received neither drugs nor iNO.

MEASUREMENTS AND MAIN RESULTS

Methemoglobinemia was measured before the beginning of each experiment, 30 mins later, and every hour for 3 hrs. There was no significant difference in methemoglobinemia at any time between groups receiving acetaminophen (0.90%+/-0.12%), phytomenadione (0.88%+/-0.11%), or EMLA cream alone (0.97%+/-0.11%) and the control group (0.92%+/-0.12%). At 3 hrs, methemoglobinemia was slightly but significantly increased in group receiving iNO alone (1.04%+/-0.17% at 40 ppm iNO and 1.14%+/-0.16% at 80 ppm iNO; p < .05). Conversely, methemoglobinemia increased as a function of time in groups in which iNO was associated to drug administration and was significantly greater than the control group at 3 hrs (80 ppm iNO + acetaminophen, 2.80%+/-0.47%; 80 ppm iNO + phytomenadione, 2.38%+/-0.45%; 80 ppm iNO + EMLA cream, 2.33%+/-046%; p < .001).

CONCLUSIONS

These results demonstrate that if oxidant drugs (acetaminophen, phytomenadione, or EMLA cream) did not increase blood methemoglobinemia in neonatal piglets, their association with iNO caused an increase in methemoglobin. Special care should be taken to monitor methemoglobinemia when iNO is combined to such drugs in newborn infants.

Cutaneous allergic reaction to intramuscular vitamin K1

A 40-year-old woman with no pre-existing hepatic disease developed a cutaneous allergic reaction to intramuscular vitamin K1. She received this medication prophylactically prior to surgery, developed severe localized, and subsequently generalized, dermatitis, beginning 5 days after administration of the Konakion Cremophor-EL form of vitamin K1 by intramuscular injection at four sites on her thighs. Investigation by patch and intradermal testing revealed delayed-type hypersensitivity to Konakion Cremophor-EL, Konakion Mixed Micelles and pure vitamin K1, but not Cremophor-EL vehicle alone. This case is unusual because the patient was also shown to be patch test positive to vitamin K3 sodium bisulfite.

Oral versus intramuscular phytomenadione: safety and efficacy compared

Oral and intramuscular phytomenadione (vitamin K1) prophylaxis became an issue following the report of a potential carcinogenic effect of intramuscular but not oral phytomenadione prophylaxis. There is increasing evidence, however, that oral phytomenadione prophylaxis is less effective for the prevention of late vitamin K deficiency bleeding (VKDB) than intramuscular prophylaxis. Following a report of an increased cancer risk after intramuscular phytomenadione, a series of papers on this issue appeared. Although an increased risk for solid tumours could almost certainly be excluded, a potential risk for acute lymphatic leukaemia in childhood could not be ruled out definitively. Almost all cases of late VKDB are preventable with intramuscular phytomenadione prophylaxis administered once at birth, whereas a single oral dose given at birth is much less effective. Repeated oral phytomenadione doses given to breast-fed infants either weekly (1 mg) or daily (25 microg) seem to be as effective as intramuscular phytomenadione prophylaxis. The efficacy of 3 oral 2mg doses with the new mixed micellar preparation ('Konakion MM') remains to be established. Although a number of studies have failed to confirm a cancer risk with phytomenadione, these studies have been unable to rule out a risk definitely because absence of evidence is not evidence of absence. A meta-analysis of the available studies might provide 95% confidence intervals narrow enough to exclude even a small cancer risk with some certainty. Oral prophylaxis will probably be as safe as the intramuscular prophylaxis if given daily (25 microg) or weekly (1 mg).

Effect of vitamin K1 on glucose-6-phosphate dehydrogenase deficient neonatal erythrocytes in vitro

AIM

To determine whether vitamin K1, which is routinely administered to neonates, could act as an exogenous oxidising agent and be partly responsible for haemolysis in glucose-6-phosphat-dehydrogenase (G-6-PD).

METHODS

G-6-PD deficient (n = 7) and control (n = 10) umbilical cord blood red blood cells were incubated in vitro with a vitamin K1 preparation (Konakion). Two concentrations of Vitamin K1 were used, both higher than that of expected serum concentrations, following routine injection of 1 mg vitamin K1. Concentrations of reduced glutathione (GSH) and methaemoglobin, indicators of oxidative red blood cell damage, were determined before and after incubation, and the mean percentage change from baseline calculated.

RESULTS

Values (mean (SD)) for GSH, at baseline, and after incubation with vitamin K1 at concentrations of 44 and 444 microM, respectively, and percentage change from baseline (mean (SD)) were 1.97 + 0.31 mumol/g haemoglobin, 1.89 +/- 0.44 mumol/g (-4.3 +/- 13.1%), and 1.69 +/- 0.41 mumol/g (-14.5 +/- 9.3%) for the G-6-PD deficient red blood cells, and 2.27 +/- 0.31 mumol/g haemoglobin, 2.09 +/- 0.56 mumol/g (-7.2 +/- 23.2%), and 2.12 +/- 0.38 mumol/g (-6.0 + 14.1%) for the control cells. For methaemoglobin (percentage of total haemoglobin), the corresponding values were 2.01 +/- 0.53%, 1.93 +/- 0.37% (-0.6 +/- 17.4%) and 2.06 +/- 0.43% (5.7 +/- 14.2%) for the G-6-PD deficient red blood cells, and 1.56 +/- 0.74%, 1.70 +/- 0.78% (12.7 +/- 21.9%), and 1.78 +/- 0.71% (20.6 +/- 26.8%) for the control red blood cells. None of the corresponding percentage changes from baseline was significantly different when G-6-PD deficient and control red blood cells were compared.

CONCLUSIONS

These findings suggest that G-6-PD deficient red blood cells are not at increased risk of oxidative damage from vitamin K1.

[Scleroderma-like patch on the thigh in infants after vitamin K injection at birth: six observations]

INTRODUCTION

Texier's disease or pseudosclerodermatous reaction after intramuscular injection of vitamin K1 is well known in adults although only 1 report of a case in a newborn was found in the literature. We report 6 cases.

CASE REPORTS

Six infants (4 boys, 2 girls) developed "peau d'orange" skin lesions after the age of 6 months which was localized in the lower third of the medial aspect of the thigh. Initial rapid locoregional extension was followed by stabilization and then regression. In all 6 cases, histology showed lesions of the fascia and/or the deep hypoderma associated with variable mononuclear inflammatory infiltration and hyalin fibrosis. When performed, immunological studies (complement fixation, search for autoantibodies) were always negative or normal. No visceral involvement was found.

DISCUSSION

A pseudosclerodermatous lesion of the lower third of the thigh occurred in 6 infants at the site of an intramuscular injection of vitamin K1 administered at birth. The history, clinical manifestations, histology and outcome of these cases are compatible with the diagnosis of Texier's disease. We discuss the role of the solvent in the Roche vitamin K1 injection. The pathogenesis of this side effect remains unknown.

CONCLUSION

Texier's disease in infants after injection of vitamin K1 at birth is a stereotypic dermatosis. Diagnosis is based on history and clinical presentation. The causal effect of injectable vitamin K1 should be entertained whenever pseudosclerodermatous lesions are observed in a young child.

Vitamin K1-induced localized scleroderma (morphea) with linear deposition of IgA in the basement membrane zone

We describe a 45-year-old white man in whom distinctive clinical and histologic features of localized scleroderma developed at sites of injection of vitamin K1 (phytonadione). A direct immunofluorescence test demonstrated prominent linear deposition of IgA along the basement membrane zone. No circulating antibasement membrane zone IgA antibodies were identified on indirect immunofluorescence testing. We believe that the unusual immunofluorescence finding in our patient is nonspecific and represents an epiphenomenon caused by cutaneous injury.

Pharmacokinetics and tolerance of intravenous and intramuscular phylloquinone (vitamin K1) mixed micelles formulation

1. The pharmacokinetics and tolerance of phylloquinone(vitamin K1) mixed micelles formulation (Konakion MM) were evaluated, in normal human adult volunteers (n = 30) using an open randomized crossover design protocol following a 10 mg intravenous or intramuscular injection. 2. Blood samples were collected for up to 12 h after the intravenous and up to 72 h after the intramuscular injections and the phylloquinone(vitamin K1) levels determined by reversed phase h.p.l.c. with fluorometric detection after post-column electrochemical reduction. 3. Konakion MM was well tolerated after either route of administration. Pharmacokinetic analysis of plasma phylloquinone(vitamin K1) concentration vs time profiles revealed that in one-fifth of the subjects systemic availability of intramuscular phylloquinone (vitamin K1) was below 65%. 4. Our data suggest that due to sustained, but irregular and unpredictable absorption of the phylloquinone(vitamin K1) from the depot site, the intramuscular route of Konakion MM administration is not suitable and thus not recommended. 5. Konakion MM i.v. is indicated to be well tolerated and effective in antagonizing coumarin-type-anticoagulants like Marcoumar.

Pseudoscleroderma secondary to phytomenadione (vitamin K1) injections: Texier's disease

Cutaneous reactions to vitamin K1 (phytomenadione) are uncommon. They can present as acute eczematous reactions or late reactions that resemble localized scleroderma after vitamin K1 injections. A case is reported here of a patient who developed bilateral sclerodermoid plaques in a cowboy's holster pattern, which persisted for more than 10 years after subcutaneous vitamin K1 injections. Positive intradermal test with vitamin K1 that persisted as an erythematous indurated plaque at the test site for more than 5 months confirmed marked cutaneous hypersensitivity to vitamin K1 in this patient. Serial biopsies of the erythematous plaque at the test site showed transition from spongiotic eczematous features initially to inflammatory morphoea-like histology over a 5 month period. Possible pathogenic mechanisms for phytomenadione-induced pseudoscleroderma are discussed.

Cutaneous hypersensitivity reactions to vitamin K: 2 case reports and a review of the literature

Between 1964 and 1994, at least 52 patients with cutaneous adverse effects of vitamin K have been described in the European and North American literature. A review of the details of these patients is given and 2 new cases reported. Adverse effects are seen not only in patients with liver-function disturbances but also in patients without liver diseases, and occur mostly after intramuscular or subcutaneous administration of vitamin K1, independent of the total dose. Patch and intracutaneous tests often give positive reactions. The mechanism of action is probably in many patients a delayed-type hypersensitivity reaction.

Cutaneous reactions to vitamin K1 injections

Cutaneous reactions to vitamin K1 injections are reported infrequently. Most previously reported cases have been associated with liver disease, primarily alcoholic cirrhosis and viral hepatitis. Four new cases are reported. One patient had polycythemia vera and the Budd-Chiari syndrome, the second such report in the literature. The other three patients had no known hepatic disease. The reactions consisted of erythematous plaques at the injection site without progression to sclerodermatous plaques. Histopathologic examination in three cases showed spongiotic changes and mononuclear infiltrates typical of cutaneous reactions to vitamin K1. In one instance a neutrophilic infiltrate was associated with the reaction site. Our findings support the observation that liver disease is not a necessary condition for the occurrence of vitamin K1 hypersensitivity.

Childhood cancer, intramuscular vitamin K, and pethidine given during labour

OBJECTIVE

To assess unexpected associations between childhood cancer and pethidine given in labour and the neonatal administration of vitamin K that had emerged in a study performed in the 1970 national birth cohort.

DESIGN AND SETTING

195 children with cancer diagnosed in 1971-March 1991 and born in the two major Bristol maternity hospitals in 1965-87 were compared with 558 controls identified from the delivery books for the use of pethidine during labour and administration of vitamin K.

MAIN OUTCOME MEASURES

Odds ratios for cancer in the presence of administration of pethidine or of intramuscular vitamin K. Both logistic regression and Mantel-Haenszel techniques were used for statistical analyses.

RESULTS

Children of mothers given pethidine in labour were not at increased risk of cancer (odds ratio 1.05, 95% confidence interval 0.7 to 1.5) after allowing for year and hospital of delivery, but there was a significant association (p = 0.002) with intramuscular vitamin K (odds ratio 1.97, 95% confidence interval 1.3 to 3.0) when compared with oral vitamin K or no vitamin K. There was no significantly increased risk for children who had been given oral vitamin K when compared with no vitamin K (odds ratio 1.15, 95% confidence interval 0.5 to 2.7). These results could not be accounted for by other factors associated with administration of intramuscular vitamin K, such as type of delivery or admission to a special care baby unit.

CONCLUSIONS

The only two studies so far to have examined the relation between childhood cancer and intramuscular vitamin K have shown similar results, and the relation is biologically plausible. The prophylactic benefits against haemorrhagic disease are unlikely to exceed the potential adverse effects from intramuscular vitamin K. Since oral vitamin K has major benefits but no obvious adverse effects this could be the prophylaxis of choice.

Pharmacokinetics and safety of a new solution of vitamin K1(20) in children with cholestasis

In cholestatic diseases, the absorption of fat-soluble compounds, including vitamin K1(20), is low and periodic administration of vitamin K1(20) is often necessary. Due to the low absorption of vitamin K1(20) from the Konakion formulation, late hemorrhagic disease of the newborn also occurs especially after oral vitamin K1(20) prophylaxis with Konakion. We investigated the pharmacokinetics and the safety of a new formulation of vitamin K1(20) in a mixed micelles (MM) solution. Compared to the old formulation (Konakion) using Cremophor EL as a solubilizer, the higher vitamin K1(20) levels (as measured by HPLC) in serum obtained after oral administration of the MM formulation clearly demonstrate a superiority of this new formulation. Additionally, the elimination of Cremophor EL as well as of propylene glycol from the formulation avoids possible adverse effects associated with intravenous or intramuscular administration. Furthermore, in most cases, the discomfort of parenteral injections can be overcome by simple oral administration even in children with severe cholestasis.

New histopathologic findings in drug eruptions

Several new findings associated with hyperpigmentation have been reported in the past decade, the most notable being amiodarone-induced hyperpigmentation, which was shown to demonstrate both a lymphocytic dermatitis as well as yellowish brown granules that can be found within several cell types. The nature of this material has not been elucidated, although the drug or one of its metabolites composes at least a portion of the granules. The nature of the clofazimine-induced hyperpigmentation was shown to be caused by the accumulation of a ceroid lipofuscin within lipid-laden macrophages. Several chemotherapy-induced clinical and histologic changes have been reported in the past decade because of new chemotherapeutic drugs, better recognition of histologic reaction patterns, and the use of higher dosages by oncologists. A unique dermatitis, cutaneous eruption of lymphocyte recovery--although not directly due to use of chemotherapeutic agents--occurs after the return of immunocompetent lymphocytes in the peripheral circulation and skin, producing a maculopapular eruption that demonstrates a nonspecific superficial perivascular dermatitis on biopsy. Another clinically specific reaction, chemotherapy-induced acral erythema, demonstrates a nonspecific histologic pattern characterized by an interface dermatitis. Specific histologic patterns were reported for reactions following use of etoposide--starburst cells--and of busulfan--large atypical keratinocytes. There have been reports of new reactions due to chemotherapeutic agents involving sweat glands: neutrophilic eccrine hidradenitis, characterized by neutrophils and necrosis; and syringosquamous metaplasia, a histologic reaction of the sweat duct characterized by squamous metaplasia. New inflammatory reaction patterns include drug-induced generalized pustular toxic erythema, which histologically shows subcorneal pustules and occasional eosinophils. Cephalosporins were reported to produce a syndrome that clinically and histologically resembles pemphigus. Naproxen is reported to produce a clinical and histologic reaction similar to porphyria cutanea tarda. Quinine and piroxicam both induce a photosensitive dermatitis that histologically shows a nonspecific spongiotic dermatitis. A histologically unique reaction pattern manifesting as a lichenoid giant cell dermatitis may be produced by use of either methyldopa or chlorothiazide. Both phenytoin and carbamazepine produce a dermatitis that histologically imitates mycosis fungoides. Finally, phytonadione injections may produce a clinical and histologic reaction that resembles morphea.

Analysis of chromosome aberrations and sister chromatid exchanges in peripheral blood lymphocytes of newborns after vitamin K prophylaxis at birth

In many countries vitamin K prophylaxis at birth is recommended to prevent bleeding in infants due to vitamin K deficiency. Because the incidence of clinical vitamin K deficiency is very low, such a vitamin K administration should be completely safe. However, an increase in sister chromatid exchanges in lymphocytes of fetal sheep 24 h after injection of vitamin K1 has been reported. Therefore, a study concerning genotoxicity of vitamin K1 in man was conducted. Sister chromatid exchanges and chromosome aberrations were analyzed in peripheral blood lymphocytes of six newborns 24 h after intramuscular administration of 1 mg vitamin K1 and in six control neonates. The mean number of sister chromatid exchanges per metaphase in the vitamin K group was 8.88 +/- 1.22 as compared with 9.05 +/- 1.14 in the control group (NS). The mean number of chromosome aberrations per 100 mitoses was 3.00 +/- 2.61 in the vitamin K group and 2.50 +/- 1.87 in the control group (NS). Vitamin K1 plasma concentrations ranged from 115 to 1150 ng/mL (255 to 2555 x 10(-9) M) in the supplemented group, a 5000-fold rise as compared with the control group (p less than 0.01). We did not find any evidence for genetic toxicity due to the administration of 1 mg vitamin K1 intramuscularly to the newborn child.

Vitamin K therapy in severe liver disease

A middle-aged man with parenchymatous liver disease and a decrease in vitamin K-dependent factors was given large doses of intravenous phylloquinone (10 mg/d for 20 days) without improvement in the synthesis of vitamin K-dependent factors. During subsequent liver transplantation, he exsanguinated. Although the exact role of over treatment with phylloquinone in this case is unclear, plasma levels of phylloquinone 300 times normal were attained after 5 days of treatment without effect on factors II, VII, IX, and X. Further therapy with vitamin K was unnecessary.

Pseudoscleroderma secondary to phytonadione (vitamin K1) injections

Two patients showed symmetrical sclerodermoid (morphea-like) skin lesions at sites of intramuscular phytonadione (vitamin K1) injections. The lesions appeared one and two years after the injections. A dense sclerosis involving the reticular dermis and subcutaneous fat was observed on histologic examination of biopsy specimens. Local adverse reactions to phytonadione are reviewed. Possible causative mechanisms for phytonadione-induced pseudoscleroderma are discussed.

Severe complication to phytomenadione after intramuscular injection in woman in labor. Case report and review of literature

A 28-year-old woman in labor developed a severe anaphylactoid reaction, necessitating acute cesarean section, with subsequent neonatal death, after receiving 10 mg of phytomenadione (Konakion) by the intramuscular route. Allergologic investigations revealed no type I reaction against the drug, and the symptoms were considered to be caused by drug-induced intolerance. Prophylactic administration of phytomenadione to the infant rather than to the parturient is recommended.

Cutaneous hypersensitivity to vitamin K1 injection

Cutaneous hypersensitivity to vitamin K1 injection has been reported once in North America. This case and most of the others in European literature have been associated with alcoholic liver disease. We report six patients who developed persistent skin hypersensitivity reactions at the site of vitamin K1 injection. These cases are the first reported to occur in liver disease associated with primary biliary cirrhosis, chronic myeloid leukemia, amyloidosis, and preeclampsia. Patch and intradermal skin tests demonstrated a hypersensitivity that seems to have an immune basis and is restricted to fat-soluble vitamin K1. This finding suggests that patients with any type of liver disease may be at risk for vitamin K hypersensitivity and that the hypersensitivity may be a marker of liver disease.