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Toxicity, Vitamin: Treatment & Medication

Author: Mark Rosenbloom, MD, MBA, FACEP, Adjunct Associate Professor of Medicine, Northwestern University Feinberg School of Medicine; Chief Executive Officer and Editorial Director, PEPID, LLC; Founder and Chairman, The Unicorn Children's Foundation
Contributor Information and Disclosures

Updated: Apr 20, 2009

Treatment

Emergency Department Care

All ingestions require supportive management and an intravenous line. Serious ingestions require hydration if vomiting or diarrhea is present. Oxygen, monitoring, and ABCs are essential if potential life-threats are present. If potentially lethal co-ingestions are present, perform gastric lavage if the patient presents within 1 hour postingestion. Other care is symptomatic and supportive.

  • Vitamin A
    • Symptoms usually resolve after stopping vitamin A and instituting supportive therapy.
    • Increased ICP may require daily therapeutic LPs or further increased ICP treatment (diuretics, mannitol).
    • Symptomatic hypercalcemic patients may require fluids or electrolyte correction.
  • Vitamin D
    • Place patients with vitamin D toxicity on a low-calcium diet.
    • Consider calcium disodium edetate orally to increase fecal excretion of calcium.
    • In severe hypercalcemia, patients may require hydration, diuretics, steroids (hydrocortisone 100 mg IV q6h), calcitonin (4-8 IU/kg q6-12h), and/or mithramycin (25 mcg/kg qd IV over 4-6 h for 1-4 d). Peritoneal or hemodialysis may be necessary if large amounts of fluids cannot be given.
  • Vitamins E, K, B-1, B-2, B-6, B-12, and C, and folate usually require only supportive measures.
  • Vitamin B-3 (ie, niacin)
    • Provide supportive treatment as needed.
    • Aspirin taken 30 minutes before niacin decreases the flush response.

Consultations

Consult the regional poison control center or a local medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations.

Medication

Care is generally symptomatic and supportive. Gastrointestinal decontamination may be helpful to minimize amount of vitamin absorbed systemically. Administer charcoal for acute overdoses. Antiemetics or antidiarrheals are helpful if needed.

GI decontaminant

Empirically used to minimize systemic absorption of the toxin. May only benefit if administered within 1 h of ingestion.


Activated charcoal (Liqui-Char)

Binds vitamin within the GI tract. Multiple doses can be administered to help enhance elimination. However, little evidence supports multiple doses of activated charcoal in vitamin overdose. Initial dose may be administered with a cathartic (eg, sorbitol). Subsequent doses should be administered at one-half original dose, without a cathartic, as often as q2-6h. Do not administer subsequent doses in presence of ileus.

Adult

30-100 g with 240 mL diluent per 30 g charcoal PO/NG (1-2 g/kg PO; not to exceed 150 g per dose in adults)

Pediatric

Infants: 1-2 g/kg PO
Children: 15-30 g PO (1-1.5 g/kg PO as a 35% solution not to exceed 50 g per dose)

May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases adsorptive properties)

Documented hypersensitivity; subsequent doses of charcoal in presence of ileus

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Protect airway in patients with absent gag reflex; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administration; after emesis with ipecac syrup, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black

More on Toxicity, Vitamin

Overview: Toxicity, Vitamin
Differential Diagnoses & Workup: Toxicity, Vitamin
Treatment & Medication: Toxicity, Vitamin
Follow-up: Toxicity, Vitamin
References
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References

  1. North America, Asia lead vitamin and supplement usage. Nielsen Wire. Available at http://blog.nielsen.com/nielsenwire/consumer/north-america-asia-lead-vitamin-and-supplement-usage/. Accessed March 20, 2009.

  2. Griffin RM, Hoffman H. Live well vitamins & supplements center. WebMD. Available at http://gnc.webmd.com/vitamin-facts. Accessed March 22, 2009.

  3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline]. [Full Text].

  4. Dietary Supplement Fact Sheet: Vitamin A and Carotenoids. National Institutes of Health - Office of Dietary Supplements. Available at http://ods.od.nih.gov/factsheets/vitamina.asp. Accessed July 5, 2007.

  5. Pazirandeh S, Burns DL. Overview of vitamin A. UpToDate. Available at www.uptodate.com. Accessed July 5, 2007.

  6. Bakerman S. ABC's of Interpretive Laboratory Data. 4th ed. Scottsdale, AZ: Interpretive Laboratory Data, Inc; 2002.

  7. Brody JE. In vitamin mania, millions take a gamble on health. In: New York Times. October 26, 1997:1, 20.

  8. Cristoph RA. Vitamins. In: Manual of Toxicologic Emergencies. Year Book Medical Publishers; 1989:490-5.

  9. Dietary Supplement Fact Sheet: Vitamin E. National Institutes of Health - Office of Dietary Supplements. Available at http://ods.od.nih.gov/factsheets/vitamine.asp. Accessed March 20, 2009.

  10. Fischbach F. A Manual of Laboratory and Diagnostic Tests. 7th ed. Lippincott Williams & Wilkins; 2004.

  11. Food and Nutrition Board. Recommended Dietary Allowances. 10th ed. National Academy Press: Washington, DC; 1989.

  12. Goldfrank L, Lewis R. Vitamins. In: Goldfrank's Toxicologic Emergencies. 5th ed. Prentice Hall; 1994:535-44.

  13. Hathcock JN. Vitamins and minerals: efficacy and safety. Am J Clin Nutr. Aug 1997;66(2):427-37. [Medline].

  14. Hoffman RS. Thiamine hydrochloride. In: Goldfrank L, ed. Goldfrank's Toxicologic Emergencies. 5th ed. New York: Prentice Hall; 1997:825-6.

  15. Med Lett Drugs Ther. Toxic effects of vitamin overdosage. Med Lett Drugs Ther. Aug 3 1984;26(667):73-4. [Medline].

  16. Meyers DG, Maloley PA, Weeks D. Safety of antioxidant vitamins. Arch Intern Med. May 13 1996;156(9):925-35. [Medline].

  17. NIH Clinical Center. Vitamin E. National Institutes of Health - Office of Dietary Supplements. Available at http://ods.od.nih.gov/factsheets/vitamine.asp. Accessed July 5, 2007.

  18. Sachter JJ. Vitamins. In: Handbook of Medical Toxicology. Little Brown & Co Inc; 1993:399-402.

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Further Reading

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Keywords

vitamin A, retinol, vitamin D, cholecalciferol, vitamin E, alpha-tocopherol, vitamin K, phytonadione, vitamin B-1, thiamine, vitamin B-2, riboflavin, vitamin B-3, niacin, vitamin B-6, pyridoxine, vitamin B-12, cyanocobalamin, vitamin C, ascorbic acid, folic acid, B complex vitamins, nicotinic acid, beta-carotene, provitamin A, vitamin K-3, menadione, vitamin toxicity, iron-containing vitamins, fat-soluble vitamins, multiple vitamins, acute vitamin overdose, chronic vitamin overdose, craniotabes, bulging fontanelle, osteoporosis, angular cheilitis, alopecia, epiphyseal capping, premature epiphyseal closure, frontal headache, blurred vision, papilledema, hepatomegaly, ascites, erythematous dermatitis, migratory arthritis, increased bone resorption, bone pain, calcinosis, hypercalcemia, jaundice, hemolytic anemia, hyperbilirubinemia, sensory neuropathies, burning pains, paresthesias, ataxia, paralysis, perioral numbness, sensory ataxias, nephrolithiasis, renal colic, occult rectal bleeding, dental decalcification, diminished tendon reflexes, impairment of position sense, impairment of vibration sense

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Contributor Information and Disclosures

Author

Mark Rosenbloom, MD, MBA, FACEP, Adjunct Associate Professor of Medicine, Northwestern University Feinberg School of Medicine; Chief Executive Officer and Editorial Director, PEPID, LLC; Founder and Chairman, The Unicorn Children's Foundation
Mark Rosenbloom, MD, MBA, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Sports Medicine, American Medical Association, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard Lavely, MD, JD, MS, MPH, Lecturer in Health Policy and Administration, Department of Public Health, Yale University School of Medicine
Richard Lavely, MD, JD, MS, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Legal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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