http://www.hfme.org/researchbvitaminsandme.htm



Copyright © Jodi Bassett July 2010. Taken from http://www.hfme.org


Each member of the B vitamin family has unique therapeutic properties. What the B vitamins have in common is that they occur together in nature, and they are responsible for producing energy from the carbohydrates, proteins and fats in our foods.

The B vitamins play an essential role in the Krebs energy cycle, support the adrenals and proper neurological, cognitive and cardiac function, help maintain and repair the myelin sheath, help lower homocysteine levels and help the body cope with stress.

The B vitamins are water-soluble and any excess is readily excreted in the urine and so B vitamins are generally low in toxicity. When nutrients are water soluble it means that they are not stored in the body for long and so must supplements must be taken in 2 or 3 or more daily doses spread throughout the day rather than all at once.

Because the B vitamins are so intertwined, it is important to take B vitamins as a complex rather than taking a large amount of one or two B vitamins and possibly creating new imbalances. Individual B vitamins should never be taken without also taking a B complex product of a roughly similar strength.

B vitamins are supplied by foods such as eggs, meat, nuts, seeds and unprocessed whole grains and some fruits, vegetables and beans.



Different ways of taking B vitamins

Many M.E. patients do far better taking B vitamins intravenously (by IV) or intramuscular (IM) injections or in their coenzymate (or 'active') forms, than orally.

To get the most powerful effect from B vitamins they should be given by IV, generally speaking. The next best choices in order of preference are: B vitamins injected IM, B vitamins in coenzymate and sublingual forms, B vitamins in sublingual OR fat soluble forms and standard oral vitamin B supplements.

In some cases, however, particularly where liver function or metabolic function is very poor, coenzymated B vitamin products will be the best choice, and all other forms of B vitamins will have little or no effect. (This is explained further in the section on coenzymated B vitamins to come.)

What follows is a basic overview of each of the B vitamins. (If you're overwhelmed by too much information, then just skip this section and know that you can easily cover your basic needs just by taking an oral or coenzymated/sublingual B complex product 1 - 2 times daily. Getting the B vitamins you need need not be complicated!)



A basic overview of each of the B vitamins

Vitamin B1

Vitamin B1 is essential in treating cardiomyopathy and chronic heart failure as it improves cardiac function. Vitamin B1 also improves peripheral neuropathy, nerve function and chronic pain and is known as 'the brain energiser.' Vitamin B1 also improves the body's ability to withstand stressful conditions and strengthens the immune system. Vitamin B1 is one of the most important B vitamins for M.E. patients.

Vitamin B1 is also an important nutrient for patients with Alzheimers, an overactive thyroid, serious mental health or addiction issues, learning difficulties and lead poisoning.

The therapeutic dosage of thiamin (vitamin B1) is generally 50 - 300 mg but may sometimes be significantly higher (when used to treat severe pain or neurological disease). Dr. Atkins explains that a dose of 1 - 4 g daily, taken orally, may be used to treat pain. 150 - 300 mg daily is the dosage used to cardiomyopathy or chronic heart failure and 400 mg daily is the dose needed to treat Depression (and to act as a mood elevator). Peripheral neuropathy treatment requires B1 injections (or benfotiamine supplements).

Dr. Klenner's neurological disease treatment protocol strongly emphasises vitamin B1 as it plays an important role in the metabolic cycle, facilitating muscle function and also aids in the remyelination of damaged nerves. (Klenner's protocol recommends 1g of thiamine HCl taken orally thirty minutes before meals and at bedtime, plus 400 mg of thiamine given IM 5 - 7 days a week - plus large amounts of each of the other B vitamins. See the notes section of this paper for details.)

Dr. Atkins recommends a dose of 1400 mg of B1 daily in Parkinson's disease (and similar neurological diseases) and writes that in his opinion, higher daily doses than 1400 mg should be taken only under medical supervision. (This seems a very sensible guidelines to follow. Note that this 1400 mg figure may be made up of any combination of oral or sublingual thiamine HCl, benfotiamine or activated vitamin B1.)

Thiamin diphosphate (TDP), also called thiamin pyrophosphate (TPP) or cocarboxylase, is the active, coenzyme form of vitamin B1. This may be the best form of B1 for treating severe pain (including Fibromyalgia).

TPP is a critical link between the glycolytic cycle and its main energy-producing cycle, the Krebs' cycle, and plays key roles in the Krebs' cycle itself. TPP participates in the conversion of amino acids into energy and is a key coenzyme in the pentose phosphate pathway, which provides red blood cells with their energy. TPP is also critical in fatty acid synthesis, synthesis of the key neurotransmitter acetylcholine, and for nerve cell membrane function (this is critically important since the nerves' messages must pass along its cell membrane). Sublingual dosage is 16 mg daily or more.

A synthetic fat soluble form of vitamin B1 called benfotiamine (belonging to the family of compounds knows as "allithiamines') is also more bioavailable and physiologically active than thiamin. Benfotiamine raises the blood level of TPP, the biologically active coenzyme of thiamine. Benfotiamine controls formation of advanced glycation end-products (AGEs) and helps maintain healthy cells in the presence of blood glucose. This form of vitamin B1 takes longer to have an effect, as it is fat soluble rather than water soluble. Dosage is 150 to 1000 mg daily.



Vitamin B2

Vitamin B2 is an antioxidant involved in energy production. It is one of the major nutrients involved in recycling glutathione. Riboflavin limits the cell damage caused by stroke or heart attack and minimises respiratory damage from various toxins. Low vitamin B2 levels increase the risk of depression. Signs of B2 deficiency include cracks at the corners of the mouth and difficulty adjusting to darkness or bright lights.

The therapeutic dosage of riboflavin (vitamin B2) is generally 50 - 200 mg. Riboflavin may cause urine to turn a bright yellow colour. (This is not cause for concern. It is a sign that you are taking enough B2 and that it is being properly absorbed, according to Dr. Atkins.)

Flavin mononucleotide (FMN), also called riboflavin phosphate, is one of the two metabolically active coenzyme forms of vitamin B2. FMN is the precursor for the other B2 coenzyme, FAD. FMN is also involved in bioconverting B6 to its coenzyme form. Sublingual dosage is 18 mg or more daily.



Vitamin B3

Vitamin B3 is critical for energy production as well as heart health and optimal circulation. It is involved in over 50 reactions that turn fat into energy. Vitamin B3 comes in two forms, niacin and niacinamide. While both will meet the body's requirements for B3, their overall therapeutic qualities differ.

Niacinamide helps osteoarthritis (at a dose of 1.5 - 2 g daily) and may help prevent diabetes. Niacinamide will not cause skin flushing but neither will it improve cholesterol readings or blood circulation. Like niacin, niacinamide has a gentle sedating effect.

Niacin can lower cholesterol and triglycerides, improve heart health and circulation, promote relaxation and relieve anxiety. Niacin taken at night can promote sleep. Niacin is one also of the major orthomolecular treatments used at high doses to treat schizophrenia and other mental illnesses.

Doses of niacin larger than 50 mg should be taken as flush-free niacin/inositol hexanicotinate (IHN) where the 'niacin flush' is undesirable. (The niacin flush is a harmless feeling of warmth that occurs when certain amounts of niacin are taken, and lessens over time.) There is some uncertainty whether or not flush-free niacin could be used instead of the plain niacin recommended by Dr. Klenner and others for those who wish to avoid the 'niacin flush' that these doctors want patients to aim for. However, many other doctors recommend flush-free niacin as an excellent replacement for niacin and comment that is has all the same benefits as standard niacin, just without the flushing.

Note that vasodilating or cholesterol reducing drugs will need to be lowered with niacin or IHN supplementation and this should be done with the help of the doctor that prescribed these drugs for you.

The three forms of B3 are generally safe to supplement in moderate doses of 500 mg. More than 1000 mg of niacin should be taken under a doctor's care. To improve heart health, a dose of 800 - 2400 mg IHN daily is usually necessary, according to Dr Atkins. (IHN is probably the best B3 supplement for M.E. patients as it improves cardiac function and blood circulation.) For basic health maintenance, 100 mg of niacinamide daily will suffice. High doses of niacinamide may cause nausea or extreme drowsiness in some people.

Nicotinamide adenine dinucleotide (NAD), is one of two main metabolically active forms of vitamin B3. The other is NAD phosphate (NADP). Some doctors suggest that taking NAD has little effect however, and recommend instead a sublingual supplement containing NADH. (Enteric coated NADH is not recommended.) NADH is a coenzyme, antioxidant form of vitamin B3. Dosage for sublingual NADH is 10 mg tried for 4 weeks. If this initial dose is ineffective, the dose may then be raised to 20 mg daily.

Some find NADH very helpful, while others feel it is not worth the expense and than taking extra B2 and B3 (as niacin or IHN) gives a much more powerful effect.



Vitamin B5

Vitamin B5 supports the adrenals and can help patients with adrenal problems lower their cortisone dosage as it allows the adrenal glands to produce more cortisone. Vitamin B5 helps in the formation of acetylcholine, the metabolism of fatty acids, and the incorporation of fatty acids into cell membrane phospholipids. It is also involved in making steroid hormones, vitamin A, vitamin D, and cholesterol. Pantethine lowers cholesterol and triglycerides, helps to control yeast infections, helps the body with detoxification issues which arise as a result of a yeast infection and helps treat autoimmune diseases and allergies.

Vitamin B5 is available as pantothenic acid and pantethine. Both forms have their own unique therapeutic effects and often they are both prescribed for a patient. The therapeutic dosage of pantothenic acid and/or pantethine is generally at least 200 mg daily.

Pantethine is a combination of pantothenic acid (vitamin B5) and beta-mercaptoethylamine. Pantethine is the precursor to coenzyme A (CoA), the critical starting point in the Krebs energy production cycle. (CoA also works with CoQ10 in improving detoxification.) While both forms of B5 can be used to make CoA, at least twice as much CoA will be formed with pantethine as opposed to pantothenic acid.

To stabilise cholesterol and triglycerides or tame inflammation, allergies or an autoimmune condition the dosage is 600 - 900 mg of both pantethine and pantothenic acid daily, according to Dr. Atkins. Pantethine is one of the few B vitamins also available in sublingual form.



Vitamin B6

Vitamin B6 is a natural antihistamine and detoxifier and helps lower homocysteine levels. It is also integrally involved in women's health, diabetes and heart disease prevention, Arthritis treatment and immune system strength and a useful treatment in neurological and mental disorders.

The therapeutic dosage of pyridoxine (vitamin B6) is 75 - 200 mg. More than 200 mg of B6 should not be necessary. Vitamin B6 should be taken with a magnesium and zinc supplement. (Without an additional magnesium, zinc and B complex supplement, doses of B6 above 500 mg can cause temporary sensory neuropathy: a numbness or tingling in the arms or legs.) Doses of 200 - 400 mg may sometimes be used for some of the conditions mentioned previously (if a higher doses prove necessary) under medical supervision.

Pyridoxal-5'-Phosphate (PLP or P-5'-P) is the main metabolically active coenzyme form of vitamin B6. It is primarily in the liver that P-5'-P is synthesized from pyridoxine, with the help of enzymes that require vitamin B-2, zinc and magnesium for their activity. P-5'-P is associated with numerous enzymes, many or which are involved in the conversion of amino acids into the neurotransmitters dopamine, norepinephrine and serotonin. P-5'-P is also required for the synthesis of the hemoglobin molecule. Only 20% as much P-5'-P is needed as compared to standard pyridoxine supplements. Sublingual dosage is 17 mg or more daily.

Dr Atkins comments that many people cannot convert pyridoxine into its active form. He recommends that at least 20% of the B6 supplemented should come from P-5'-P.



Biotin, vitamin B7

Biotin is particularly important in childhood. Biotin promotes healthy skin, hair and nerves. Dosage for biotin starts at 50 - 180 mcg. The therapeutic dosage of biotin is 300 - 3000 mcg or more. Dosages of 2 -4 mg may be used to treat hypoglycaemia.



Inositol, vitamin B8

Inositol is the relaxing and sleep inducing B vitamin. Inositol is needed for cell growth and is required by the brain and spinal cord. Dosage begins at 25 - 150 mcg.

As Dr Atkins explains, the therapeutic dosage of inositol for improving sleep and relieving insomnia is 1 - 1.5 g taken at bedtime. At a dose of 6 - 18 g daily, inositol is a safe and effective treatment for obsessive compulsive disorder (and also Depression and panic disorders) and can replace tranquilisers and sleeping pills. For moderate anxiety Dr Atkins recommends 1 - 2 g daily.



Folate B9

Folate helps to lower homocysteine levels, is needed in red blood cell formation, can prevent neural tube birth defects, may improve skin problems and peripheral neuropathy, is essential for brain and nerve function and is a useful treatment in various neurological and mental disorders. Folate can also treat chronic pain (at a dose of 6 mg and when combined with some B12).

Doses of 40 mg daily or more can improve transient or long-term diarrhoea and various intestinal disorders such as Chrohn's disease and colitis. Folate at a dose of 40 - 60 mg daily has oestrogen-like effects and can be used by women who cannot tolerate the side-effects of standard oestrogen replacement therapy. 50 mg of the methyl form of folate is sometimes used to treat depression.

Standard synthetic folate supplements (folic acid) may not be adequate. Some experts claim that they may not be well utilised and may even be converted into glutamate and so be brain excitory (something that does not happen with natural/activated folate). 20% or more of the population are also not able to utilise standard folate supplements properly due the MTHFR genetic mutation. These individuals require the special natural form of folate called L-5-Methyl Tetrahydrofolate (or Metafolin) and absorption of this form of folate may be blocked by standard folic acid supplements. Less L-5-Methyl Tetrahydrofolate is needed than standard folate. This supplement should be started at very small doses in M.E., i.e. 1/10th of a tablet.

The therapeutic dosage of folate is 1 mg (1000 mcg) or more. Dr. Atkins recommends a dose of 3 - 8 mg of folate daily for those with neurological or cardiovascular disorders, 10 - 20 mg for those with high homocysteine levels and 20 - 60 mg daily for those with cancer, menopausal symptoms and severe colitis. Dosage recommendations for folate vary widely. In rare cases, doses over 15 mg daily may cause gastrointestinal and sleep problems.

It is important to take extra folate when extra B12 is taken; at least 1 mg (1000 mcg). To enhance the body's absorption of folate, take a probiotic supplement. Folic acid is one of the safest supplements.



Vitamin B12

Vitamin B12 guards against stroke, lowers homocysteine levels, improves general wellbeing and sleep, improves allergies and asthma, treats peripheral neuropathy, is required by the body to make myelin, is needed for healthy nerve function, improves CNS function and cognitive function, can help normalise low blood pressure (and low blood pressure or faintness on standing), improves digestion, plays an important role in forming red blood cells and supports detoxification processes. Doses over 1mg should also be taken with at least 1 mg of folate. There are several different forms of vitamin B12.

Hydroxycobalamin: This form of B12 is longer acting and raises blood levels of B12 higher. The therapeutic dosage of vitamin B12 as hydroxycobalamin is usually 1 - 5 mg, or sometimes 10 mg at the beginning of treatment. May reset the sleep/wake cycle too severely at higher doses, requiring that the dose be lowered.

Dibencozide: Extra B12 as dibencozide may also be useful and is also well tolerated in M.E. Dibencozide is a primary coenzyme form of vitamin B12. It is required for processing branch chain amino acids through the Kreb's cycle for sustained energy production and is involved in methionine and choline metabolism, red blood cell formation, and maintaining the integrity of myelin (a fatty insulation that covers some nerves), as well as promoting normal folic acid metabolism. Sublingual dosage is 1 mg or more daily.

Methylcobalamin: Methylcobalamin is an active coenzyme form of vitamin B12, is essential for cell growth and replication. It is more concentrated than other forms of B12 in the cerebral spinal fluid where it can be used by the central nervous system. It donates methyl groups to the myelin sheath that insulates certain nerve fibers. It also plays a role in maintaining a healthy sleep/wake cycle, as well as normal nerve function.

Large doses may work too well to reset the sleep/wake cycle. They may reduce total sleep time and promote early waking causing severe relapse in M.E. Thus, this form of B12 should only be tried at very low doses to start with (as B12 takes months to leave the system) and may only be able to be tolerated in very low doses longer term. As with activated folate, a good starting dose may be just 1/10th of a (1 mg) tablet a day. Where MB12 is well tolerated, dosage is 1 - 5 mg daily. 200 - 500 mcg daily (plus some extra B12 in another form) may be a better dose if problems caused by MB12 with the sleep/wake cycle are severe.

Another way to get some of the benefits of methylcobalamin B12 is to take hydroxycobalamin. Despite the fact it is not an activated form of vitamin B12, this form of B12 is one of the most beneficial and highly recommended in M.E. as it is a potent detoxifier. A small part of hydroxycobalamin supplements taken will be turned into methylcobalamin by the body, and so hydroxycobalamin also has a positive but more subtle effect on the sleep/wake cycle that is less likely to cause relapse. For more information on B12s effect on the sleep/wake cycle see the section on sleep in the main Treating M.E. paper.

Cyanocobalamin: This form is okay to take if it is included in small amounts in multivitamins or B complex products but should never be the form of B12 chosen when purchasing a stand-alone B12 supplement. At high doses hydroxycobalamin, methylcobalamin or dibencozide rather than cyanocobalamin must be used to avoid the toxicity of the cyanide in the later.

Vitamin B12 may be injected or given by IV, or taken equally effectively via sublingual tablets. There is no need for injections if you can find a good sublingual product, as these articles explain: Vitamin B12 Shot Problems and Vitamin B12 Shot Side Effects. At higher doses, both sublingual and injectable B12 are well absorbed so choose which you prefer and is more cost effective.

Whichever form you take, it is essential to start at a low dose and work up slowly as B12 (especially hydroxocobalamin) helps with detoxification. Going slow is also very important as if enough is taken to too-severely affect the sleep/wake cycle this can then take several months to wear off, as B12 is stored in the muscles and in organs. B12 is well tolerated by most M.E. patients although some patients seem unable to tolerate this supplement in anything but a tiny dose. B12 is extraordinarily safe even in high amounts.

The effects from B12 may seem to wear off after a long period of treatment, so some doctors recommend stopping B12 treatment for a month and then restarting it to get around this problem. Note that HB12 in sublingual form can be hard to find,click here,here, here, here or here for links. Vitamin B12 may also be well absorbed intranasally, according to the 'Fire your doctor!' book.



Choline

The therapeutic dosage of choline (a B vitamin) is 50 - 1150 mg or more. Choline is a component of lecithin. Choline may be supplemented equally well via lecithin granules (1 - 3 tsp daily) or phosphidatylcholine.



PABA Bx

While it is not actually a B vitamin, para-amino benzoic acid (PABA) is sometimes included in B complex supplements in small amounts as it helps us synthesise folic acid in our gastrointestinal tract. PABA may be prescribed to treat autoimmune disorders at a dose of 500 - 1500 mg daily.

The therapeutic dosage of PABA (sometimes called vitamin Bx) is up to 250 - 500 mg.



Oral B vitamin supplements

Probably the easiest and cheapest way to take a B vitamin supplement is to take a 50 mg B complex capsule or tablet 2 - 3 times daily or a 100 mg product 1 - 1 ½ times daily (along with a good quality multivitamin).

(Note that B complex products labelled '50 mg' do not contain the same amount of each of the B vitamins, as this would be inappropriate. The '50 mg' refers to the dosage of the main vitamins such as vitamin B1 and B2 etc.)

Some M.E. patients may find that oral B supplements are adequate, but that somewhat higher doses are needed due to absorption problems caused by M.E. Where higher doses of some of the B vitamins are required, one or more additional single B vitamin products may also be taken with the B complex product in oral, sublingual or injectable form.



Taking B vitamins in activated and/or sublingual forms

In order for B vitamins to be utilized by the body, they must first be converted into their active coenzyme forms by the liver. This conversion takes time and requires metabolic energy, which may be in short supply in M.E. For most healthy, young individuals, this conversion of synthetic B vitamins into coenzymated vitamins does not present a problem. However, in older, ill or nutritionally-deficient people or certain individuals with a particular biochemical deficiency, the conversion may be problematic. When this occurs, supplementing with non-coenzymated B vitamins may have little effect.

Our livers are working harder than ever before with the hugely increased amount of toxins they have to process and neutralise in the 21st century. This is one reason why the liver's ability to coenzymate vitamins into their active forms can be greatly impaired (which can affect our entire biochemistry). Some people also have particular problems converting vitamin B6 or folate to their active forms. For these people, only the coenzymated form of these vitamins will be able to be used by the body.

Where there are problems converting one or more of the B vitamins into their active coenzyme forms by the liver coenzymated sublingual B vitamins will be by far the best choice of B supplement. In studies with chronic alcoholics (a group at high risk of poor liver function) large doses of B vitamins were given by IV. Normally, the administration of these IVs would raise the body's coenzyme levels, but in the case of liver-impaired alcoholics, it did not. This shows that a compromised liver may not be able to Coenzymate vitamins optimally. Thus when a person cannot convert B vitamins properly, even injections or IVs of non-coenzymated vitamins will have little or no effect. So for some people, the optimum way to take in B vitamins is not by IV but through coenzymated products.

Coenzyme forms of vitamins are biologically identical to those used by the body, making them highly bioavailable, especially when they are also in a sublingual form. Sublingual tablets are absorbed rapidly into the highly capillarised tissues found in the cheeks and under the tongue and enter the bloodstream intact, without the risk of being degraded or diminished by the digestive system. Taking coenzymate and sublingual forms of B vitamins also conserves valuable metabolic energy and reduces the load on the (probably very overworked already) liver. Vitamins taken in this form will also be faster acting.

Smaller doses are needed when the coenzymate forms of vitamins are taken and when nutrients are taken sublingually. Coenzymated forms of vitamin B are up to five times more biologically active than other forms. One study using both sublingual and oral supplements (testosterone in this case) found that the absorption of the sublingual was twice that of the oral dose.

Taking 150 mg daily of a B vitamin complex product should bring noticeable effects and benefits within 2 - 4 weeks. It should improve wellbeing generally, improve concentration, improve mood and make you feel more able to cope with stress. You should really be able to feel a significant difference. If 150 mg of an oral B complex is taken for a month with little or no effect, a sublingual coenzymated B complex product should be trialled. Try 2 or 3 sublingual lozenges daily (depending on the brand).

A short trial of this nature is a very good idea in M.E. and is very highly recommended as it's an easy way to see if perhaps your body is not converting the B vitamins to their useable forms very well. If this is the case a far more noticeable effect will be seen from the coenzymate product than from standard B vitamin products.

A bottle of sublingual coenzymated B complex containing 60 lozenges (a month's supply) costs around $14 (USD/AUD/NZD/CAD). Coenzymated sublingual B vitamins can be bought singly or as a complex. Note that not all of the B vitamins are available in a coenzymate form, only vitamins B1, B2, B3, B6, B12 and folate.

The downside of sublingual vitamins is the higher cost and taking in so much mannitol or sorbitol and other undesirable substances. Sourcing coenzymated sublingual vitamins can also be somewhat difficult. The leading brand in this area is US company Source Naturals. Source naturals makes a good quality coenzymated B complex, plus sells each of the coenzymated B vitamins individually as well. A product called Smart City Coenzymated B formula is available in Europe. The Holistic Heal website sells coenzymated B12 (plus hydroxycobalmain B12) and folate. Solgar sells activated folate as Metafolin. Methylcobalamin B12 is widely available in sublingual form.



Taking B vitamins in injectable or IV form

Intravenous administration of nutrients can achieve serum concentrations not obtainable with oral, or even intramuscular administration.

B vitamin injections or IVs must be administered by an experienced and qualified practitioner and thus may not be a practical or affordable option for all M.E. patients.

Individual B vitamins may be given via injection, and this may be combined with an oral or sublingual B complex product, or a B complex product may be given via injection or IV. IV vitamin expert Dr. Klenner says of B vitamin complex given by IV, 'Intravenous medication can be given daily; it should be administered at least twice weekly. Due to sensitivity possibilities, we always have the patient take the intramuscular injections for three weeks before starting intravenous therapy.'

Some doctors may offer a 'Myers' cocktail' which is an IV containing B vitamins, magnesium and calcium in particular amounts. This IV may be taken once or twice weekly or more (along with daily B vitamins etc. given orally each day). This treatment must be administered by an experienced and qualified practitioner. For more information on this treatment and instructions for doctors on how to make the IV, see the excellent article: Intravenous nutrient therapy: the "Myers' cocktail" by IV vitamin expert Alan R. Gaby. He explains,

All ingredients are drawn into one syringe, and 8-20 mL of sterile water (occasionally more) is added to reduce the hypertonicity of the solution. After gently mixing by turning the syringe a few times, the solution is administered slowly, usually over a period of 5-15 minutes (depending on the doses of minerals used and on individual tolerance), through a 25G butterfly needle. Occasionally, smaller or larger doses than those listed in Table 1 have been used. Low doses are often given to elderly or frail patients, and to those with hypotension. Doses for children are lower than those listed, and are reduced roughly in proportion to body weight. The most commonly used regimen has been 4 mL magnesium, 2 mL calcium, 1 mL each of B12 (as hydroxycobalamin), B6, B5, and B complex, 6 mL vitamin C, and 8 mL sterile water.

As the Myers' cocktail only contains a relatively small amount of vitamin C, full-strength vitamin C IVs may also be given (perhaps on alternate days). The preservatives used in vitamin C or B complex IVs (or injections) can cause problems in some patients and preservative free preparations may be a better (if more expensive) choice. Patients that are very sensitive to chemicals may do better when glass rather than plastic IV bags/flasks are used.

While the Myers' cocktail is generally very well tolerated, the magnesium (and calcium) in the Myers' IV may cause problems for those with low blood pressure - which includes M.E. patients. For this reason, it may be preferable to get a Myers' cocktail without calcium and magnesium and to take these supplements separately. (Magnesium should be taken in transdermal or liquid form, if possible, rather than orally, in this instance.) As with standard B complex IVs, it is recommended that the vitamins be given IM first for several weeks to check that they are well tolerated, before the IVs begin.

Some doctors may follow the Klenner protocol for treating neurological diseases which involves high dose vitamin C and B vitamins given by IV and injection as well as orally. A summary of this protocol is included in the notes section of this paper.



Combining different B vitamin products

Many M.E. patients choose to take more than one B vitamin product at a time, depending on their needs. As a very general example, the daily intake of B vitamins may be as follows:

* A daily multivitamin, a 50 mg B complex product x 2 -3, 500 mg of flush-free niacin, plus some sublingual B12 daily
* A daily multivitamin, a 100 mg B complex product x 1, plus some sublingual B1 and B12 daily
* A daily multivitamin, a 50 mg B complex product x 2, 500 mg of flush-free niacin, 250 mg of B1 as benfotiamine, plus a sublingual coenzymate B complex 2 times daily, plus some sublingual B12 daily
* A daily multivitamin, a 50 mg B complex product 3 times daily, 250 mg of niacin, plus weekly B1 injections
* A daily multivitamin, a sublingual coenzymate B complex 3 times daily, flush-free niacin 1000 mg, plus some extra sublingual B1, B12 and NADH daily
* A daily multivitamin, a sublingual coenzymate B complex 3 times daily, flush-free niacin 250 mg, plus some extra sublingual pantethine, B1 and B12 - plus a B complex (or Myers' cocktail) IV once or twice a week, for the first 1 - 6 months.



Initial doses vs maintenance doses

Over time, the doses of some of the B vitamins given at therapeutic doses may be able to be lowered. They may also no longer need to be injected or given by IV. How you feel should be used to determine the correct dosage of each of the B vitamins over time.

B vitamin IVs may only be necessary for the first 1 - 6 months (depending on the severity of the condition), at which time the B complex vitamins can be taken sublingually and/or orally several times daily instead. If your doctor has experience in giving B vitamins by IV they will most likely be able to guide you appropriately in these matters.

As an absolute minimum dosage it is important to take 50 - 100 mg of B1, B2 and B6, 100 - 200 mg of B5, 100 - 250 mg of B3, 800 mcg of folate and 500 mcg of B12. This is roughly the amount of each of the B vitamins contained in a good quality multivitamin or a 50 mg B complex supplement.



Vitamin B cautions

Individual B vitamins should never be taken at higher doses without also taking a high-strength B complex product.

Occasionally, high-dose B vitamins may interfere with sleep. If you have trouble getting to sleep at night, try taking your B vitamins as early in the evening as possible and see if this helps.

Betaine trimethylglycine (betaine TMG or TMG) may be included in soem B complex formulas. Such products may be best avoided as TMG is often very poorly tolerated in M.E. and can cause severe relapse while the supplement is taken and for a week or so afterwards. If well tolerated however, TMG is a beneficial supplement as it aids in the process of methylation. TMG is probably best taken alone to start with, at very small doses of just 100 - 200 mg.

B vitamins given by IV or IM should be given by medical practitioners that have considerable experience in this area. The collected works of Dr. Klenner and the article Intravenous nutrient therapy: the "Myers' cocktail by Alan R. Gaby are essential reading for patients and doctors involved with IM or IV B vitamin therapy. These papers include all sorts of useful cautions and extra information that comes with administering this treatment to many thousands of patients over many years. Dr. Klenner spent over 30 years perfecting his high-dose vitamin C and B vitamin etc. protocol for MS and other neurological diseases; a summary of his protocol is included in the notes section of this paper.

Dr. Atkins warns that women who need to shrink uterine fibroids, or prevent Breast Cancer recurrences, or deal with endometriosis or fibrocystic breasts should limit supplemental folate to 600 mcg daily.

An advantage of water-soluble nutrients is that any side-effects wear off very quickly. The exceptions to this are benfotiamine, which is a fat-soluble form of vitamin B1, and vitamin B12. Side effects from vitamin B12 (such as changes to the sleep/wake cycle) take several months to wear off, as B12 is stored in the muscles and in organs.