Usual Adult Dose for Schilling Test

Flushing dose: 1000 mcg intramuscularly

Usual Adult Dose for Vitamin B12 Deficiency

Intramuscular formulation:
Initial dose: 30 mcg intramuscularly daily for 5 to 10 days
Maintenance dose: 100 to 200 mcg intramuscularly monthly

Comments:

• Patients with normal intestinal absorption may use oral preparations containing 15 mcg B12 daily.
• Isolated B12 deficiency is very rare.
• Conditions associated with malabsorption include tropical and nontropical sprue (idiopathic steatorrhea, gluten induced-enteropathy); folate deficiency is usually more severe than B12 deficiency in these patients.
• Total gastrectomy always causes B12 deficiency.
• Structural lesions associated with B12 deficiency include regional ileitis, ileal resections, and malignancies.
• The fish tapeworm (Diphyllobothrium latum) absorbs large quantities of B12, and gastric atrophy is common; the blind-loop syndrome may cause B12 or folate deficiency.
• Parenteral B12 is recommended for Addisonian Pernicious Anemia, with treatment being life long.

• Pernicious anemia, uncomplicated or with nervous system involvement
• Dietary B12 deficiency occurring in strict vegetarians and their breastfed infants
• B12 malabsorption from structural or functional damage to the stomach ( where intrinsic factor is secreted) or ileum (where intrinsic factor facilitates B12 absorption)
• Inadequate intrinsic factor secretions from gastric mucosa destroying lesions (e.g. ingestion of corrosives, extensive neoplasia) and other conditions associated with gastric atrophy (e.g. multiple sclerosis, endocrine disorders, iron deficiency, subtotal gastrectomy).
• Competition for B12 by intestinal parasites or bacteria
• Inadequate B12 utilization (e.g. during use of vitamin antimetabolites for neoplasia)

Usual Adult Dose for Cyanide Poisoning

Cyanokit(R):
Initial dose: 5 grams intravenously over 15 minutes (approximately 15 mL/min)

• A second 5-gram dose may be given depending on poisoning severity and clinical response.
• Second dose infusion rate ranges from 15 minutes (patients in extremis) to 2 hours as clinically indicated.

• If suspicion of cyanide poisoning is high, start treatment without delay.
• Regional poison control centers with expert advice can be reached at 800-222-1222.
• Administer in conjunction with airway, ventilatory, and circulatory support.
• Poisoning can occur via inhalation (including smoke from closed-space fires), ingestion, or dermal exposure to cyanide containing compounds, including hydrogen cyanide and its salts, aliphatic nitriles, cyanogenic plants, and prolonged sodium nitroprusside exposure.
• The presence and extent of poisoning are often unknown, and no confirmatory blood test is widely available or rapid.
• Base treatment decisions on clinical history and cyanide toxicity signs and symptoms.
• Cyanide poisoning signs and symptoms:
• Headache
• Confusion
• Dyspnea
• Chest tightness
• Nausea
• Altered mental status (e.g. confusion, disorientation)
• Seizures or coma
• Mydriasis
• Tachypnea/hyperpnea (early)
• Bradypnea/apnea (late)
• Hypertension (early) / hypotension (late)
• Cardiovascular collapse
• Vomiting
• Plasma lactate concentration 8 mmol/L or higher
• Panic symptoms (including tachypnea and vomiting) may mimic early cyanide poisoning signs.
• Altered mental status and/or mydriasis suggest true cyanide poisoning, although other toxic exposures can also cause these signs.
• Not all smoke inhalation patients will have cyanide poisoning; burns, trauma, and exposure to other toxins make diagnosing cyanide poisoning difficult.
• Before administration, assess smoke inhalation patients for exposure to fire/smoke in an enclosed area, soot around the mouth/nose/oropharynx, and altered mental status.
• Although hypertension strongly suggests cyanide poisoning, this occurs in only a small percentage of cyanide smoke inhalation poisonings.
• Plasma lactate 10 mmol/L or higher in smoke inhalation patients is suggestive of cyanide poisoning; this is higher than that listed as a typical cyanide poisoning sign because carbon monoxide from smoke inhalation also adds to serum lactate.
• Do not delay treatment of suspected poisoning to obtain plasma lactate.
• The safety of administering other cyanide antidotes concomitantly has not been studied; if used, do not administer concurrently via the same intravenous line.

Usual Adult Dose for Vitamin/Mineral Supplementation

Recommended Dietary Allowance (RDA): 2.4 mcg

Usual Pediatric Dose for Schilling Test

Flushing dose: 1000 mcg intramuscularly

Usual Pediatric Dose for Vitamin B12 Deficiency

Intramuscular formulation:
Initial dose: 100 mcg doses intramuscularly, totaling 1 to 5 mg and given over a period of 2 weeks or more
Maintenance dose: 30 to 50 mcg intramuscularly every 4 weeks

Comments:

• Isolated B12 deficiency is very rare.
• Conditions associated with malabsorption include tropical and nontropical sprue (idiopathic steatorrhea, gluten induced-enteropathy); folate deficiency is usually more severe than B12 deficiency in these patients.
• Total gastrectomy always causes B12 deficiency.
• Structural lesions associated with B12 deficiency include regional ileitis, ileal resections, and malignancies.
• The fish tapeworm (Diphyllobothrium latum) absorbs large quantities of B12, and gastric atrophy is common; the blind-loop syndrome may cause B12 or folate deficiency.
• Parenteral B12 is recommended for Addisonian Pernicious Anemia, with treatment being life long.

• Patients with normal intestinal absorption may use oral preparations containing 15 mcg B12 daily.
• Pernicious anemia, uncomplicated or with nervous system involvement
• Dietary B12 deficiency occurring in strict vegetarians and their breastfed infants
• B12 malabsorption from structural or functional damage to the stomach ( where intrinsic factor is secreted) or ileum (where intrinsic factor facilitates B12 absorption)
• Inadequate intrinsic factor secretions from gastric mucosa destroying lesions (e.g. ingestion of corrosives, extensive neoplasia) and other conditions associated with gastric atrophy (e.g. multiple sclerosis, endocrine disorders, iron deficiency, subtotal gastrectomy).
• Competition for B12 by intestinal parasites or bacteria
• Inadequate B12 utilization (e.g. during use of vitamin antimetabolites for neoplasia)

Usual Pediatric Dose for Vitamin/Mineral Supplementation

Estimated average requirement (EAR):
1 to 3 years: 0.7 mcg/day
4 to 8 years: 1 mcg/day
9 to 13 years: 1.5 mcg/day
14 to 18 years: 2 mcg/day

Recommended Dietary Allowance (RDA):
1 to 3 years: 0.9 mcg/day
4 to 8 years: 1.2 mcg/day
9 to 13 years: 1.8 mcg/day
14 to 18 years: 2.4 mcg/day

Renal Dose Adjustments

Data not available

• Hydroxocobalamin and cyanocobalamin are eliminated by the kidneys unchanged.

Liver Dose Adjustments

Data not available

Dose Adjustments

Recommended Dietary Allowance (RDA): 2.6 mcg in pregnancy; 2.8 mcg during lactation

Lactation: 50 to 100 mcg or more may be needed to correct deficiency during lactation (these doses do not expose the infant to excessive B12 and may improve status if B12 was previously inadequate).

Precautions

CONTRAINDICATIONS:

• None when used for cyanide poisoning
• Hypersensitivity to any of the ingredients (other indications)

Dialysis

Data not available

• May cause hemodialysis machines to shut down when the deep red color of hydroxocobalamin is seen as a "blood leak".

Other Comments

Storage requirements:

• Intramuscular solution: Protect from light

• Dilute 5-gram vial in 200 mL 0.9 NaCl; Lactated Ringers and 5% dextrose may be used if NaCl is not readily available.
• Rock or repeatedly invert diluted lipolyzed powder for at least 60 seconds until mixed; do not shake.
• Reconstituted 5-gram solution is stable up to 6 hours at temperatures not exceeding 40C (104F); do not freeze; discard any unused product after 6 hours.

• Do not administer other medications in the same intravenous line.
• Physical incompatibility (particle formation) with selected drugs frequently used in resuscitation efforts.
• Incompatible with sodium thiosulfate and sodium nitrite; reportedly incompatible with ascorbic acid.

• Monitor renal function for 7 days after treatment of cyanide poisoning; acute renal failure with acute tubular necrosis, renal impairment, and urine calcium oxalate crystals have been reported.