The first workshop ever in Myanmar on the topic of "How to reduce unnecessary IV/IM vitamin injection in primary care". This is a part of this workshop and evidenced that injections exceed the RDA (Recommended Daily Allowance) of various vitamins.

1. Biochemical & Nutritional
Aspects of IV/IM Injection
of Vitamins
Dr Theikdi Oo
M.B.,B.S (Ygn), Dip.Med.Sc (Family Medicine)

3. Sources of Water-soluble Vitamins

4. Recommended Daily Allowance of Water-
soluble Vitamins

6. Thiamine (Vitamin-B1)
 Sources – fortified bread & cereals, fish, lean meat and milk
 Daily requirements – 1.2-1.5 mg (0.8mg per 2000 Cals)
 Biochemical functions – as coenzyme for pyruvate
dehydrogenase (Pyruvate → acetyl CoA), for α-ketogluterate
dehydrogenase (α-ketogluterate → succinyl CoA), for
transketolase (in Pentose Phosphate Pathway), for α-keto acid
dehydrogenases (for amino acid catabolism)

7. Biochemical Function of Thiamine
 Major co-enzyme in energy
metabolism pathway, Citric Acid
Cycle

8. Uses of Thiamine
Certainly effective for –
 Metabolic disorders
 Thiamine deficiency
 Wernicke-Korsakoff syndrome (WKS)
Possibly effective for –
 Cataracts
 Kidney disease in people with diabetes
 Painful menstruation (dysmenorrhea)
* WebMD – vitamins and supplements

9. Thiamine Deficiency

11. Pyridoxine (Vitamin-B6)
 Sources – meat, fish, potato, banana, vegetables
and intestinal microflora synthesis
 Daily requirements – 1.4 mg (♂), 1.2 mg (♀)
 Biochemical functions – transamination (coenzyme
for SGOT & SGPT), decarboxylation (L-Glutamate →
ϒ-amino butyrate), deamination, heme synthesis,
production of niacin, as an integral part of glycogen
phosphorylase

12. Biochemical Function of Pyridoxine
1. Transamination
2. Decarboxylation
3. Heme synthesis (coenzyme of ALA synthesis in
formation of α-amino-β-keto adipic acid)

13. Uses of Pyridoxine
Effective for –
 Sideroblastic anaemia
 Pyridoxine dependent seizures
 Pyridoxine deficiency
Likely effective for –
 High blood homogentisate level
Possibly effectively for –
 Macular degeneration
 Hyperkinetic cerebral dysfunction
 Kidney stones (oxalate)
 Premenstrual syndrome
 Tardive dyskinesia
 Vomiting in pregnancy
 Lung CA prevention in those who smoke
* WebMD – vitamins and supplements

14. Deficiency of Pyridoxine
Neurological manifestation
 Demyelination of nerves
 Seizures
Dermatological manifestation
 Pellagra (d/t ↓ed niacin biosynthesis)
Hematological manifestation
 Hypochromic microcytic anemia (d/t ↓ed
heme synthesis)

16. Cobalamin (Vitamin-B12)
 Sources – animal products, bacterial colonization
 Daily requirement – 1.5-3 μg
 Biochemical function – methionine & cysteine
metabolism, isomerization of methty melonyl CoA

17. Biochemical Functions of Cobalamin

18. Biochemical Functions of Cobalamin

19. Uses of Cobalamin
Effective for –
 Cobalamin deficiency
 Pernicious anemia
Likely effective for –
 Cyanide poisoning
 Homocysteinuria
Possibly effective for -
 Macular degeneration (ARMD)
Not enough evidence –
 Alzheimer’s disease
* WebMD – vitamins and supplements

20. Deficiency of Cobalamin

21. Deficiency of Cobalamin

22. Deficiency of Cobalamin

23. Ascorbic Acid
 Sources – citrus fruits, fresh fruits, fresh & frozen
vegetables
 Daily requirement – 50-60mg (according to age)

24. Biochemical functions –
 Collagen synthesis (hydroxylation of proline &
lysine),
 Catabolism of tyrosine,
 Catacholamine & steroid hormone synthesis,
 Bile acid formation,
 Anti-oxidant action (inhibit nitrosamine),
 Reducing agent(Fe2+ absorption),
 ? Immunity

27. Uses of Ascorbic Acid
Effective for –
 Vitamin C deficiency
Likely effective for –
 Iron absorption
 Newborns with tyrosinemia
Possibly effective for –
 ARMD (age related macular degeneration)
 Reduce hardening of atherosclerotic vessels
 Anti-cancer
 Chronic regional pain $
 Lead poisoning
 Methemoglobinemia
 Osteoarthrosis
* WebMD – vitamins and supplements

29. It is not only the vitamins that is
unnecessarily being injected…..

30. Glucose
 Undoubtedly certain “Energy supply” for our body systems
 Sources – ………..
 Biochemical functions of glucose – key substrate in
glycolysis/glycogenesis/HMS/uronic acid pathways,
precursor for lipogenesis/cholesterol synthesis through
supplying “Acetyl CoA” from glycolysis pathway, and many
others …..
Energy value from
 1 ampoule of 25%(50%) glucose = 20(40) Cals

31. No matter how important these vitamins
are, over-use/misuse of such elements
are not without RISKS …..
also because of routes of administration
(through IV/IM injection)

32. Side effects of Injections – You should not
ignore them!
For IM injection -
 Abscess
 Pain
 Nerve palsy (anatomically unsound injection site)
 Provocation of poliomyelitis
 Hematoma (especially in hemophiliacs)
For IV injection -
 Phlebitis
 Transmission of blood borne infection
 Infective endocarditis (impurities from cutting materials)
 And so on…..

33. Every thing should be in balance
– bad if either less or more.

34. Toxicity of Thiamine Excess
 Anaphylaxis (rare orally), skin irritation*
 Mild & transient dizziness and flushing
* WebMD – vitamins and supplements

35. Toxicity of Pyridoxine Excess
Doses > 2mg (RDA) would leads to
 seizures in infants
 Neuropathy in adults (probably)
Drug interaction
 Amiodarone (↑ed photosensitivity)
 Phenobarbital (↑ed breakdown)
 Phenytoin (↑ed breakdown)
 Levodopa (↑ed peripheral conversion of dopamine)
* WebMD – vitamins and supplements

36. Toxicity of Cobalamin Excess
 Hypokalemia (as forming red cells take up K+ into
the cells)
 Allergic reactions
* WebMD – vitamins and supplements

37. Toxicity if excess – dose > 2000 mg (renal stone d/t
↑ed oxalate synthesis, diarrhea, etc.,)

38. Other Vitamins

39. Vitamins Sources RDA Biochemical
Functions
Use
(other than deficiency)
Riboflavin Milk, milk
products, cereals,
bread
1.3 mg (♂)
1.2 mg (♀)
Electron transfer Cataract, homocysteinemia,
migraine prophylaxis
Niacin Meats, cereals 17 mg (♂)
13 mg (♀)
Electron transfer High chol:, OA, Alzheimer’s
d/s, prevention of cataract,…
Pantothenic
Acid
Animal, plants 5-10 mg Acyl carrier as
Coenzyme A
Topical dexpanthenol after
radiation Tx
Biotin Egg yolk, bacterial
flora
(avidin in white of
egg - ↓ absorption)
100-300
mg
Carboxylation reactions Seborrheic dermatitis in
infants
Folic Acid Liver, green leafy
vegetables,
fortified cereals
200 μg Transfer of one-carbon
units, synthesis of
methionine, purines,
thymine
Homocysteinemia, to counter
anti-folate agents, to prevent
birth defects, ARMD,
depression, gum problem in
preg:/phenytoin Tx

40. Vitamins Deficiency Excess
Riboflavin Angular stomatitis Relatively safe
Niacin Pellagra Commom minor S.E (flushing (↑
by alcohol), GI upset), ↑ RBS,
irregular HR when > 3G taken,
allergy, ↑ GB d/s & gout attack
Pantothenic Acid Burning foot $ (rare) Should be avoided in hemophilia
and stomach obstruction
(Dexpanthenol)
Biotin Depression, hallucination, m/s
pain, dermatitis
(–)
Folic Acid Megaloblastic A°, glossitis,
fatigue/ loss of well-being
Avoid using after angioplasty,
precipitate SACD in B12 def:, may
↑ seizure frequency in epilepsy,
may ↑ risk of cancer

41. Thank You for Your Attention…..