Hydroxocobalamin interference in routine laboratory tests: Development of a protocol for identifying samples and reporting results from patients treated with CyanokitTM.

OBJECTIVES: Hydroxocobalamin (OHCob) is an antidote for cyanide poisoning in patients rescued from house fires and is known to cause interference with certain laboratory tests. Consensus is lacking on the extent of this interference and on how to handle these samples. The objectives of this study were to characterize OHCob interference across a wide range of laboratory tests and to develop protocols for identifying and reporting these samples. DESIGNS & METHODS: Patient plasma samples (n = 5) were spiked with OHCob (1.5 mg/mL) and compared to controls without this drug. A series of analytes were measured using chemistry, urinalysis, coagulation, hematology, and blood gas instruments. Dose-response testing was performed on a subset of assays that showed interferences ≥10%. RESULTS: Of the 77 analytes evaluated, 27 (35%) showed interference from OHCob, with chemistry and coagulation analytes showing the greatest effects. Of those affected, 22 analytes had a positive interference, whereas 5 analytes had negative interference. Dose-response studies showed dose-dependent increases and/or decreases consistent with initial spiking studies. Although red in colour, plasma samples with OHCob did not trigger hemolysis index flags, necessitating a special sample identification and reporting protocol. CONCLUSION: OHCob had significant effects on several analytes across different instruments. These findings led to the development of special sample handling and reporting protocols to identify OHCob samples and ensure only accurate results are released. It is vital for emergency departments to document and notify their laboratories whenever blood samples from these patients are drawn.

Differences in Tissue Distribution of Cyano⁻B12 and Hydroxo⁻B12 One Week after Oral Intake: An Experimental Study in Male Wistar Rats.

Foods contain natural vitamin B12 forms, such as hydroxo⁻B12 (HO⁻B12), whereas vitamin pills contain the synthetic cyano⁻B12 (CN⁻B12). Recent studies in rats showed different tissue distributions of CN⁻B12 and HO⁻B12 24 h after oral administration. Here, we investigate whether these differences are sustained or leveled out with time in both B12-deplete and -replete rats, thereby assessing if the two forms are equally good at maintaining a normal B12 status. Male Wistar rats were fed diets with low (n = 16) or high (n = 12) B12 content for 17 days. At day 10, the rats received a single oral dose of [57Co]-labeled CN⁻B12 or HO⁻B12 (n = 6 and n = 8, respectively, in each diet group). The rats were sacrificed on day 17 and endogenous B12 and [57Co]⁻B12 were measured in liver, kidney, and plasma. We found that the low-B12 diet introduced a B12-deplete state as judged from medians of endogenous B12 compared to rats on a (high-B12 diet): Plasma (565 (1410) pmol/L), liver (28.2 (33.2) pmol/g), and kidneys (123 (1300) pmol/g). One week after oral administration, the labeled B12 was distributed as follows: HO⁻B12 > CN⁻B12 (liver) and CN⁻B12 > HO⁻B12 (kidneys, plasma). The tissue/plasma ratios showed different equilibriums for labeled CN⁻B12 and HO⁻B12 in the B12-deplete and -replete groups. The equilibrium of endogenous B12 resembled [57Co]CN⁻B12 in replete rats but differed from both [57Co]CN⁻B12 and [57Co]HO⁻B12 in deplete rats. The data suggest long-term differences in tissue utilization of the two B12 forms and warrant further studies concerning the possible benefits of consuming HO⁻B12 instead of CN⁻B12 in oral B12 replacement.

Comparative study of the tissue distribution of equimolar repeated doses of hydroxocobalamin and cobalt chloride in the rats.

High dose of the cobalt atom is toxic for mammals. Hydroxocobalamin is considered safe due to the inclusion of the cobalt atom into the heminic moiety. The tissue distribution of cobalt following repeated doses of either hydroxocobalamin or cobalt chloride was studied in Wistar rats. In both cases, cobalt was administered in equimolar doses daily for an overall period of three weeks. Three groups were designed. In the hydroxocobalamin treated group, ten rats received hydroxocobalamin 17.5 mg by intraperitoneal route daily. In the cobalt-treated group, ten rats received cobalt chloride 3 mg i.p. daily. In the control group, six rats received a daily injection of 0.35 mL isotonic sodium chloride i.p. Cobalt concentrations were measured by Inductively Coupled Plasma Atomic Emission. Ours results showed that in rats having received either hydroxocobalamin or cobalt chloride, the tissue concentrations of cobalt were greater than those in the control group. The present study documented that in naive rats, the repeated administration of high doses of cobalt as hydroxocobalamin leads to tissue concentrations of the atom of cobalt significantly lower than those induced by equimolar doses of cobalt administered as cobalt chloride (p <0.05). We conclude that hydroxocobalamin reduced the tissue distribution of the cobalt atom in comparison with cobalt chloride.

Hibiscus sabdariffa increases hydroxocobalamin oral bioavailability and clinical efficacy in vitamin B12 deficiency with neurological symptoms.

The aim of the study was to evaluate the bioavailability and clinical benefits of oral new formulation (HB12 ) of hydroxocobalamin (Hdrx) with Hibiscus sabdariffa (HS). First, in an observational study, a cohort of 30 vitamin B12 -deficient patients (vit B12 < 200 pg/mL) with neurological symptoms received oral fixed dose of Hdrx containing 15 mg Hdrx daily for 10 days followed by 15 mg monthly. Clinical benefits were evaluated on haematological and biochemical parameters, and neurological improvement at days 10 and 90 compared to day 0. To understand the mechanism, intestinal mucosa from mice were mounted in vitro in Ussing chambers to measure Hdrx Fluxes. In the clinical study, serum vitamin B12 level increased from 55.1 ± 36.9 to 1330 ± 335.5 pg/mL at day 10 and 431.0 ± 24.27 pg/mL at day 90, without overt adverse effects. In mice ileum, (i) intestinal bioavailability of Hdrx increased in dose-dependent manner with HB12 . The apparent permeability of Hdrx was Papp = 34.9 ± 4.6 × 10-6 cm/s in the presence of 3 mg/mL (HB12 B) compared to the control Papp = 6.2 ± 0.7 × 10-6 cm/s. (ii) Total transepithelial electrical conductance (Gt ) increased in dose-dependent manner with HB12 , Gt = 161.5 ± 10.8 mS/cm² with HB12 B (Hdrx 1 mg + HS 3 mg) compared to the control Hdrx, Gt = 28.7 ± 4.0 mS/cm². In conclusion, the clinical study suggests that injections are not required when Hdrx is given orally. Intestinal bioavailability of Hdrx increased in vitro when it was used concomitantly with HS.

Treatment of vitamin B12 deficiency-methylcobalamine? Cyancobalamine? Hydroxocobalamin?-clearing the confusion.

Vitamin B12 (cyancobalamin, Cbl) has two active co-enzyme forms, methylcobalamin (MeCbl) and adenosylcobalamin (AdCbl). There has been a paradigm shift in the treatment of vitamin B12 deficiency such that MeCbl is being extensively used and promoted. This is despite the fact that both MeCbl and AdCbl are essential and have distinct metabolic fates and functions. MeCbl is primarily involved along with folate in hematopiesis and development of the brain during childhood. Whereas deficiency of AdCbl disturbs the carbohydrate, fat and amino-acid metabolism, and hence interferes with the formation of myelin. Thereby, it is important to treat vitamin B12 deficiency with a combination of MeCbl and AdCbl or hydroxocobalamin or Cbl. Regarding the route, it has been proved that the oral route is comparable to the intramuscular route for rectifying vitamin B12 deficiency.

Hydroxocobalamin in cyanide poisoning.

INTRODUCTION: On theoretical grounds, hydroxocobalamin is an attractive antidote for cyanide poisoning as cobalt compounds have the ability to bind and detoxify cyanide. This paper reviews the pharmacokinetic and pharmacodynamic aspects of hydroxocobalamin, its efficacy in human cyanide poisoning and its adverse effects. METHODS: PubMed was searched for the period 1952 to April 2012. A total of 71 papers were identified in this way; and none was excluded. PHARMACOKINETICS AND PHARMACODYNAMICS: Pharmacokinetic studies in dogs and humans suggest a two-compartment model, with first order elimination kinetics. Pharmacodynamic studies in animals suggest that hydroxocobalamin would be a satisfactory antidote for human cyanide poisoning. EFFICACY IN HUMAN POISONING: There is limited evidence that hydroxocobalamin alone is effective in severe poisoning by cyanide salts. The evidence for the efficacy of hydroxocobalamin in smoke inhalation is complicated by lack of evidence for the importance of cyanide exposure in fires and the effects of other chemicals as well as confounding effects of other therapeutic measures, including hyperbaric oxygen. Evidence that hydroxocobalamin is effective in poisoning due to hydrogen cyanide alone is lacking; extrapolation of efficacy from poisoning by ingested cyanide salts may not be valid. The rate of absorption may be greater with inhaled hydrogen cyanide and the recommended slow intravenous administration of hydroxocobalamin may severely limit its clinical effectiveness in these circumstances. ADVERSE EFFECTS: Both animal and human data suggest that hydroxocobalamin is lacking in clinically significant adverse effects. However, in one human volunteer study, delayed but prolonged rashes were observed in one-sixth of subjects, appearing 7 to 25 days after administration of 5 g or more of hydroxocobalamin. Rare adverse effects have included dyspnoea, facial oedema, and urticaria. CONCLUSIONS: Limited data on human poisonings with cyanide salts suggest that hydroxocobalamin is an effective antidote; data from smoke inhalation are less clear-cut. Although clinically important reactions to hydroxocobalamin have not been seen, some, non-life threatening, adverse reactions can occur.

Liquid chromatographic mass spectrometric (LC/MS/MS) determination of plasma hydroxocobalamin and cyanocobalamin concentrations after hydroxocobalamin antidote treatment for cyanide poisoning.

Cyanide poisoning occurs in individuals after fire smoke inhalation and after oral ingestion of cyanide. Hydroxocobalamin (HOCbl), a hydroxylated form of vitamin B(12), is often used as an antidote to treat cyanide toxicity. It has a high affinity for cyanide and rapidly removes cyanide from tissue by forming cyanocobalamin (CNCbl). Little information is available on the pharmacokinetics of HOCbl and CNCbl largely because of the lack of analytical methods for analyzing HOCbl and CNCbl. In this study, we developed a new liquid chromatographic mass spectrometric (LC/MS/MS) method for the quantitative analysis of plasma HOCbl and CNCbl in the porcine (Sus scrofa) model. The method uses on-column extraction, reversed phase gradient chromatography, and multiple reaction monitoring (MRM) for quantitation. MRM transitions monitored were 664.7→147.3 and 664.7→359.2 for HOCbl and 678.8→147.3, 678.8→359.1 678.8→457.1 for CNCbl. The limit of detection (LOD) and the lower limit of quantitation (LLOQ) were 1.0 and 1.0 µmole/L, respectively, for plasma HOCbl and 0.1 and 0.5 µmole/L for plasma CNCbl. The within-day and between-day CVs were 4.3 and 6.4% for plasma HOCbl at 500.0 µmole/L and 5.5 and 5.7% for CNCbl at 100.0 µmole/L (n=6). The plasma HOCbl and CNCbl calibrations curves were linear from 100.0 to 2000.0 and 50.0 to 500.0 µmole/L, respectively. Based on 6 separate calibration curves the average linear regression coefficient (R(2)) for both HOCbl and CNCbl was 0.992. The LC/M/MS method was found to be accurate and precise and has been validated by determining the plasma HOCbl and CNCbl concentrations in 11 pigs that were treated with HOCbl for cyanide poisoning.

Rapid and complete bioavailability of antidotes for organophosphorus nerve agent and cyanide poisoning in minipigs after intraosseous administration.

STUDY OBJECTIVE: Management of chemical weapon casualties includes the timely administration of antidotes without contamination of rescuers. Personal protective equipment makes intravenous access difficult but does not prevent intraosseous drug administration. We therefore measured the systemic bioavailability of antidotes for organophosphorus nerve agent and cyanide poisoning when administered by the intraosseous, intravenous, and intramuscular routes in a small study of Göttingen minipigs. METHODS: Animals were randomly allocated to sequentially receive atropine (0.12 mg/kg by rapid injection), pralidoxime (25 mg/kg by injection during 2 minutes), and hydroxocobalamin (75 mg/kg during 10 minutes) by the intravenous or intraosseous route, or atropine and pralidoxime by the intramuscular route. Plasma concentrations were measured for 6 hours to characterize the antidote concentration-time profiles for each route. RESULTS: Maximum plasma concentrations of atropine and pralidoxime occurred within 2 minutes when administered by the intraosseous route compared with 8 minutes by the intramuscular route. Maximum plasma hydroxocobalamin concentration occurred at the end of the infusion when administered by the intraosseous route. The mean area under the concentration-time curve by the intraosseous route was similar to the intravenous route for all 3 drugs and similar to the intramuscular route for atropine and pralidoxime. CONCLUSION: This study showed rapid and substantial antidote bioavailability after intraosseous administration that appeared similar to that of the intravenous route. The intraosseous route of antidote administration should be considered when intravenous access is difficult.

Changes in blood pressure after administration of hydroxocobalamin: relationship to changes in plasma cobalamins-(III) concentrations in healthy volunteers.

OBJECTIVE: To assess the relationship between blood pressure changes following infusion of antidotal doses of hydroxocobalamin and plasma concentrations of total and free cobalamins-(III). METHODS: Independent groups of healthy volunteers received single intravenous doses of 2.5, 5, 7.5, or 10 g hydroxocobalamin over 7.5 to 30 minutes. RESULTS: In the pharmacokinetic population (n = 41), hydroxocobalamin caused short-lived mean blood pressure increases. Blood pressure increased shortly after initiation of infusion and returned nearly to baseline by 4 hours post-infusion. The time course of blood pressure changes coincided with that of changes in plasma total and free cobalamins-(III). Change in mean arterial pressure (MAP) was strongly correlated with plasma area-under-the-concentration-time curves (AUCs) of total and free cobalamins-(III) during infusion (r > 0.7) but not through 24 hours post-infusion (r < or = 0.36). CONCLUSION: The short-lived increase in mean blood pressure during administration of antidotal doses of hydroxocobalamin is closely linked to initial exposure to total and free cobalamins-(III).

Role of hydroxocobalamin in acute cyanide poisoning.

OBJECTIVE: To review the recently approved cyanide antidote, hydroxocobalamin, and describe its role in therapy. DATA SOURCES: Relevant publications were identified through a systematic search of PubMed using the MeSH terms and key words hydroxocobalamin and cyanide. This search was then limited to human studies published since 2000. Systematic searches were conducted through January 2008. References from identified articles were reviewed for additional pertinent human studies. STUDY SELECTION AND DATA EXTRACTION: The literature search retrieved 7 studies on the safety and/or efficacy of hydroxocobalamin in humans. Four new studies were identified by the search and 3 studies were identified from the references. DATA SYNTHESIS: Studies of antidote efficacy in humans are ethically and logistically difficult. A preclinical study demonstrated that intravenous doses of hydroxocobalamin 5 g are well tolerated by volunteer subjects. Hydroxocobalamin has been shown to reduce cyanide concentrations in controlled studies of nitroprusside therapy and in heavy smokers. A retrospective study of 14 acute cyanide poisonings also demonstrated hydroxocobalamin's safety and efficacy. Two studies examining hydroxocobalamin for smoke inhalation-associated cyanide poisoning indicated a possible benefit, but they are insufficient to establish definitive criteria for use in this setting. Randomized controlled trials of hydroxocobalamin and traditional cyanide antidotes (nitrites/thiosulfate) are lacking. CONCLUSIONS: Cyanide poisoning can rapidly cause death. Having an effective antidote readily available is essential for facilities that provide emergency care. In cases of cyanide ingestion, both the nitrite/thiosulfate combination and hydroxocobalamin are effective antidotes. Hydroxocobalamin offers an improved safety profile for children and pregnant women. Hydroxocobalamin also appears to have a better safety profile in the setting of cyanide poisoning in conjunction with smoke inhalation. However, current data are insufficient to recommend the empiric administration of hydroxocobalamin to all victims of smoke inhalation.

[Vitamin B12 and folate in non-institutionalized urban older people]. / Vitamina B12 y folato en adultos mayores urbanos no institucionalizados.

Vitamin B12 and folate deficiencies are the main nutritional determinants of hyperhomocysteinemia, which is an independent risk factor for cardiovascular diseases. There is scarce information about nutritional status on vitamin B12 and serum levels of folate in Mexican older people. The objective was to evaluate the nutritional status of vitamin B12 and folic acid concentration in non-institutionalized, urban elderly men and women subjects. One hundred volunteers over 60 years were included in this cross-sectional study. Serum levels of vitamin B12 and folate were measured. In addition some biochemical and anthropometric indicators were also evaluated. Considering serum values of vitamin, 30% had vitamin B12 deficiency, 52% normal status and 18% with high levels. None subjects had folic acid deficiency, by the contrary, a high proportion (62%) showed elevated levels in serum. There was an effect of sex on vitamin B12 status. Elderly men showed significantly lower levels of vitamin B12, and it was according with significant higher prevalence of vitamin B12 deficiency in this group as compared with the women group. The high proportion of vitamin B12 deficiency found in this study underline a possible public health problem and guarantee further survey-studies about vitamin B12 status and to explore causes and consequences of the deficiency. Finally, due the sample size and the design of the study, the results must be seen with caution and not try to generalize.

Biosynthesis of 32P-labelled hydroxocobalamin and a study of its behaviour in rats.

Using Propionibacterium freudenreichii and 32P-ATP, batches of 32P-labelled cobalamin (Cbl) were biosynthesized with a maximum specific activity of 61 microCi/mg, i.e. about 100 times higher than previously reported. Pharmacological doses mixed with 57Co-Cbl were injected subcutaneously in the form of hydroxo-Cbl into rats subsequently killed 5-20 days later. The two labelled Cbls were distributed in approximately the same way, the highest concentration being found in kidney (typical for rats) and about one-fifth of that in liver. These findings tallied with previous observations with radioactive cyano-Cbl and microbiological assay. In all injected rats, the 57Co/32P ratio was lower in liver than in kidney. Drugs eradicating the intestinal flora had no influence. In rats receiving the vitamin orally, the ratio was higher in liver than in kidney. All of our findings could be due to formation of a cobinamide-like compound lacking phosphorus. It is concluded that we have produced radiophosphorus-labelled Cbl that enables studies in vivo.

Direct access of drugs to the human brain after intranasal drug administration?

It has been suggested that intranasal (IN) drug delivery could be used to administer drugs directly to the brain, bypassing the blood-brain barrier. Conclusive evidence of this proposed route of drug transport has not been observed by IN-IV comparison. In eight neurosurgery patients with a CSF drain, the uptake in CSF and plasma after IN and IV drug administration was compared. No evidence of direct access of the drugs from the nose to the CSF was found.

Nasal absorption of hydroxocobalamin in healthy elderly adults.

AIMS: To investigate the nasal absorption of hydroxocobalamin in 10 healthy elderly adults. METHODS: In a cross-over study, blood samples were collected before administration of the drug and after 10, 20, 30, 40, 60, 120, 180 and 240 min. The plasma cobalamin concentration was determined by competitive radioisotope binding technique. RESULTS: The maximal plasma cobalamin concentration (Cmax) after nasal administration of 750 microg hydroxocobalamin was 1900 +/- 900 pmol l(-1) (mean +/- s.d.). The maximal plasma cobalamin concentration was reached in 35 +/- 13 min (t[max]). The Cmax after nasal administration of 1500 microg hydroxocobalamin was 3500 +/- 2500 pmol l(-1) with a t(max) of 28 +/- 16 min. Both the AUC(0,240 min) and AUC(0,00) increased significantly with an increase of the dose from 750 microg to 1500 microg (P = 0.037 and P = 0.028, respectively). The nasal spray was well tolerated. No signs of irritation or local sensitivity were noted. CONCLUSIONS: The nasal absorption of hydroxocobalamin in healthy elderly adults is rapid, high and well tolerated.