How is folate deficiency treated?

Treatment of Folate Deficiency

Folate deficiency should be treated with oral folic acid 5 mg daily for a minimum of 4 months, after first ruling out vitamin B12 deficiency. 1

Diagnosis and Assessment

Before initiating treatment, proper assessment is essential:

• Folate status should be assessed in plasma/serum (short-term status) or RBC (long-term status) using validated methods 1
• Serum folate levels should be ≥10 nmol/L and red blood cell folate ≥340 nmol/L 1
• Always check vitamin B12 status before treating folate deficiency to avoid masking B12 deficiency, which could precipitate subacute combined degeneration of the spinal cord 1
• Analysis of homocysteine at the same time improves interpretation of laboratory measurements 1

Treatment Protocol

Standard Treatment

1. Oral folic acid 5 mg daily for a minimum of 4 months 1
2. Treatment should continue until the reason for deficiency is corrected 1
3. When clinical symptoms have subsided and blood picture normalizes, switch to maintenance dose:
   • 0.4 mg daily for adults
   • 0.8 mg daily for pregnant and lactating women 2

Alternative Administration Routes

• If oral treatment is ineffective or not tolerated, folic acid can be administered subcutaneously, IV, or IM at 0.1 mg/day 1
• Parenteral administration is generally not advocated except in patients receiving parenteral/enteral alimentation 2

Special Populations

Patients with Chronic Hemodialysis

• 1-5 mg folic acid per day may be given orally 1
• Non-diabetic patients: 5 mg/day
• Diabetic patients: up to 15 mg/day 1

Pregnant Women

• Women planning pregnancy or of childbearing age should take folic acid supplements (400 μg/day) periconceptionally to prevent neural tube defects 1
• Pregnant women with IBD should have iron status and folate levels monitored regularly 1

Patients on Specific Medications

• Patients on anticonvulsants, sulphasalazine, or methotrexate require special attention due to increased folate requirements 1, 3
• For patients on methotrexate: 5 mg once weekly 24-72 hours after methotrexate, or 1 mg daily for 5 days per week 1

Important Precautions

• Never exceed 1 mg daily unless vitamin B12 deficiency has been ruled out 2
• Daily doses greater than 1 mg do not enhance hematologic effect, and excess is excreted unchanged in urine 2
• Upper limit for folic acid is established at 1 mg/day to avoid masking vitamin B12 deficiency 1
• Patients with alcoholism, hemolytic anemia, anticonvulsant therapy, or chronic infection may need higher maintenance levels 2

Monitoring

• Folate status should be reassessed within 3 months after supplementation to verify normalization 1
• In diseases known to increase folate needs, measure folate status every 3 months until stabilization, then once yearly 1

Common Pitfalls to Avoid

1. Masking B12 deficiency: Always rule out vitamin B12 deficiency before starting folate supplementation 1
2. Inadequate dosing: Resistant cases may require larger doses than standard therapy 2
3. Insufficient duration: Treatment should continue for at least 4 months 1
4. Overlooking drug interactions: Certain medications (anticonvulsants, methotrexate, sulphasalazine) affect folate metabolism and may require adjusted dosing 1, 3
5. Neglecting maintenance therapy: After correction of deficiency, appropriate maintenance dosing is needed to prevent recurrence 2

By following this treatment approach, folate deficiency can be effectively corrected while minimizing potential risks associated with inappropriate supplementation.