From the Guidelines
Nitrous oxide can deplete vitamin B12 levels in the body, potentially leading to neurological damage with prolonged or frequent exposure, and therefore, supplementation with vitamin B12 is recommended for individuals using nitrous oxide, either recreationally or medically. The use of nitrous oxide has been studied in various medical contexts, including endoscopic sedation, where its benefits include rapid onset, rapid recovery, and an excellent safety profile 1. However, its potential to deplete vitamin B12 levels is a significant concern, as vitamin B12 deficiency can lead to neurological damage and other health issues.
According to the most recent guidelines, for individuals with vitamin B12 deficiency and possible neurological involvement, hydroxocobalamin 1 mg intramuscularly should be administered on alternate days until there is no further improvement, then hydroxocobalamin 1 mg intramuscularly administered every 2 months 1. For those without neurological involvement, hydroxocobalamin 1 mg intramuscularly should be administered three times a week for 2 weeks, followed by maintenance treatment with 1 mg intramuscularly every 2–3 months for life.
Key points to consider include:
- Nitrous oxide inactivates vitamin B12 by oxidizing its cobalt atom, disrupting DNA synthesis and myelin formation.
- Symptoms of vitamin B12 deficiency can range from numbness and tingling to severe neurological damage in extreme cases.
- Regular B12 monitoring is advisable for those with repeated nitrous oxide exposure, and immediate supplementation should begin if symptoms of deficiency appear.
- Patients with existing B12 deficiency should inform their anesthesiologist before surgery, and healthcare providers may recommend B12 supplementation before and after the procedure.
Overall, the potential risks associated with nitrous oxide-induced vitamin B12 depletion necessitate careful consideration and management to prevent long-term neurological damage and other health complications.
From the Research
Nitrous Oxide and Vitamin B12 Deficiency
- Nitrous oxide use can lead to a functional vitamin B12 deficiency, resulting in neurological and hematological effects 2, 3, 4, 5, 6.
- The deficiency occurs because nitrous oxide inactivates vitamin B12, which is essential for various bodily functions, including the production of red blood cells and the maintenance of the nervous system 2, 3, 4, 5, 6.
- Symptoms of vitamin B12 deficiency due to nitrous oxide use can include numbness in fingers, peripheral neuropathy, megaloblastic anemia, and subacute combined degeneration of the spinal cord 2, 3, 4, 5, 6.
Diagnostic Challenges
- Diagnosing vitamin B12 deficiency in individuals who use nitrous oxide can be challenging, as serum concentrations of vitamin B12 may be normal despite a functional deficiency 3, 4, 6.
- Complementary testing, such as measuring homocysteine and methylmalonic acid levels, may be necessary to confirm the diagnosis 3, 4, 6.
- Magnetic Resonance Imaging (MRI) can also be useful in diagnosing vitamin B12 deficiency, particularly in cases where neurological symptoms are present 4, 6.
Treatment Options
- Treatment for vitamin B12 deficiency due to nitrous oxide use typically involves cessation of nitrous oxide use and supplementation with intramuscular injections of cobalamin 4, 5.
- In some cases, additional treatment may be necessary to manage neurological or hematological complications 4, 6.
- It is essential to educate individuals who use nitrous oxide about the risks of vitamin B12 deficiency and the importance of seeking medical attention if symptoms occur 2, 6.