What is the treatment for a vitamin deficient state?

Treatment of Vitamin Deficient States

Treat vitamin deficiencies immediately with specific replacement protocols tailored to each vitamin, prioritizing parenteral routes for B12 with neurological involvement, thiamine deficiency at risk for Wernicke's encephalopathy, and malabsorption states, while using oral supplementation for most other deficiencies with appropriate loading and maintenance dosing. 1

Critical Emergency Situations Requiring Immediate Treatment

Thiamine Deficiency/Wernicke's Encephalopathy

• Administer thiamine 200-300 mg orally daily PLUS vitamin B compound strong 1-2 tablets three times daily immediately upon clinical suspicion 1
• If oral route not tolerated, give full-dose intravenous vitamin B preparation 1
• Never give glucose (oral or IV) before thiamine replacement, as this precipitates Wernicke-Korsakoff syndrome 1
• Refer to neurology if neurological symptoms present 1

Vitamin B12 Deficiency with Neurological Involvement

• Administer hydroxocobalamin 1 mg intramuscularly on alternate days until no further improvement 1
• Then continue 1 mg IM every 2 months lifelong 1
• Never give folic acid before treating B12 deficiency, as this masks deficiency and precipitates subacute combined degeneration of the spinal cord 1
• Seek urgent specialist advice from neurologist and hematologist for unexplained sensory/motor/gait symptoms 1

Vitamin B12 Deficiency without Neurological Involvement

• Administer hydroxocobalamin 1 mg IM three times weekly for 2 weeks 1
• Follow with maintenance 1 mg IM every 2-3 months lifelong 1
• For pernicious anemia specifically: 100 mcg daily IM for 6-7 days, then alternate days for seven doses, then every 3-4 days for 2-3 weeks, then 100 mcg monthly for life 2

Fat-Soluble Vitamin Deficiencies

Vitamin A Deficiency

• Oral vitamin A 10,000-25,000 IU daily for 1-2 weeks for clinical improvement 1
• Recheck levels at 3 months 1
• For night blindness or non-response to oral therapy, refer to specialist for intramuscular injections 1
• In adolescents, refer for specialist support 1
• Consider ophthalmology referral for visual symptoms 1

Vitamin D Deficiency

• Loading dose: 50,000 IU ergocalciferol or cholecalciferol weekly for 8-12 weeks 3, 4
• Follow Royal Osteoporosis Society guidelines if available locally 1
• Maintenance: 800-2,000 IU daily or 50,000 IU monthly after achieving target levels ≥30 ng/mL 3
• For malabsorption or post-bariatric surgery patients, intramuscular vitamin D 50,000 IU is more effective than oral 3
• Refer to specialist if deficiency persists despite treatment 1

Vitamin E Deficiency

• Oral vitamin E 100-400 IU daily 1
• Recheck levels after 3 months 1
• Monitor serum levels and continue until normalized 1
• Caution: Large vitamin E doses exacerbate vitamin K deficiency and affect coagulation 1
• Refer to specialist for intramuscular injections if oral supplementation fails 1

Vitamin K Deficiency

• Oral vitamin K 1-2 mg daily (Ketovite tablets, menadiol sodium phosphate, or phytomenadione) 1
• Recheck levels after 3 months 1
• Seek hematologist advice if patient taking anticoagulants like warfarin 1
• Refer to specialist if no response to treatment 1

Water-Soluble Vitamin Deficiencies

Folic Acid Deficiency

• Always check and treat vitamin B12 deficiency BEFORE initiating folic acid to avoid subacute combined degeneration of spinal cord 1
• Folic acid 5 mg orally daily for minimum 4 months 1
• Further investigations if malabsorption suspected 1

Iron Deficiency Anemia

• Follow NICE Clinical Knowledge Summary guidelines for Anaemia—iron deficiency 1
• Investigate and exclude sources of blood loss 1
• Treat according to standard protocols for patients over 12 years and pregnant women 1

Trace Element Deficiencies

Zinc and Copper Deficiency

• If both zinc and copper low: prescribe two Forceval daily for 3 months and recheck levels 1
• For mild deficiency of either: two Forceval daily, recheck after 3 months 1
• Severe zinc deficiency with normal/borderline copper: high-dose zinc supplement for 3 months 1
• Severe copper deficiency: refer for specialist advice immediately 1
• Maintain zinc:copper ratio of 8-15 mg zinc to 1 mg copper when supplementing 1
• Close monitoring required as each affects absorption of the other 1

Special Clinical Situations

Unexplained Anemia or Fatigue

• Investigate for protein, zinc, copper, and selenium deficiencies 1
• Check all nutritional parameters before attributing symptoms to single deficiency 1

Prolonged Vomiting or Dysphagia

• Refer back to bariatric center immediately for investigation 1
• Give additional thiamine and vitamin B compound strong immediately due to thiamine deficiency risk 1
• Prolonged vomiting/dysphagia is never normal and requires investigation 1

Neurological Symptoms (Myeloneuropathy)

• Consider deficiencies of vitamin B12, thiamine, copper, or vitamin E 1
• Assess and correct all identified deficiencies simultaneously 1
• Refer to neurologist for persistent or severe symptoms 1

Critical Pitfalls to Avoid

• Never administer folic acid before excluding/treating B12 deficiency 1, 2
• Never give glucose before thiamine in at-risk patients 1
• Never use intravenous route for vitamin B12 as it results in urinary loss 2
• Never use active vitamin D analogs (calcitriol, alfacalcidol) to treat nutritional vitamin D deficiency 3
• Never give single ultra-high vitamin D doses (>300,000 IU) as they may be harmful 3
• Avoid excessive vitamin E supplementation without monitoring vitamin K status 1

Monitoring and Follow-Up

• Recheck vitamin levels at 3 months after initiating treatment for most deficiencies 1, 3
• Monitor hematocrit and reticulocyte counts daily from days 5-7 of B12 treatment, then frequently until normalized 2
• Serum potassium must be monitored closely in first 48 hours of pernicious anemia treatment 2
• Adjust supplementation doses based on follow-up levels and clinical response 1, 3