Vitamin Toxicity Treatment & Management
- Author: Mark Rosenbloom, MD, MBA; Chief Editor: Asim Tarabar, MD more...
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 potentially life-threatening manifestations are present.
If potentially lethal coingestions are present, perform gastric lavage if the patient presents within 1 hour postingestion. Always check whether the vitamin overdose included iron supplements, and manage such an overdose aggressively.
Identify other potentially lethal coingestants, such as acetaminophen, aspirin, and dangerous prescription drugs (ie, digoxin, lithium, phenothiazines). Other care is symptomatic and supportive.
Consult a neurosurgeon if evidence of CNS hemorrhage is present. For more information on vitamin toxicity management, consult a regional poison control center or a local medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine).
Patients on isotretinoin should be evaluated by their dermatologist for consideration of stopping the drug.
Symptoms of vitamin A toxicity usually resolve after stopping vitamin A and instituting supportive therapy. The pigmentation of carotenemia usually disappears with the omission of carrots from the diet.
Patients with increased intracranial pressure may need therapeutic lumbar punctures or further treatment with medications such as diuretics and mannitol.
Patients with symptomatic hypercalcemia require the following:
Treatment with intravenous fluids and diuretics
Additional therapy, including pamidronate, calcitonin, corticosteroids, or mithramycin
Discontinuation of vitamin A
Place patients with vitamin D toxicity on a low-calcium diet. Consider oral calcium disodium edetate to increase fecal excretion of calcium.
In cases of 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 qDay IV over 4-6 h for 1-4 days). Peritoneal or hemodialysis may be necessary if large amounts of fluids cannot be given.
Vitamins K, B-1, B-2, B-6, B-12, and C, and folate
These usually require only supportive measures.
Provide supportive treatment as needed. Aspirin taken 30 minutes before niacin decreases the flush response.
Management of vitamin E toxicity consists of discontinuing vitamin E supplements and monitoring the PT if bleeding complications develop.
Vitamin K replacement through the oral or subcutaneous route should reduce the elevated PT and decrease the risk of bleeding in patients who are taking anticoagulants or who have vitamin K deficiency.
Admit patients with the following conditions:
Risk for suicide
Altered mental status
Metabolic derangements - Eg, hypercalcemia, severe electrolyte abnormalities, ECG changes, renal or liver damage)
Patients with vitamin E toxicity require hospitalization only if bleeding complications, including intracranial hemorrhage, occur.
If an intracranial hemorrhage is suggested or the patient has focal neurologic findings on examination, order a head CT scan without contrast to rule out an existing hemorrhage.
If hemorrhage is present, the patient should receive inpatient medical management, with a neurosurgeon consulted for possible drainage of the fluid collection.
Patients who present with other forms of bleeding should receive vitamin K and should be observed until they are stable, with follow-up evaluation provided on an outpatient basis.
Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015 Dec. 53 (10):962-1147. [Medline]. [Full Text].
American Association of Poison Control Centers’ National Poison Data System. Annual Reports. Available at http://www.aapcc.org/annual-reports. Accessed: December 5, 2015.
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: December 5, 2015.
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Multivitamin/mineral Supplements. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/MVMS-HealthProfessional/. July 8, 2015; Accessed: December 5, 2015.
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin A. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/vitamina.asp. June 05, 2013; Accessed: December 5, 2015.
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin B6. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/VitaminB6-HealthProfessional/. September 15, 2011; Accessed: December 5, 2015.
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin B12. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/. June 24, 2011; Accessed: December 5, 2015.
Fritz H, Flower G, Weeks L, Cooley K, Callachan M, McGowan J, et al. Intravenous Vitamin C and Cancer: A Systematic Review. Integr Cancer Ther. 2014 May 26. 13(4):280-300. [Medline].
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin C. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/. June 05, 2013; Accessed: December 5, 2015.
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. November 10, 2014; Accessed: December 5, 2015.
Miller ER 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E. Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med. 2005 Jan 4. 142(1):37-46. [Medline]. [Full Text].
Bjelakovic G, Nikolova D, Gluud LL, Simonetti RG, Gluud C. Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases. Cochrane Database Syst Rev. 2012 Mar 14. 3:CD007176. [Medline].
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin E. National Institutes of Health. Available at http://ods.od.nih.gov/factsheets/VitaminE-HealthProfessional/. Accessed: October 13, 2014.
Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Vitamins. Available at http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/RDA%20and%20AIs_Vitamin%20and%20Elements.pdf. Accessed: October 13, 2014.
Tan KP, Kosuge K, Yang M, Ito S. NRF2 as a determinant of cellular resistance in retinoic acid cytotoxicity. Free Radic Biol Med. 2008 Dec 15. 45(12):1663-73. [Medline].
Maqbool A, Stallings VA. Update on fat-soluble vitamins in cystic fibrosis. Curr Opin Pulm Med. 2008 Nov. 14(6):574-81. [Medline].
Mawson AR. On the association between low resting heart rate and chronic aggression: retinoid toxicity hypothesis. Prog Neuropsychopharmacol Biol Psychiatry. 2009 Mar 17. 33(2):205-13. [Medline].
Corrigan JJ Jr, Marcus FI. Coagulopathy associated with vitamin E ingestion. JAMA. 1974 Dec 2. 230(9):1300-1. [Medline].
Brown BG, Zhao XQ, Chait A, Fisher LD, Cheung MC, Morse JS, et al. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med. 2001 Nov 29. 345(22):1583-92. [Medline]. [Full Text].
Cheung MC, Zhao XQ, Chait A, Albers JJ, Brown BG. Antioxidant supplements block the response of HDL to simvastatin-niacin therapy in patients with coronary artery disease and low HDL. Arterioscler Thromb Vasc Biol. 2001 Aug. 21(8):1320-6. [Medline]. [Full Text].
Liu M, Wallin R, Wallmon A, Saldeen T. Mixed tocopherols have a stronger inhibitory effect on lipid peroxidation than alpha-tocopherol alone. J Cardiovasc Pharmacol. 2002 May. 39(5):714-21. [Medline].
Hathcock JN, Azzi A, Blumberg J, et al. Vitamins E and C are safe across a broad range of intakes. Am J Clin Nutr. Apr 2005. 81(4):736-45.
Debreceni B, Debreceni L. Why do homocysteine-lowering B vitamin and antioxidant E vitamin supplementations appear to be ineffective in the prevention of cardiovascular diseases?. Cardiovasc Ther. 2012 Aug. 30(4):227-33. [Medline].
Harling L, Rasoli S, Vecht JA, Ashrafian H, Kourliouros A, Athanasiou T. Do antioxidant vitamins have an anti-arrhythmic effect following cardiac surgery? A meta-analysis of randomised controlled trials. Heart. 2011 Oct. 97(20):1636-42. [Medline].
Vivekananthan DP, Penn MS, Sapp SK, Hsu A, Topol EJ. Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials. Lancet. 2003 Jun 14. 361(9374):2017-23. [Medline].
Cook NR, Albert CM, Gaziano JM, Zaharris E, MacFadyen J, Danielson E, et al. A randomized factorial trial of vitamins C and E and beta carotene in the secondary prevention of cardiovascular events in women: results from the Women's Antioxidant Cardiovascular Study. Arch Intern Med. 2007 Aug 13-27. 167(15):1610-8. [Medline]. [Full Text].
Klein EA, Thompson IM Jr, Tangen CM, Crowley JJ, Lucia MS, Goodman PJ, et al. Vitamin E and the risk of prostate cancer: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). JAMA. 2011 Oct 12. 306(14):1549-56. [Medline].
MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002 Jul 6. 360(9326):23-33. [Medline].
Shekelle PG, Morton SC, Jungvig LK, Udani J, Spar M, Tu W, et al. Effect of supplemental vitamin E for the prevention and treatment of cardiovascular disease. J Gen Intern Med. 2004 Apr. 19(4):380-9. [Medline]. [Full Text].
Orrell RW, Lane RJ, Ross M. A systematic review of antioxidant treatment for amyotrophic lateral sclerosis/motor neuron disease. Amyotroph Lateral Scler. 2008 Aug. 9(4):195-211. [Medline].
Lane JS, Magno CP, Lane KT, Chan T, Hoyt DB, Greenfield S. Nutrition impacts the prevalence of peripheral arterial disease in the United States. J Vasc Surg. 2008 Oct. 48(4):897-904. [Medline].
Mahabir S, Schendel K, Dong YQ, Barrera SL, Spitz MR, Forman MR. Dietary alpha-, beta-, gamma- and delta-tocopherols in lung cancer risk. Int J Cancer. 2008 Sep 1. 123(5):1173-80. [Medline]. [Full Text].
Lonn E, Bosch J, Yusuf S, Sheridan P, Pogue J, Arnold JM, et al. Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA. 2005 Mar 16. 293(11):1338-47. [Medline]. [Full Text].
Eidelman RS, Hollar D, Hebert PR, Lamas GA, Hennekens CH. Randomized trials of vitamin E in the treatment and prevention of cardiovascular disease. Arch Intern Med. 2004 Jul 26. 164(14):1552-6. [Medline].
Liede KE, Haukka JK, Saxén LM, Heinonen OP. Increased tendency towards gingival bleeding caused by joint effect of alpha-tocopherol supplementation and acetylsalicylic acid. Ann Med. 1998 Dec. 30(6):542-6. [Medline].
Leppälä JM, Virtamo J, Fogelholm R, Huttunen JK, Albanes D, Taylor PR, et al. Controlled trial of alpha-tocopherol and beta-carotene supplements on stroke incidence and mortality in male smokers. Arterioscler Thromb Vasc Biol. 2000 Jan. 20(1):230-5. [Medline]. [Full Text].
Handelman GJ. High-dose vitamin supplements for cigarette smokers: caution is indicated. Nutr Rev. 1997 Oct. 55(10):369-70. [Medline].
Spiller HA, Good TF, Spiller NE, Aleguas A. Vitamin D exposures reported to US poison centers 2000-2014: Temporal trends and outcomes. Hum Exp Toxicol. 2015 Oct 30. [Medline].
Genaro Pde S, Martini LA. Vitamin A supplementation and risk of skeletal fracture. Nutr Rev. 2004 Feb. 62(2):65-7. [Medline].
Ribaya-Mercado JD, Blumberg JB. Vitamin A: is it a risk factor for osteoporosis and bone fracture?. Nutr Rev. 2007 Oct. 65(10):425-38. [Medline].
Miksad R, de Lédinghen V, McDougall C, Fiel I, Rosenberg H. Hepatic hydrothorax associated with vitamin a toxicity. J Clin Gastroenterol. 2002 Mar. 34(3):275-9. [Medline].
Barker ME, Blumsohn A. Is vitamin A consumption a risk factor for osteoporotic fracture?. Proc Nutr Soc. 2003 Nov. 62(4):845-50. [Medline].
Bhalla K, Ennis DM, Ennis ED. Hypercalcemia caused by iatrogenic hypervitaminosis A. J Am Diet Assoc. 2005 Jan. 105(1):119-21. [Medline].
Johnson-Davis KL, Moore SJ, Owen WE, Cutler JM, Frank EL. A rapid HPLC method used to establish pediatric reference intervals for vitamins A and E. Clin Chim Acta. 2009 Jul. 405(1-2):35-8. [Medline].