Can multivitamin injections cause anaphylaxis?

Multivitamin Injections Can Cause Anaphylaxis

Yes, multivitamin injections can cause anaphylaxis, which can be life-threatening and requires immediate medical intervention with epinephrine. While rare, anaphylactic reactions to injectable vitamins have been documented in medical literature, with reactions potentially triggered by specific vitamin components or excipients in the formulation.

Mechanisms of Anaphylaxis to Vitamin Injections

Anaphylaxis to multivitamin injections can occur through several mechanisms:

• IgE-mediated reactions to specific vitamin components:

  • Riboflavin (vitamin B2) has been documented as a cause of anaphylaxis 1
  • Cyanocobalamin (vitamin B12) can trigger severe anaphylactic reactions 2
  • Folic acid has been associated with IgE-mediated anaphylaxis 3

• Reactions to excipients and carriers:

  • Cremophor, an emulsifying agent used in some injectable preparations, has been identified as a hidden culprit in cases of repeated anaphylaxis 4
  • Gelatin stabilizers in some preparations may trigger reactions in susceptible individuals 5

Risk Factors for Severe Reactions

Certain patient factors increase the risk of severe anaphylactic reactions:

• Patients taking β-blockers are at higher risk for more serious anaphylaxis as these medications can interfere with the body's compensatory mechanisms and reduce effectiveness of epinephrine treatment 6
• Previous history of allergic reactions to any vitamin component
• History of atopy or multiple drug allergies

Clinical Presentation

Anaphylactic reactions to multivitamin injections typically present with:

• Cutaneous symptoms: diffuse warmth, itching, erythema, urticaria, angioedema
• Respiratory symptoms: laryngeal edema, bronchospasm, dyspnea
• Cardiovascular symptoms: hypotension, tachycardia, vascular collapse
• Gastrointestinal symptoms: nausea, vomiting, abdominal pain, diarrhea

Symptoms can progress rapidly from mild to severe and life-threatening 5.

Management of Anaphylaxis

When anaphylaxis is suspected:

1. Stop administration of the multivitamin injection immediately 5
2. Maintain IV access 5
3. Administer epinephrine promptly:
   • 0.01 mg/kg (1mg/mL dilution, maximum 0.5 mL) intramuscularly into the lateral thigh
   • Can be repeated every 5-15 minutes if needed 5
4. Position the patient appropriately:
   • Trendelenburg position for hypotension
   • Sitting up for respiratory distress
   • Recovery position if unconscious 5
5. Administer oxygen as needed 5
6. Provide fluid resuscitation:
   • Rapid infusion of 1-2 liters of normal saline at 5-10 mL/kg in first 5 minutes 5
7. Consider adjunctive therapies:
   • H1 and H2 antihistamines in combination
   • Corticosteroids to prevent biphasic reactions 5

Prevention Strategies

For patients requiring vitamin supplementation with history of reaction:

1. Consider alternative routes of administration:

   • Oral vitamin supplementation may be better tolerated (as demonstrated in the case of a patient who reacted to injectable B12 but tolerated oral B12) 2

2. Pre-medication protocols may be considered for less severe previous reactions:

   • H1 and H2 antihistamines
   • Corticosteroids

3. Skin testing may help identify the specific component causing the reaction:

   • Testing with individual vitamin components can identify the specific trigger 1, 3

4. Emergency preparedness:

   • All facilities administering injectable vitamins should have epinephrine, oxygen, and resuscitation equipment immediately available 6
   • Monitor patients for 15-30 minutes after injection, as most systemic reactions occur within this timeframe 6

Important Caveats

• Never attempt rechallenge in patients who have experienced severe (CTCAE grade 3 or higher) reactions or true anaphylaxis 5
• Accurate documentation of any reaction is essential for future medical care 5
• Consider the risk-benefit ratio carefully when deciding whether to administer injectable vitamins to patients with previous reactions

When vitamin supplementation is necessary for patients with previous anaphylactic reactions, consultation with an allergist/immunologist is strongly recommended to develop a safe management plan.