Indications/Dosage
Labeled
- macrocytic anemia
- nutritional supplementation
- pernicious anemia
- vitamin B12 deficiency
- vitamin B12 deficiency diagnosis
- vitamin B12 deficiency megaloblastic anemia
NOTE: Hematocrit, reticulocyte count, vitamin B12, folate, and iron concentrations should be obtained prior to treatment. If folate concentrations are low in a patient with low B12 concentrations, folic acid should only be administered in combination with B12. Vitamin blood concentrations and peripheral blood counts should be monitored at one month of treatment and then at intervals of 3 to 6 months.[30895]
Off-Label
- methylmalonic aciduria
For nutritional supplementation
for the recommended dietary allowance (RDA) of cyanocobalamin in healthy individuals
Oral dosage
Adults and Adolescent pregnant females
2.6 mcg orally daily.
Adults and Adolescent lactating females
2.8 mcg orally daily.
Adults and Adolescents >= 14 years
2.4 mcg PO daily. NOTE: Due to malabsorption of food-bound vitamin B12, individuals older than age 50 years are advised to meet their recommended daily allowance mainly by taking vitamin B12-containing supplements or through foods fortified with vitamin B12.[27866]
Children 9—13 years
1.8 mcg PO daily.
Children 4—8 years
1.2 mcg PO daily.
Children 1—3 years
0.9 mcg PO daily.
Infants 7—12 months
0.5 mcg/day PO is the adequate intake. Recommended daily allowance has not been established.
Infants 0—6 months
0.4 mcg/day PO is the adequate intake. Recommended daily allowance has not been established.
Intranasal dosage
Adults and Adolescents
500 mcg intranasally into 1 nostril once weekly. The intranasal route is for maintenance of adequate nutritional intake in patients who cannot absorb vitamin B12 via the oral route.
Children and Infants
Safety and efficacy of intranasal use have not established; see oral dosage guidelines from the Institute of Medicine.
For the treatment and prevention of vitamin B12 deficiency or for the treatment of vitamin B12 deficiency megaloblastic anemia or macrocytic anemia thought to be due to vitamin B12 deficiency
Oral dosage
Adults
1,000 to 2,000 mcg/day PO for 1 to 2 weeks, then 500 to 1,000 mcg/day PO.[59569] [60922]
Adolescents
1,000 to 2,000 mcg/day PO for 1 to 2 weeks, then 500 to 1,000 mcg/day PO.[59569] [60922]
Intramuscular or Subcutaneous dosage
Adults
1,000 mcg IM once daily or every other day for 1 week, then once weekly for 4 to 8 weeks, then once monthly until recovery is the usual dosage.[43996] [43997] [60922] 100 mcg IM/subcutaneously once daily for 6 or 7 days is the FDA-approved dosage. After clinical improvement and if a reticulocyte response is seen, give 100 mcg IM/subcutaneously on alternate days for 7 doses, then every 3 to 4 days for another 2 to 3 weeks, then 100 mcg IM/subcutaneously monthly. Administer with folic acid, if needed.[43995]
Adolescents†
1,000 mcg IM once daily or every other day for 1 week, then once weekly for 4 to 8 weeks, then once monthly until recovery.[43997] [60922]
Children†
Dosing is not well established and should be guided by clinical response and laboratory measurements.[60926] [60930] 1,000 mcg IM once daily for 2 to 7 days, then 100 mcg IM/subcutaneously once weekly for 4 weeks, then once monthly until recovery has been recommended and used in children.[60922] [60925] [60928] [60929] [60930] The adult dosage (1,000 mcg IM once daily or every other day for 1 week, then once weekly for 4 to 8 weeks, then once monthly) has also been used in children.[60922] [60939] [62570]
Infants†
Dosing is not well established and should be guided by clinical response and laboratory measurements.[60926] [60930] 250 to 1,000 mcg IM once daily for 4 to 10 days, then 100 to 1,000 mcg IM once weekly or once monthly until recovery has been recommended and used in infants in case reports.[60922] [60923] [60924] [60925] [60937] [60942] [62570]
Intranasal dosage
Adults
Initial dose is 500 mcg intranasally into 1 nostril once weekly. Consider increasing the dose if serum concentrations of B12 decrease after one month of therapy. Assess serum B12 concentrations one month after each dosage adjustment. Continued low serum concentrations may indicate that the patient may need alternative therapy (i.e., IM or subcutaneous B12 administration).[30895]
For the treatment of pernicious anemia
NOTE: Patients with pernicious anemia are 3 times more likely to develop carcinoma of the stomach than the general population, necessitating an appropriate work-up.
Intramuscular or Subcutaneous dosage
Adults
1,000 mcg IM given daily or every other day for 1 week, then weekly for 4 to 8 weeks, then monthly for life is the usual dosage.[43996] [43997] [60922] 100 mcg IM/subcutaneously once daily for 6 or 7 days is the FDA-approved dosage. After clinical improvement and if a reticulocyte response is seen, give 100 mcg IM/subcutaneously on alternate days for 7 doses, then every 3 to 4 days for another 2 to 3 weeks, then 100 mcg IM/subcutaneously monthly for life. Administer with folic acid, if needed.[43995]
Adolescents†
1,000 mcg IM given daily or every other day for 1 week, then weekly for 4 to 8 weeks, then monthly for life is the usual dosage.[43997] [60922]
Children†
Dosing is not well established in pediatric patients and should be guided by clinical response and laboratory measurements.[60926] [60930] 1,000 mcg IM daily for 2 to 7 days, then 100 mcg IM weekly for 4 weeks, then monthly has been recommended and used in children.[60922] [60925] [60928] [60929] [60930] The adult dosage (1,000 mcg IM given daily or every other day for 1 week, then weekly for 4 to 8 weeks, then monthly for life) has also been used in children.[60922] [60926] [60939] [60941] [62570]
Infants†
Dosing is not well established in pediatric patients and should be guided by clinical response and laboratory measurements.[60926] [60930] 250 to 1,000 mcg IM daily for 4 to 10 days, followed by 100 to 1,000 mcg IM weekly or monthly, has been recommended and used in infants in case reports.[60922] [60923] [60924] [60925] [60937] [60942] [62570]
Oral dosage†
Adults
1,000 to 2,000 mcg/day PO for life.[59569] [60922]
Adolescents
1,000 to 2,000 mcg/day PO for life.[59569] [60922]
for the treatment of pernicious anemia in patients who are in hematologic remission with no nervous system involvement
Intranasal dosage
Adults
Initial dose is 500 mcg intranasally into 1 nostril once weekly. Consider increasing the dose if serum concentrations of B12 decrease after one month of therapy. Assess serum B12 concentration one month after each dosage adjustment. Continued low serum concentrations may indicate that the patient may need alternative therapy (i.e., IM or subcutaneous B12 administration).[30895]
For the treatment of methylmalonic aciduria†
Intramuscular dosage
Neonates
1,000 mcg intramuscularly once daily for 11 days with a protein-restricted diet.
For vitamin B12 deficiency diagnosis
Intramuscular dosage
Adults
1,000 mcg IM once is the flushing dose for Schilling test/vitamin B12 absorption test.[43995]
Therapeutic Drug Monitoring
Maximum Dosage Limits
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
Intermittent hemodialysis
Specific guidelines are not available; it appears that no dosage adjustments are needed.
† Off-label indicationReferences
How Supplied
Calcium, Phosphorus, Vitamin B12 (Cyanocobalamin) Oral tablet
Vitamin B-12 500mcg Tablet (37864-0913) (Plus Pharma, Inc) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Vitamin B-12 500mcg Tablet (11917-0361) (Walgreens Co) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Walgreens Vitamin B-12 500mcg Tablet (11917-0036) (Walgreens Co) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Nature Made Vitamin B12 500mcg Tablet (31604-0010) (Pharmavite, LLC) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Nature Made Vitamin B12 500mcg Tablet (31604-0012) (Pharmavite, LLC) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Vitamin B12 500mcg Tablet (35046-0001) (Windmill Health Products, LLC) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Nature Made Vitamin B12 1000mcg Tablet (31604-0027) (Pharmavite, LLC) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Vitamin B12 250mcg Tablet (35046-0001) (Windmill Health Products, LLC) nullCalcium, Vitamin B12 (Cyanocobalamin) Oral tablet
Nature Made Vitamin B12 2500mcg (31604-0027) (Pharmavite, LLC) nullCalcium, Vitamin B12 (Cyanocobalamin) Sublingual tablet
Optimum Vitamin B12 1000mcg Sublingual Tablet (43292-0559) (Magno-Humphries Labs, Inc.) nullStevia Leaf Extract, Vitamin B12 (Cyanocobalamin) Sublingual tablet
Vitamin B-12 3000mcg Sublingual Tablet (35046-0003) (Windmill Health Products, LLC) nullVitamin B12 (Cyanocobalamin) Chewable tablet
Vitamin B-12 1000mcg Chewable Tablet (88395-0024) (J.R. Carlson Laboratories, Inc.) nullVitamin B12 (Cyanocobalamin) Nasal gel
Nascobal 500mcg/0.1mL Nasal Gel (57459-1972) (Adhera Therapeutics, Inc., formerly Marina Biotech) (off market)Vitamin B12 (Cyanocobalamin) Nasal gel
Nascobal 500mcg/0.1mL Nasal Gel (57459-1002) (Adhera Therapeutics, Inc., formerly Marina Biotech) (off market)Vitamin B12 (Cyanocobalamin) Nasal gel
Nascobal 500mcg/0.1mL Nasal Gel (63004-7732) (Mallinckrodt Pharmaceuticals, formerly Questcor Pharmaceuticals Inc) (off market)Vitamin B12 (Cyanocobalamin) Nasal gel
Nascobal 500mcg/0.1mL Nasal Gel (67871-7732) (QOL Medical, LLC) (off market)Vitamin B12 (Cyanocobalamin) Nasal gel
Nascobal 500mcg/0.1mL Nasal Gel (00091-7033) (UCB Pharma Inc) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
CaloMist 25mcg/0.1ml Nasal Spray (00256-0203) (Fleming Pharmaceuticals) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
CaloMist 25mcg/0.1ml Nasal Spray (00256-0203) (Fleming Pharmaceuticals) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
Cyanocobalamin 500mcg/0.1mL Nasal Spray (43386-0237) (Gavis Pharmaceuticals, LLC, wholly owned subsidiary of Lupin) nullVitamin B12 (Cyanocobalamin) Nasal spray, solution
Cyanocobalamin 500mcg/0.1mL Nasal Spray (45802-0491) (Padagis US LLC) nullVitamin B12 (Cyanocobalamin) Nasal spray, solution
Nascobal 500mcg/0.1ml Nasal Spray (67871-7733) (Endo USA, Inc.) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
Nascobal 500mcg/0.1ml Nasal Spray (49884-0270) (Endo USA, Inc.) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
Nascobal 500mcg/0.1ml Nasal Spray (49884-0270) (Endo USA, Inc.) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
Nascobal 500mcg/0.1ml Nasal Spray (67871-7733) (QOL Medical, LLC) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
Nascobal 500mcg/0.1mL Nasal Spray (49884-0270) (Endo USA, Inc.) (off market)Vitamin B12 (Cyanocobalamin) Nasal spray, solution
Nascobal 500mcg/0.1mL Nasal Spray (49884-0270) (Endo USA, Inc.) nullVitamin B12 (Cyanocobalamin) Oral capsule, liquid filled
CVS Satin Collection Vitamin B12 1000mcg Softgel (null) (CVS Health) nullVitamin B12 (Cyanocobalamin) Oral capsule, liquid filled
Nature Made Vitamin B12 1000mcg Softgel (31604-0027) (Pharmavite, LLC) nullVitamin B12 (Cyanocobalamin) Oral capsule, liquid filled
Nature Made Vitamin B12 1000mcg Softgel (31604-0041) (Pharmavite, LLC) nullVitamin B12 (Cyanocobalamin) Oral capsule, liquid filled
Nature Made Vitamin B12 Maximum Strength 5000mcg Softgel (31604-0028) (Pharmavite, LLC) nullVitamin B12 (Cyanocobalamin) Oral disintegrating tablet
Nature Made Vitamin B12 1000mcg Tablet (31604-0027) (Pharmavite, LLC) nullVitamin B12 (Cyanocobalamin) Oral disintegrating tablet
Sundance Vitamin B12 1000mcg Fast Dissolve Tablet (40093-0102) (Piping Rock Health) nullVitamin B12 (Cyanocobalamin) Oral disintegrating tablet
Nature Made Vitamin B 12 3000mcg Fast Dissolve Tablet (Cherry) (31604-0027) (Pharmavite, LLC) nullVitamin B12 (Cyanocobalamin) Oral disintegrating tablet
Nature Made Vitamin B 12 3000mcg Fast Dissolve Tablet (Cherry) (31604-0028) (Pharmavite, LLC) nullVitamin B12 (Cyanocobalamin) Oral drops, solution
RITE AID Vitamin B-12 1000mcg Sublingual Liquid (null) (Rite Aid Corp) nullVitamin B12 (Cyanocobalamin) Oral drops, solution
Vitamin B-12 3000mcg Liquid Drops (Raspberry) (54629-8980) (National Vitamin Company Inc) nullVitamin B12 (Cyanocobalamin) Oral drops, solution
Vitamin B12 3000mcg Sublingual Drops (Raspberry) (null) (National Vitamin Company Inc) nullVitamin B12 (Cyanocobalamin) Oral drops, solution
B-12 5000mcg Sublingual Liquid (null) (Nature's Bounty, a subsidiary of NBTY, Inc.) nullVitamin B12 (Cyanocobalamin) Oral lozenge
Vitamin B12 500mcg Lozenge (null) (Freeda Vitamins, Inc.) nullVitamin B12 (Cyanocobalamin) Oral solution
CVS B-12 1000mcg Liquid (null) (CVS Health) nullVitamin B12 (Cyanocobalamin) Oral solution
CVS B12 1000mcg Liquid (Cherry) (null) (CVS Health) nullVitamin B12 (Cyanocobalamin) Oral solution
Walgreens B-12 1000mcg Liquid (11917-0101) (Walgreens Co) nullVitamin B12 (Cyanocobalamin) Oral solution
Walgreens B-12 1000mcg Liquid (11917-0138) (Walgreens Co) nullVitamin B12 (Cyanocobalamin) Oral tablet, extended release
Vitamin B12 1500mcg Time Release Tablet (null) (Sundown Nutrition, a subsidiary of NBTY, Inc.) nullVitamin B12 (Cyanocobalamin) Oral tablet, extended release
Dual Spectrum Vitamin B-12 5000mcg Extended-Release Tablet (74312-0537) (Nature's Bounty, a subsidiary of NBTY, Inc.) nullVitamin B12 (Cyanocobalamin) Soft chew
CVS B12 500mcg Gummies (null) (CVS Health) nullVitamin B12 (Cyanocobalamin) Soft chew
Vitamin B12 500mcg Gummies (null) (Sundown Nutrition, a subsidiary of NBTY, Inc.) nullVitamin B12 (Cyanocobalamin) Soft chew
Vitamin B12 1500mcg Gummies (null) (Sundown Nutrition, a subsidiary of NBTY, Inc.) nullVitamin B12 (Cyanocobalamin) Soft chew
CVS Vitamin B12 2500mcg Soft Chew (Mixed Berry) (null) (CVS Health) nullVitamin B12 (Cyanocobalamin) Solution for injection
B-12 Compliance Injection Kit (49836-0527) (Rx Pharma Pack Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
B-12 Injection Kit (69959-0112) (Maveron Health, LLC. ) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 10000mcg/10mL Solution for Injection (00143-9620) (Hikma Pharmaceuticals USA Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 10000mcg/10mL Solution for Injection (67457-0399) (Mylan Institutional LLC ) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 10000mcg/10mL Solution for Injection (16714-0302) (NorthStar Rx LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 10000mcg/10mL Solution for Injection (69680-0113) (Vitruvias Therapeutics, Inc) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 10000mcg/10mL Solution for Injection (70710-1664) (Zydus Pharmaceuticals (USA) Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (00517-0032) (American Regent Inc, a division of Luitpold Pharmaceuticals) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (00517-0130) (American Regent Inc, a division of Luitpold Pharmaceuticals) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (00517-0031) (American Regent Inc, a division of Luitpold Pharmaceuticals) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (00641-0370) (Baxter Anesthesia/Critical Care) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (63323-0044) (Fresenius Kabi AG) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (63739-0476) (McKesson Packaging Inc) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/ml Solution for Injection (49727-0722) (Vita-Rx Corporation) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (68001-0542) (BluePoint Lab Injectables) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (68001-0509) (BluePoint Laboratories) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (76420-0075) (Enovachem Manufacturing) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (55150-0364) (Eugia US LLC fka AuroMedics Pharma LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (00143-9621) (Hikma Pharmaceuticals USA inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (71288-0303) (Meitheal Pharmaceuticals, Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (16714-0165) (NorthStar Rx LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (25021-0502) (Sagent Pharmaceuticals) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (70512-0840) (Sola Pharmaceuticals) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (70069-0005) (Somerset Therapeutics, LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (70069-0172) (Somerset Therapeutics, LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (69680-0112) (Vitruvias Therapeutics, Inc) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (70710-1663) (Zydus Pharmaceuticals (USA) Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 1000mcg/mL Solution for Injection (PREMIER ProRx) (63323-0044) (Fresenius Kabi USA, LLC ) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (00517-0130) (American Regent Inc, a division of Luitpold Pharmaceuticals) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (00143-9619) (Hikma Pharmaceuticals USA inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (67457-0400) (Mylan Institutional LLC ) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (16714-0609) (NorthStar Rx LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (70069-0171) (Somerset Therapeutics, LLC) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (69680-0121) (Vitruvias Therapeutics, Inc) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyanocobalamin 30000mcg/30mL Solution for Injection (70710-1665) (Zydus Pharmaceuticals (USA) Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Cyomin 1000mcg/ml Solution for Injection (00456-1015) (Allergan USA, Inc.) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Dodex 10000mcg/10mL Solution for Injection (16729-0533) (Accord Healthcare, Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Dodex 1000mcg/mL Solution for Injection (16729-0533) (Accord Healthcare, Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
Dodex 30000mcg/30mL Solution for Injection (16729-0533) (Accord Healthcare, Inc.) nullVitamin B12 (Cyanocobalamin) Solution for injection
LA-12 1000mcg/ml Solution for Injection (00314-0678) (Hyrex Pharmaceuticals) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Nutri-Twelve 1000mcg/ml Solution for Injection (49910-0029) (Gyn Nutriment Pharmacology) nullVitamin B12 (Cyanocobalamin) Solution for injection
Physicians EZ Use B-12 Compliance Injection Kit (76420-0527) (Enovachem Manufacturing) nullVitamin B12 (Cyanocobalamin) Solution for injection
Primabalt 1000mcg/ml Solution for Injection (00684-0123) (Primedics Laboratories) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Primabalt 1000mcg/ml Solution for Injection (00684-0153) (Primedics Laboratories) (off market)Vitamin B12 (Cyanocobalamin) Solution for injection
Vitamin Deficiency Injectable System - B12 Injection Kit (70529-0290) (IT3 Medical, LLC) nullDescription/Classification
Description
Cyanocobalamin, or vitamin B12, is a B-vitamin. It is found in a variety of foods such as fish, shellfish, meats, and dairy products. Although cyanocobalamin and vitamin B12 are terms used interchangeably, vitamin B12 is also available as hydroxocobalamin, a less commonly prescribed drug product. Cyanocobalamin is available nasally, orally, and parenterally, and is equal in biologic activity to hydroxocobalamin. Cyanocobalamin is used to treat pernicious anemia and prevent and treat vitamin B12 deficiency, as well as to determine vitamin B12 absorption in the Schilling test. Vitamin B12 is an essential vitamin found in foods such as meat, eggs, and dairy products. Deficiency in healthy individuals is rare; the elderly, strict vegetarians (i.e., vegan), and patients with malabsorption problems are more likely to become deficient. If vitamin B12 deficiency is not treated with a vitamin B12 supplement, then anemia, intestinal problems, and irreversible nerve damage may occur. Oral therapy is not always effective, as some persons lack intrinsic factor, an endogenous substance produced by the stomach and necessary for oral B12 absorption. Other patients may not be able to absorb oral vitamin B12 due to surgical removal or dysfunction of the intestines in the area where absorption of vitamin B12 occurs. Thus, parenteral or nasal therapy may be needed; however, intranasal therapy should only be instituted for maintenance treatment after control of the condition has been obtained by the parenteral route.[30895] [43995]
Classifications
- Blood and Blood Forming Organs
- Anti-anemic Agents
- Cyanocobalamin/Vitamin B12 and Analog Supplements
- Anti-anemic Agents
- Vitamins, Minerals, and Dietary or Nutritional Supplements
- Dietary Supplements
- Miscellaneous Dietary Supplements
- Vitamin and Mineral Supplements
- Vitamin B Supplements
- Vitamin B12 (Cyanocobalamin) Supplements
- Injectable Vitamin B12 (Cyanocobalamin) Supplements
- Non-injectable Vitamin B12 (Cyanocobalamin) Supplements
- Vitamin B12 (Cyanocobalamin) Supplements
- Vitamin B Supplements
- Dietary Supplements
References
Administration Information
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Route-Specific Administration
Oral Administration
- To increase oral absorption, administer on an empty stomach.[63836]
Injectable Administration
- Administer intramuscularly or by deep subcutaneous injection; intravenous (IV) injection is not recommended as cyanocobalamin is excreted more readily following IV injection.
- Cyanocobalamin may be mixed with TPN solutions.
- Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.[43995]
Intramuscular Administration
- Inject deeply into a large muscle mass.
Subcutaneous Administration
- Inject deeply into subcutaneous tissue taking care not to inject intradermally or into upper subcutaneous tissue.
Inhalation Administration
Intranasal Inhalation Administration
- Administer intranasally.
- Each unit contains only 1 spray; it is not necessary to prime before use.
- Instruct patient on proper administration technique.
- Administer at least one hour before or after ingestion of foods or liquids that may cause nasal congestion or rhinorrhea.
- Delay administration in patients with active symptoms of nasal congestion, allergic rhinitis, or upper respiratory infection.
- After administration, the spray may be discarded in usual trash.[30895]
Clinical Pharmaceutics Information
From Trissel's 2‚Ñ¢ Clinical Pharmaceutics DatabaseCyanocobalamin
pH Range
pH 4.5 to 7Osmolality/Osmolarity
Cyanocobalamin 0.1-mg/mL injection had a measured osmolality of 446 mOsm/kg.Stability
Cyanocobalamin injection is stable at room temperature and even when autoclaved at 121 degree C for short periods such as 15 to 20 minutes. Although compatible with a number of intravenous infusion solutions, intravenous administration is not recommended because of very rapid excretion of most of the cyanocobalamin in the urine. Vazquez et al. (2 reports) reported the stability of multiple vitamins injection (Cernevit, Baxter) diluted in three parenteral nutrition admixtures. Except for ascorbic acid, all of the vitamins, including cyanocobalamin, retained nearly 100% of the initial concentrations for 48 hours at ambient conditions.pH Effects
Cyanocobalamin is stable over the pH range of 3 to 7 with maximum stability exhibited at pH 4.5 to 5. It is unstable in alkaline solutions and very strongly acidic solutions.Light Exposure
Cyanocobalamin is light sensitive; protection from exposure to light is recommended for storage. If exposed to light, the organometallic bond may be cleaved. The extent of the decomposition increases with increasing light intensity.Filtration
Cyanocobalamin from Wyeth at 1 mcg/mL in dextrose 5% and in sodium chloride 0.9% did not display substantial loss due to binding to a 0.22-micron Ivex-2 cellulose ester membrane filter when filtered over 6 hours at 120 mL/hour.Sorption Leaching
Cyanocobalamin from Organon 30 mcg/mL did not exhibit substantial sorption over 24 hours to a polyvinyl chloride (PVC) plastic test strip.Other Information
Ascorbic acid: Cyanocobalamin is variously reported to be compatible and incompatible with ascorbic acid. Coles and Lees indicated that cyanocobalamin combined with ascorbic acid may be stored for 24 hours at room temperature protected from exposure to light without loss of vitamin activity. However, Ichikawa et al. studied the degradation of cyanocobalamin in aqueous pH 4.8 acetate buffer solution. Degradation of cyanocobalamin was not observed in the absence of ascorbic acid. However, adding ascorbic acid to the solution was found to substantially increase the rate of cyanocobalamin decomposition along with ascorbic acid decomposition. This effect was inhibited by the addition of sodium halides to the solution as might be found in a parenteral nutrition admixture. Potassium, magnesium, and calcium halides also exerted the stabilizing effect. Other Drugs: Cyanocobalamin is stated to be incompatible with a number of drugs including chlorpromazine hydrochloride, dextrose, phytonadione, prochlorperazine edisylate, and warfarin sodium, although some reported incompatibilities may have been due to hydroxocobalamin formerly present in the injection as a contaminant. It is also incompatible with heavy metals and oxidizing and reducing agents. Cyanocobalamin is stated to be compatible with other B vitamins and iron dextran.References
Adverse Reactions
Severe
- aluminum toxicity
- anaphylactic shock
- heart failure
- pulmonary edema
- thrombosis
Mild
- anxiety
- asthenia
- diarrhea
- dizziness
- dyspepsia
- headache
- hypoesthesia
- infection
- myalgia
- nausea
- paresthesias
- pruritus
- rash
- vomiting
0
- back pain
Moderate
- dyspnea
- edema
- glossitis
- hypokalemia
- polycythemia
- thrombocytosis
In most cases, cyanocobalamin is nontoxic, even in large doses. Pruritus, transitory exanthema (rash), and a feeling of swelling (edema) of the entire body have been reported after IM injection.[30895] [43995] Some patients have also experienced a hypersensitivity reaction after IM injection that has resulted in anaphylactic shock and death.[43995]
Pulmonary edema and congestive heart failure have been reported early in treatment with parenteral cyanocobalamin. Peripheral vascular thrombosis and peripheral vascular disorder have also occurred.[30895] [43995]
Hypokalemia and thrombocytosis could occur upon conversion of severe megaloblastic anemia to normal erythropoiesis with intensive cyanocobalamin therapy. Monitor platelet count and serum potassium concentrations during therapy. Polycythemia vera has also been reported with parenteral cyanocobalamin.[30895] [43995]
Musculoskeletal adverse reactions associated with cyanocobalamin administration include arthritis, asthenia, back pain, generalized pain, myalgia, abnormal gait.[30895]
Respiratory adverse reactions reported with cyanocobalamin administration include dyspnea and rhinitis. Infection (i.e., common cold, sore throat) has also been reported.[30895]
Gastrointestinal adverse reactions reported with cyanocobalamin administration include dyspepsia, glossitis, nausea, vomiting, and mild transient diarrhea.[30895] [43995]
CNS adverse reactions including anxiety, dizziness, headache, hypoesthesia, incoordination, nervousness, and paresthesias have been reported with cyanocobalamin administration.[30895]
Cyanocobalamin injection contains aluminum, and aluminum toxicity may occur with prolonged administration in high-risk patients, including those with renal impairment and premature neonates. Premature neonates are at particular risk for aluminum toxicity because of immature renal function, and they require large amounts of calcium and phosphate solutions, which contain aluminum. Research indicates that patients with renal impairment, who receive parenteral aluminum at more than 4 to 5 mcg/kg/day, may develop aluminum-related CNS and bone toxicities. Tissue loading may occur at lower administration rates.[43995]
References
Contraindications/Precautions
Absolute contraindications are italicized.
- anemia
- benzyl alcohol hypersensitivity
- bone marrow suppression
- breast-feeding
- folate deficiency
- geriatric
- hereditary optic nerve atrophy (Leber's disease)
- hypokalemia
- infection
- iron-deficiency anemia
- neonates
- polycythemia vera
- pregnancy
- renal failure
- respiratory infection
- rhinorrhea
- uremia
Cyanocobalamin is contraindicated in patients with cyanocobalamin hypersensitivity or hypersensitivity to any of the medication components. Cyanocobalamin is also contraindicated in patients with cobalt hypersensitivity because cyanocobalamin contains cobalt. In the case of suspected cobalt hypersensitivity, an intradermal test dose should be administered because anaphylactic shock and death have followed parenteral administration of cyanocobalamin.[30895][43995]
Intranasal formulations of cyanocobalamin are not suitable for vitamin B12 absorption test (Schilling Test).[30895]
Cyanocobalamin should not be used in patients with early hereditary optic nerve atrophy (Leber's disease). Optic nerve atrophy can worsen in patients whose cyanocobalamin levels are already elevated. Hydroxocobalamin is the preferred agent in this patient population.[30895]
Most formulations of cyanocobalamin injection contain benzyl alcohol as a preservative. Benzyl alcohol may cause allergic reactions. Cyanocobalamin injections should be used cautiously in those patients with benzyl alcohol hypersensitivity. Cyanocobalamin preparations containing benzyl alcohol should be avoided in premature neonates because benzyl alcohol has been associated with 'gasping syndrome,' a potentially fatal condition characterized by metabolic acidosis and CNS, respiratory, circulatory, and renal dysfunction.[43995]
Vitamin B12 deficiency can suppress the symptoms of polycythemia vera. Treatment with cyanocobalamin may unmask this condition.[30895]
Folic acid is not a substitute for cyanocobalamin in the treatment of vitamin B12 deficiency, although it may improve vitamin B12 megaloblastic anemia. However, exclusive use of folic acid in treating vitamin B12 deficient megaloblastic anemia could result in progressive and irreversible neurologic damage. Additionally, exclusive use of cyanocobalamin in treating folate deficient megaloblastic anemia could delay or mask the real diagnosis. Before receiving folic acid or cyanocobalamin, patients should be assessed for deficiency and appropriate therapy started concurrently. The intranasal formulations are not approved to treat acute B12 deficiency; all hematologic parameters should be normal before beginning the cyanocobalamin intranasal formulations. Concurrent iron-deficiency anemia and folate deficiency may result in a blunted or impeded response to cyanocobalamin therapy.[30895] Secondary to an increase in red cell production with cyanocobalamin therapy, there is a corresponding increase in iron requirements; thus, patients should be closely monitored for the development of iron deficiency and treated accordingly.[33671]
Certain conditions may blunt or impede therapeutic response to cyanocobalamin therapy, such as serious infection, uremia or renal failure, or drugs with bone marrow suppression properties (e.g., chloramphenicol).[33665] The mechanism appears to be interference with erythropoiesis.
Patients with rhinorrhea (rhinitis) who are receiving the intranasal formulations of cyanocobalamin may experience decreased medication absorption secondary to nasal discharge. These patients may experience a blunted or impeded response to the intranasal medication. Treatment with intranasal cyanocobalamin should be delayed until symptoms resolve in patients with nasal congestion, allergic rhinitis, and upper respiratory infection. Intranasal cyanocobalamin therapy is not ideal for patients with chronic nasal symptoms or significant nasal pathology. If used in these patients, more frequent monitoring is required because of the potential for erratic or blunted absorption.[30895]
Adequate studies in humans have not been conducted; however, no maternal or fetal complications have been associated with doses that are recommended during pregnancy, and appropriate treatment should not be withheld from pregnant women with vitamin B12 responsive anemias. Conversely, pernicious anemia resulting from vitamin B12 deficiency may cause infertility or poor pregnancy outcomes.[49221] Vitamin B12 deficiency has occurred in breast-fed infants of vegetarian mothers whose diets contain no animal products (e.g., eggs, dairy), even though the mothers had no symptoms of deficiency at the time. Maternal requirements for vitamin B12 increase during pregnancy. The usual daily recommended amounts of cyanocobalamin, vitamin B12 either through dietary intake or supplementation should be taken during pregnancy.[43995]
Cyanocobalamin is distributed into breast milk in amounts similar to those in maternal plasma, and distribution in breast milk allows for adequate intakes of cyanocobalamin by breast-feeding infants. Adequate maternal intake is important for both the mother and infant during nursing, and maternal requirements for vitamin B12 increase during lactation. According to the manufacturer, the usual daily recommended amounts of cyanocobalamin, vitamin B12 for lactating women should be taken maternally during breast-feeding.[43995] The American Academy of Pediatrics considers vitamin B12 to be compatible with breast-feeding.[27500] Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.
Studies of intranasal cyanocobalamin did not include sufficient numbers of geriatric patients aged >= 65 years to determine whether the clinical response differs from that of younger patients. Other clinical reports have not identified differences in responses between elderly and younger patients. Generally, dose selection for elderly patients should be done with caution. Elderly patients tend to have a greater frequency of decreased hepatic, renal, or cardiac function, and also have concomitant disease or receiving other drug therapy. Start with doses at the lower end of the dosing range.
Treatment of severe megaloblastic anemia with cyanocobalamin results in the conversion to normal erythropoiesis. The change to normal erythropoiesis may cause secondary development of hypokalemia and thrombocytosis, therefore, potassium levels and platelet counts should be closely monitored.[30895]
References
Mechanism of Action
Vitamin B12, or cyanocolbalamin, is essential to growth, cell reproduction, hematopoiesis, and nucleoprotein and myelin synthesis. Cells characterized by rapid division (epithelial cells, bone marrow, myeloid cells) appear to have the greatest requirement for cyanocobalamin. Vitamin B12 can be converted to coenzyme B12 in tissues; in this form it is essential for conversion of methylmalonate to succinate and synthesis of methionine from hom*ocysteine (a reaction which also requires folate). In the absence of coenzyme B12, tetrahydrofolate cannot be regenerated from its inactive storage form, 5-methyl tetrahydrofolate, resulting in functional folate deficiency. Vitamin B12 also may be involved in maintaining sulfhydryl (SH) groups in the reduced form required by many SH-activated enzyme systems. Through these reactions, vitamin B12 is associated with fat and carbohydrate metabolism and protein synthesis. Vitamin B12 deficiency results in megaloblastic anemia, GI lesions, and neurologic damage (which begins with an inability to produce myelin and is followed by gradual degeneration of the axon and nerve head). Vitamin B12 requires an intrinsic factor-mediated active transport for absorption, therefore, lack of or inhibition of intrinsic factor results in pernicious anemia.
Revision Date: 04/12/2024, 05:57:23 PMReferences
Pharmaco*kinetics
Cyanocobalamin is administered intranasally, orally, and parenterally, while hydroxocobalamin is administered only parenterally. Once absorbed, vitamin B12 is highly bound to transcobalamin II, a specific B-globulin carrier protein and is distributed and stored primarily in the liver as coenzyme B12. The bone marrow also stores a significant amount of the absorbed vitamin B12. Vitamin B12 crosses the placenta and is distributed into breast milk. Enterohepatic recirculation conserves systemic stores. Elimination is primarily through the bile; however, excess cyanocobalamin is excreted unchanged in the urine.[30895][43995]
Route-Specific Pharmaco*kinetics
Oral Route
Oral absorption of vitamin B12 from the GI tract depends on the presence of adequate intrinsic factor, which is secreted from gastric mucosa. Drugs like the proton pump inhibitors (PPIs) (e.g., omeprazole and lansoprazole) have the potential for interfering with B12 absorption, presumably by impairing gastric acid and pepsin secretion, which are thought to be necessary for releasing B12 from its protein-binding sites in food.[23614] A vitamin B12-intrinsic factor complex is formed in the stomach following removal of cobalamin from dietary sources. This complex passes to the small intestine where attachment to receptor sites occurs on the ileal mucosa, and vitamin B12 is actively transported to portal plasma. Calcium and a pH greater than 6 are required for attachment to the receptor sites. When the receptor sites become saturated, absorption through passive diffusion occurs. Initially, oral doses of B12 and intrinsic factor (IF) will increase cobalamin levels in patients with pernicious anemia; however, 50% of patients develop intestinal antibodies to IF. After oral administration, peak plasma levels are attained in 8 to 12 hours.
Intramuscular Route
Peak plasma levels of cyanocobalamin are achieved within 1 hour after intramuscular injection. Within 48 hours after injection, 50% to 98% of the dose is excreted in the urine, with the majority within the first 8 hours.[43995]
Other Route(s)
Intranasal Route
Cyanocobalamin is passively absorbed through the highly vascular nasal mucosa. In a pharmaco*kinetic study (n = 25) comparing the bioavailability of vitamin B12 intranasal spray to the intranasal gel, peak concentrations for the nasal spray were achieved within 1 to 2 hours of administration with a mean peak plasma concentration of approximately 748 +/- 549 pg/mL. Bioavailability of the intranasal spray was found to be 10% less than the intranasal gel. Because the intranasal forms have a lower absorption than the IM dosage form, intranasal B12 forms are administered once weekly. After 1 month of treatment in pernicious anemia patients, once weekly dosing of 500 mcg of B12 intranasal gel resulted in a statistically significant increase in B12 concentrations when compared to a once monthly 100 mcg IM dose.[30895]
References
Pregnancy/Breast-feeding
pregnancy
Adequate studies in humans have not been conducted; however, no maternal or fetal complications have been associated with doses that are recommended during pregnancy, and appropriate treatment should not be withheld from pregnant women with vitamin B12 responsive anemias. Conversely, pernicious anemia resulting from vitamin B12 deficiency may cause infertility or poor pregnancy outcomes.[49221] Vitamin B12 deficiency has occurred in breast-fed infants of vegetarian mothers whose diets contain no animal products (e.g., eggs, dairy), even though the mothers had no symptoms of deficiency at the time. Maternal requirements for vitamin B12 increase during pregnancy. The usual daily recommended amounts of cyanocobalamin, vitamin B12 either through dietary intake or supplementation should be taken during pregnancy.[43995]
breast-feeding
Cyanocobalamin is distributed into breast milk in amounts similar to those in maternal plasma, and distribution in breast milk allows for adequate intakes of cyanocobalamin by breast-feeding infants. Adequate maternal intake is important for both the mother and infant during nursing, and maternal requirements for vitamin B12 increase during lactation. According to the manufacturer, the usual daily recommended amounts of cyanocobalamin, vitamin B12 for lactating women should be taken maternally during breast-feeding.[43995] The American Academy of Pediatrics considers vitamin B12 to be compatible with breast-feeding.[27500] Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally ingested drug, healthcare providers are encouraged to report the adverse effect to the FDA.
References
Interactions
Level 2 (Major)
- Baloxavir Marboxil
- Delafloxacin
- Edetate Calcium Disodium, Calcium EDTA
- Eltrombopag
- Estramustine
- Ethotoin
- Moxifloxacin
- Sulfacetamide; Sulfur
- Trientine
Level 3 (Moderate)
- Abacavir; Dolutegravir; Lamivudine
- Alendronate
- Alendronate; Cholecalciferol
- Aliskiren; Hydrochlorothiazide, HCTZ
- Amiloride; Hydrochlorothiazide, HCTZ
- Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ
- Atenolol; Chlorthalidone
- Atracurium
- Azilsartan; Chlorthalidone
- Benazepril; Hydrochlorothiazide, HCTZ
- Bictegravir; Emtricitabine; Tenofovir Alafenamide
- Bismuth Subcitrate Potassium; Metronidazole; Tetracycline
- Bismuth Subsalicylate; Metronidazole; Tetracycline
- Bisoprolol; Hydrochlorothiazide, HCTZ
- Cabotegravir
- Cabotegravir; Rilpivirine
- Calcifediol
- Calcitonin
- Calcitriol
- Calcium Phosphate, Supersaturated
- Candesartan; Hydrochlorothiazide, HCTZ
- Captopril; Hydrochlorothiazide, HCTZ
- Cardiac glycosides
- Chloramphenicol
- Chlorothiazide
- Chlorthalidone
- Ciprofloxacin
- Cisatracurium
- Colesevelam
- Demeclocycline
- Digoxin
- Dolutegravir
- Dolutegravir; Lamivudine
- Dolutegravir; Rilpivirine
- Doxercalciferol
- Doxycycline
- Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Alafenamide
- Elvitegravir; Cobicistat; Emtricitabine; Tenofovir Disoproxil Fumarate
- Enalapril; Hydrochlorothiazide, HCTZ
- Eprosartan; Hydrochlorothiazide, HCTZ
- Etidronate
- Fosinopril; Hydrochlorothiazide, HCTZ
- Hydrochlorothiazide, HCTZ
- Hydrochlorothiazide, HCTZ; Moexipril
- Ibandronate
- Ibritumomab Tiuxetan
- Irbesartan; Hydrochlorothiazide, HCTZ
- Levofloxacin
- Levothyroxine
- Levothyroxine; Liothyronine (Porcine)
- Levothyroxine; Liothyronine (Synthetic)
- Liothyronine
- Lisinopril; Hydrochlorothiazide, HCTZ
- Lithium
- Losartan; Hydrochlorothiazide, HCTZ
- Metolazone
- Metoprolol; Hydrochlorothiazide, HCTZ
- Minocycline
- Neuromuscular blockers
- Ofloxacin
- Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ
- Olmesartan; Hydrochlorothiazide, HCTZ
- Omadacycline
- Pancuronium
- Parathyroid Hormone
- Paricalcitol
- Phosphorated Carbohydrate Solution
- Phosphorus
- Potassium Phosphate
- Potassium Phosphate; Sodium Phosphate
- Quinapril; Hydrochlorothiazide, HCTZ
- Risedronate
- Rocuronium
- Sarecycline
- Sodium Fluoride
- Sodium Phosphate Monobasic Monohydrate; Sodium Phosphate Dibasic Anhydrous
- Spironolactone; Hydrochlorothiazide, HCTZ
- Succinylcholine
- Telmisartan; Hydrochlorothiazide, HCTZ
- Teriparatide
- Tetracycline
- Tetracyclines
- Thiazide diuretics
- Thyroid hormones
- Triamterene; Hydrochlorothiazide, HCTZ
- Valsartan; Hydrochlorothiazide, HCTZ
- Vecuronium
- Vitamin D analogs
Level 4 (Minor)
- Alogliptin; Metformin
- Amlodipine
- Amlodipine; Atorvastatin
- Amlodipine; Benazepril
- Amlodipine; Celecoxib
- Amlodipine; Olmesartan
- Amlodipine; Valsartan
- Atenolol
- Calcipotriene
- Calcipotriene; Betamethasone
- Calcium-channel blockers
- Canagliflozin; Metformin
- Clevidipine
- Cod Liver Oil
- Conjugated Estrogens
- Conjugated Estrogens; Bazedoxifene
- Conjugated Estrogens; Medroxyprogesterone
- Dapagliflozin; Metformin
- Desogestrel; Ethinyl Estradiol
- Dienogest; Estradiol valerate
- Diltiazem
- Drospirenone; Estetrol
- Drospirenone; Estradiol
- Drospirenone; Ethinyl Estradiol
- Drospirenone; Ethinyl Estradiol; Levomefolate
- Elagolix; Estradiol; Norethindrone acetate
- Empagliflozin; Linagliptin; Metformin
- Empagliflozin; Metformin
- Ertugliflozin; Metformin
- Esterified Estrogens
- Esterified Estrogens; Methyltestosterone
- Estradiol
- Estradiol; Levonorgestrel
- Estradiol; Norethindrone
- Estradiol; Norgestimate
- Estradiol; Progesterone
- Estrogens
- Estropipate
- Ethinyl Estradiol; Norelgestromin
- Ethinyl Estradiol; Norethindrone Acetate
- Ethinyl Estradiol; Norgestrel
- Ethynodiol Diacetate; Ethinyl Estradiol
- Etonogestrel; Ethinyl Estradiol
- Felodipine
- food
- Glipizide; Metformin
- Glyburide; Metformin
- Isradipine
- Levamlodipine
- Levonorgestrel; Ethinyl Estradiol
- Levonorgestrel; Ethinyl Estradiol; Ferrous Bisglycinate
- Levonorgestrel; Ethinyl Estradiol; Ferrous Fumarate
- Linagliptin; Metformin
- Metformin
- Metformin; Repaglinide
- Metformin; Saxagliptin
- Metformin; Sitagliptin
- Neomycin
- Nicardipine
- Nifedipine
- Nimodipine
- Nisoldipine
- Norethindrone Acetate; Ethinyl Estradiol; Ferrous fumarate
- Norethindrone; Ethinyl Estradiol
- Norethindrone; Ethinyl Estradiol; Ferrous fumarate
- Norgestimate; Ethinyl Estradiol
- Octreotide
- Perindopril; Amlodipine
- Pioglitazone; Metformin
- Relugolix; Estradiol; Norethindrone acetate
- Segesterone Acetate; Ethinyl Estradiol
- Telmisartan; Amlodipine
- Trandolapril; Verapamil
- Verapamil
- Vitamin A
References
Monitoring Parameters
- hemoglobin/hematocrit
- MCV
- platelet count
- reticulocyte count
- serum folate concentration
- serum iron
- serum potassium
- serum vitamin B12 (cyanocobalamin) concentrations
US Drug Names
- B-12 Compliance Kit
- B-12 Injection Kit
- CaloMist
- Cyomin
- Dodex
- LA-12
- Nascobal
- Nutri-Twelve
- Physicians EZ Use B-12
- Primabalt
- Vitamin Deficiency Injectable System - B12