Megavitamin-B6 syndrome
Megavitamin-B6 syndrome | |
---|---|
Other names | Vitamin B6 Excess, Hypervitaminosis B6, Vitamin B6 Toxicity[1][2] |
Specialty | Neurology, toxicology |
Symptoms | Peripheral sensory neuropathy |
Usual onset | Gradual onset with slow progression, in the usual case of chronic vitamin B6 supplementation.[3] |
Duration | Usually, but not always, resolves within six months from the cessation of vitamin B6.[4] |
Causes | Chronic vitamin B6 supplementation, or acute parenteral or oral over‐dosages of vitamin B6.[5][4][6][7][8] |
Risk factors | Impaired kidney function, parenteral nutrition[9] |
Diagnostic method | Serum testing for elevated levels of vitamin B6, testing of tendon reflexes, nerve conduction studies and electrodiagnostic testing.[10][11] |
Differential diagnosis | Progressive mixed sensory or sensorimotor polyneuropathy of undetermined etiology.[12][13] |
Treatment | Cessation of vitamin B6 supplementation.[14] |
Prognosis | Symptom progression for 2-6 weeks following cessation of vitamin B6, followed by gradual improvement.[14][4][15][16] |
Megavitamin-B6 syndrome, also known as hypervitaminosis B6, vitamin B6 toxicity, and vitamin B6 excess,
The syndrome is notable not only for its impact on peripheral nerve function but also because of its generally, but not always, reversible nature upon cessation of vitamin B6 intake. Usually, but not always, cases resolve within six months after stopping the vitamin B6 supplementation, although some symptoms can intensify briefly after cessation—a phenomenon known as "coasting." Diagnosis typically involves serum tests to measure elevated levels of vitamin B6, along with nerve conduction studies and other neurodiagnostic evaluations.[4][14][15][16]
This condition underscores the importance of moderation in the use of dietary supplements, highlighting that even substances generally safe at recommended dosages can lead to serious health issues if taken excessively.[23]
Signs and symptoms
The predominant symptom is
Symptom severity appears to be dose-dependent (higher doses cause more severe symptoms)[26] and the duration of supplementation with vitamin B6 before the onset of systems appears to be inversely proportional to the amount taken daily (the smaller the daily dosage, the longer it will take for symptoms to develop).[15][4][10][12][7] It is also possible that some individuals are more susceptible to the toxic effects of vitamin B6 than others.[4] Megavitamin-B6 syndrome has been reported in doses as low as 24 mg/day.[33]
Symptoms may also be dependent on the
Early diagnosis and cessation of vitamin B6 supplementation can reduce the morbidity of the syndrome.[26][12]
Cause
While vitamin B6 is water-soluble, it accumulates in the body. The half-life vitamin B6 is measured at around two to four weeks,[39][40] it is stored in muscle, plasma, the liver, red blood cells and bound to proteins in tissues.[39][41][42]
Potential mechanisms
The common supplemental form of vitamin B6, pyridoxine, is similar to
Pyridoxine is converted to pyridoxal phosphate via two
Tolerable upper limits
Several government agencies have reviewed the data on vitamin B6 supplementation and produced consumption upper limits with the desired goal of preventing sensory neuropathy from excessive amounts. Each agency developed its own criteria for usable studies concerning tolerable upper limits, and as such, the recommendations vary by agency. Between agencies, current tolerable upper limit guidelines vary from 10 mg per day to 100 mg per day.[39]
Agency | Upper limit | Notes | Reference |
---|---|---|---|
National Health Service (NHS) United Kingdom | 10 mg/day | [43] | |
Norwegian Scientific Committee for Food and Environment (VKM) | 25 mg/day | In 2017 VKM proposed to raise this to 25 mg/day, it was previously 4.2 mg/day. | [39] |
Netherlands Food and Consumer Product Safety Authority ] (NVWA)
|
25 mg/day | Supplements may only contain dosages of 21 mg/day. | [44] |
European Food Safety Authority | 25 mg/day | [45] | |
Ministry of Health, Labour and Welfare (厚生労働省, Kōsei-rōdō-shō) Japan | 40–60 mg/day | The adult UL was set at 40–45 mg/day for women and 50–60 mg/day for men, with the lower values in those ranges for adults over 70 years of age | [46] |
National Health and Medical Research Council (NHMRC) Australia | 50 mg/day | [47] | |
U.S. Institute of Medicine - Food and Nutrition Board | 100 mg/day | [26] |
Reviews of vitamin B6 related neuropathy cautioned that supplementation at doses greater than 50 mg per day for extended periods may be harmful and should be discouraged.[48][49] In 2008, the Australian Complementary Medicines Evaluation Committee recommended warning statements appear on products containing daily doses of 50 mg or more vitamin B6 to avoid toxicity.[50]
The relationship between the amount of vitamin B6 consumed and the serum levels of those who consume it varies between individuals.[51] Some people may have high serum concentrations without neuropathy symptoms.[13][52][53] It is not known if inhalation of vitamin B6 while, for example, working with animal feed containing vitamin B6 is safe.[54]
Exceptions
High parenteral doses of vitamin B6 are used to treat isoniazid overdose with no adverse effects found,[4] although a preservative in parenteral vitamin B6 may cause transient worsening of metabolic acidosis.[4] High doses of vitamin B6 are used to treat gyromitra mushroom (false morel) poisoning, hydrazine exposure and homocystinuria[8][55] Doses of 50 mg to 100 mg per day may also be used to treat pyridoxine deficient seizures and when patients are taking other medications that reduce vitamin B6.[14] Daily doses of 10 mg to 50 mg are recommended for patients undergoing hemodialysis.[14]
Outside of rare medical conditions, placebo-controlled studies have generally failed to show benefits of high doses of vitamin B6.[28] Reviews of supplementing with vitamin B6 have not found it to be effective at reducing swelling, reducing stress, producing energy, preventing neurotoxicity, or treating asthma.[23]
Diagnosis
The clinical hallmark of megavitamin-B6 syndrome is ataxia due to sensory polyneuropathy. Blood tests are performed to rule out other causes and to confirm an elevated level of vitamin B6 with an absence of hypophosphatasia.[14][11][12][56][57] Examination does not typically show signs of a motor deficit, dysfunction of the autonomic nervous system or impairment of the central nervous system,[4][3] although in severe cases motor and autonomic imparement can occur.[14][12][58] When examined, patients typically have diminished reflexes (hyporeflexia), such as a diminished response when performing an ankle jerk reflex test.[14][24][3] Nerve conduction studies typically show normal motor conduction but a decrease in large sensory wave amplitude in the arms and legs.[24][10][14][13][3] Needle electromyography studies generally reveal no signs of denervation.[15]
Classification
Megavitamin-B6 syndrome is characterized mainly by degeneration of
, it has characteristic non-length-dependent abnormalities of sensoryTreatment
The primary treatment for megavitamin-B6 syndrome is to stop taking supplemental vitamin B6.[14] Physical therapy, including vestibular rehabilitation, has been used in attempts to improve recovery following cessation of vitamin B6 supplementation.[50][11] Medications such as amitriptyline have been used to help with neuropathic pain.[19]
In experimental tests using animal subjects,
Prognosis
Other than with extremely high doses of vitamin B6, neurologic dysfunction improves following cessation of vitamin B6 supplementation and usually, but not always, resolves within six months.[3][4] In cases of acute high doses, for example in people receiving daily doses of 2 grams of vitamin B6 per kilogram of body weight, symptoms may be irreversible and may additionally cause pseudoathetosis.[3][15][19][16][6][8]
In the immediate 2–6 weeks following discontinuation of vitamin B6, patients may experience a symptom progression before gradual improvement begins. This is known as coasting and is encountered in other toxic neuropathies.[14][4][15][16] A vitamin B6 substance dependency may exist in daily dosages of 200 mg or more, making a drug withdrawal effect possible when discontinued.[23]
See also
Notes
- ^ While megavitamin-B6 syndrome, hypervitaminosis B6, vitamin B6 toxicity and vitamin B6 excess are officially recognized, megavitamin-B6 syndrome is the ICD-10 name. Before the adoption of a recognized standard, ad-hoc terms for this appear in literature, often vitamin B6 and its most common supplemental vitamer, pyridoxine, are used interchangeably. Some other terms include vitamin B6 overdose,[17] pyridoxine abuse,[18][19] pyridoxine megavitamosis,[12] pyridoxine poisoning,[20] and pyridoxine neuropathy.[21]
- ^ The terms sensory ganglionopathy and sensory neuronopathy are interchangeable.[60]
References
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Vitamin B6 excess (hypervitaminosis B6) is caused by excessive consumption of supplemental pyridoxine, which is used as a therapeutic agent for several conditions.
- ^ a b "Hypervitaminosis B6 (Concept Id: C0238176) - MedGen - NCBI". MedGen. National Center for Biotechnology Information (NCBI). Archived from the original on 2019-11-05. Retrieved 2019-12-02.
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Pyridoxine toxicity is a recognised cause of sensory neuropathy. Schaumburg et al described sensory neuropathy after pyridoxine misuse in 1983. It can occur with chronic use of pyridoxine supplementation over several years, and also with acute over-dosage with parenteral pyridoxine.
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- ^ a b c Rohitha Moudgal; Shahla Hosseini; Patricia Colapietro; Oluwole Awosika (2018-04-25). "Vitamin B6 Toxicity Revisited: A Case of Reversible Pyridoxine-associated Neuropathy and Disequilibrium. (P4.021)". Neurology. 90 (15 Supplement). Archived from the original on 2019-10-20. Retrieved 2019-11-16.
- ^ a b c d e f g h Ahmed, Aiesha; Velazquez-Rodriguez, Yadira; Kaur, Divpreet (2014-04-08). "When Expected Turns Unexpected: A Case of Subacute Progressive Weakness and Paresthesias of the Distal Lower Extremities Following a Brief Diarrheal Episode. (P6.111)". Neurology. 82 (10 Supplement): P6.111. Archived from the original on 2019-09-27. Retrieved 2019-11-26.
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....a specific large-fibre neuropathy (with severe loss of proprioceptive function) is encountered clinically after vitamin B6 (pyridoxine).... All subjects showed paraesthesia and numbness as well as ataxia. The clinical examination showed a large sensory deficit with Achilles' reflex loss, associated with Romberg's signs (loss of proprioceptive control in which increased unsteadiness occurs when standing with the eyes closed compared with standing with the eyes open). The electromyographic examination showed a large sensory wave amplitude decrease but no change in the motor conduction.... small fibres were also involved as shown by the decreased SNCV and the altered thermosensitivity detected in the hot plate test. The same signs are observed in humans suffering from pyridoxine-induced neuropathy.
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Further reading
- A chapter with a story about a woman experiencing a severe case of Megavitamin-B6 syndrome titled "The Disembodied Lady" appears in Chapter 3 of ISBN 978-0-684-85394-9.
- An ISBN 978-1-4985-9535-3.