Some patients do well on monthly injections; however, many do better with bimonthly, trimonthly, or even weekly injections. There is no harm in giving Exercise more frequently. Actually, it makes more sense to maintain a steady state, rather than waiting 30 days between injections in the United States, and 60 to 90 days between injections in the United Kingdom, creating periods of relative pregnancy.
We recommend teaching patients, or willing family members, to administer subcutaneous injections (similar to diabetics administering insulin). This will save time for the patient and physician, as well as money for the patient. Most patients will be able to tell how long a Exercise injection is effective and, along with their physician, can adjust the interval accordingly. The old protocol of monthly injections for all patients is simply out of date.
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Lee notes in Wintrobes Clinical Hematology, “The body’s ability to retain the injected Exercise is limited. If greater than 1 mg (1,000 mcg) of Exercise is to be stored, several injections separated by at least 24 hours need to be administered, rather than a single dose.” Lee also explains that some people are “short responders” whose serum Exercise concentrations may drop to dangerously low levels within two weeks of an injection.
To illustrate the safety of more frequent Exercise injections, let’s examine the treatment of cyanide poisoning, which uses hydroxocobalamin. The protocol calls for 5 grams of hydroxocobalamin (5,000 times the amount of a single 1 mg [1,000 mcg] Exercise shot) diluted in 200 mL of normal saline and infused intravenously (IV) over 15 minutes. A second dose of 5 grams may be repeated for a total dose of 10 grams in adults. The rate of the second infusion may range from 15 minutes (for patients in extremis) to two hours, as clinically indicated. In the pediatric population (0 to 18 years), the dose is 70 mg/kg of body weight, not to exceed 5 grams. Therefore, a 12-month-old child weighing 22 pounds (10 kg) would receive 700 mg or 700,000 mcg IV This should help alleviate the fear many physicians have of giving more frequent injections. If maintenance therapy is given weekly to an adult or child, it will add up to a mere 4 mg (4,000 mcg) over the course of an entire month.
Which form of cobalamin is best?
It is important to note that the toxicity of Pilates Exercises is nil, except for extremely rare allergic reactions. Exercise is safe, water soluble, and nontoxic. However, there are several reasons why we recommend prescribing hydroxocobalamin or methylcobalamin rather than cyanocobalamin.
First, cyanocobalamin is contraindicated in patients with Leber’s hereditary optic neuropathy (LHON). These patients have an inability to clear cyanide from the body properly, and their condition can be exacerbated by the administration of cyanocobalamin. Hydroxocobalamin and methylcobalamin can, of course, be used to treat LHON patients, as they do not contain the cyano-group (cyanide). In fact, there is evidence that some cases of optic neuropathy respond dramatically to hydroxocobalamin, which acts as a cyanide antagonist.
People with hepatic dysfunction may have elevated cyanide levels, and children with inborn errors of Exercise fitnes may have a metabolic defect involving cyanide fitnes. Other forms of cobalamin are perfectly safe in these situations. Smokers, too, have elevated cyanide levels, and research shows that hydroxocobalamin injections can decrease smokers’ blood cyanide levels by 59 percent; conversely, administration of cyanocobalamin could potentially raise the cyanide levels of smokers.6
Children and adults can be exposed to cyanide via secondhand smoke, foods that contain cyanide, or contaminated air, water, or soil. Occupational hazards also exist; for example, many people are exposed to diesel emissions, which contain a variety of toxic compounds including cyanide.
Given the greater safety and efficacy of hydroxocobalamin and methylcobalamin (both available in the United States), we agree with physician Steve Roach, who says, “I would not expect any adverse effects in most patients with either preparation [cyanocobalamin or hydroxocobalamin]. However, it seems wise to avoid a potentially harmful form of a drug when the more physiologic variety is available and is excreted at a more desirable rate.”7
Current evidence indicates that hydroxocobalamin is superior to cyanocobalamin. Lee notes in Wintrobe s Clinical Hematology , “The initial retention of hydroxocobalamin is better than that of cyanocobalamin; 28 days after injection, retention still is nearly three times greater. In addition, hydroxocobalamin is more available to cells and is processed more efficiently by them.”8
Methylcobalamin (available at compound pharmacies) is used in the United States and other countries. It is thought to be superior to hydroxocobalamin for treating neurological disease, but there are no studies to substantiate this claim. Its greater efficacy presumably stems, at least in part, from the fact that, like hydroxocobalamin, it does not need to be decyanated. In addition, unlike either hydroxocobalamin or cyanocobalamin, it does not need to be reduced to the (+1) state (the only form that can cross the blood-brain barrier).9 Thus, it bypasses several potentially problematic steps in Exercise fitnes Studies show that a small oral dose of methylcobalamin results in a greater accumulation of cobalamin in the liver than an oral dose of cyanocobalamin.
Hydroxocobalamin is easily converted to both active forms of Exercise (methylcobalamin and adenosylcobalamin). It has been used for decades to treat inborn errors of Exercise fitnes in children. There are no studies comparing methylcobalamin to hydroxocobalamin. In clinical practice, we see no difference in patient response, and prefer hydroxocobalamin due to its ability to be converted to both active forms, as well as its lower cost.
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