Liver 4

Cyanocobalamin (Liver 4) (commonly known as Vitamin B12) is the most chemically complex of all the vitamins. Cyanocobalamin (Liver 4)'s structure is based on a corrin ring, which, although similar to the porphyrin ring found in heme, chlorophyll, and cytochrome, has two of the pyrrole rings directly bonded. The central metal ion is Co (cobalt). Cyanocobalamin (Liver 4) cannot be made by plants or by animals, as the only type of organisms that have the enzymes required for the synthesis of Cyanocobalamin (Liver 4) are bacteria and archaea. Higher plants do not concentrate Cyanocobalamin (Liver 4) from the soil and so are a poor source of the substance as compared with animal tissues. Cyanocobalamin (Liver 4) is naturally found in foods including meat (especially liver and shellfish), eggs, and milk products. [HMDB]

Pyridoxine HCl (Liver 4) is the 4-methanol form of vitamin B6 and is converted to pyridoxal 5-phosphate in the body. Pyridoxal 5-phosphate is a coenzyme for synthesis of amino acids, neurotransmitters (serotonin, norepinephrine), sphingolipids, aminolevulinic acid. Although Pyridoxine HCl (Liver 4) and vitamin B6 are still frequently used as synonyms, especially by medical researchers, this practice is erroneous and sometimes misleading. [PubChem]

Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as flavin mononucleotide and flavin-adenine dinucleotide. [PubChem]

Silymarin (Liver 4), an antioxidant flavonoid complex derived from the herb milk thistle (Silybum marianum), has long been used as a liver tonic. Two new studies show that it can reduce insulin resistance (the underpinning of adult-onset diabetes, hypertension, and hypercholesterolemia) and diabetic complications. A third study reports that it may have some anti-cancer benefits as well.

Thiamine nitrate (Liver 4) or thiamin, also known as vitamin B1, is a colorless compound with the chemical formula C12H17N4OS. It is soluble in water and insoluble in alcohol. Thiamine nitrate (Liver 4) decomposes if heated. Thiamine nitrate (Liver 4) was first discovered by Umetaro Suzuki in Japan when researching how rice bran cured patients of Beriberi. Thiamine nitrate (Liver 4) plays a key role in intracellular glucose metabolism and it is thought that Thiamine nitrate (Liver 4) inhibits the effect of glucose and insulin on arterial smooth muscle cell proliferation. Thiamine nitrate (Liver 4) plays an important role in helping the body convert carbohydrates and fat into energy. It is essential for normal growth and development and helps to maintain proper functioning of the heart and the nervous and digestive systems. Thiamine nitrate (Liver 4) cannot be stored in the body; however, once absorbed, the vitamin is concentrated in muscle tissue.

Cyanocobalamin (Liver 4) Nasal Spray is indicated for the maintenance of normal hematologic status in pernicious anemia patients who are in remission following intramuscular vitamin B12 therapy and who have no nervous system involvement.

Cyanocobalamin (Liver 4) Nasal Spray is also indicated as a supplement for other vitamin B12 deficiencies, including:

I. Dietary deficiency of vitamin B12 occurring in strict vegetarians (Isolated vitamin B12 deficiency is very rare).

II. Malabsorption of vitamin B12 resulting from structural or functional damage to the stomach, where intrinsic factor is secreted, or to the ileum, where intrinsic factor facilitates vitamin B12 absorption. These conditions include HIV infection, AIDS, Crohn's disease, tropical sprue, and nontropical sprue (idiopathic steatorrhea, gluten-induced enteropathy). Folate deficiency in these patients is usually more severe than vitamin B12 deficiency.

III. Inadequate secretion of intrinsic factor, resulting from lesions that destroy the gastric mucosa (ingestion of corrosives, extensive neoplasia), and a number of conditions associated with a variable degree of gastric atrophy (such as multiple sclerosis, HIV infection, AIDS, certain endocrine disorders, iron deficiency, and subtotal gastrectomy). Total gastrectomy always produces vitamin B12 deficiency. Structural lesions leading to vitamin B12 deficiency include regional ileitis, ileal resections, malignancies, etc.

IV. Competition for vitamin B12 by intestinal parasites or bacteria. The fish tapeworm (Diphyllobothrium latum) absorbs huge quantities of vitamin B12 and infested patients often have associated gastric atrophy. The blind loop syndrome may produce deficiency of vitamin B12 or folate.

V. Inadequate utilization of vitamin B12. This may occur if antimetabolites for the vitamin are employed in the treatment of neoplasia.

It may be possible to treat the underlying disease by surgical correction of anatomic lesions leading to small bowel bacterial overgrowth, expulsion of fish tapeworm, discontinuation of drugs leading to vitamin malabsorption, use of a gluten-free diet in non-tropical sprue, or administration of antibiotics in tropical sprue. Such measures remove the need for long-term administration of vitamin B12.

Requirements of vitamin B12 in excess of normal (due to pregnancy, thyrotoxicosis, hemolytic anemia, hemorrhage, malignancy, hepatic and renal disease) can usually be met with intranasal or oral supplementation.

Cyanocobalamin (Liver 4) Nasal Spray is not suitable for vitamin B12 absorption test (Schilling Test).

* Sideroblastic anaemia

* Treatment and prophylaxis of vitamin B6 deficiency states

Oral

Prophylaxis of Riboflavin (Liver 4) deficiency

Adult: 1-2 mg daily.

Incompatibility: Incompatible with alkaline solutions and with tetracycline, erythromycin and streptomycin.

Oral

Riboflavin (Liver 4) deficiency

Adult: Up to 30 mg daily in divided doses.

Child: 3-10 mg daily.

Incompatibility: Incompatible with alkaline solutions and with tetracycline, erythromycin and streptomycin.

Oral

Microcytic anaemia

Adult: Associated with splenomegaly and glutathione reductase deficiency: 10 mg daily for 10 days.

Incompatibility: Incompatible with alkaline solutions and with tetracycline, erythromycin and streptomycin.

All forms of “hepatic cell damage” as in cases of:

1.Chronic persistent and chronic active hepatitis.

2.Liver cirrhosis.

3.Drug-induced hepatitis.

4.Alcoholic liver disease.

5.Fatty change of the liver.

6.Autoimmune hepatitis.

Thiamine nitrate (Liver 4) Hydrochloride Injection is effective for the treatment of Thiamine nitrate (Liver 4) deficiency or beriberi whether of the dry (major symptoms related to the nervous system) or wet (major symptoms related to the cardiovascular system) variety. Thiamine nitrate (Liver 4) Hydrochloride Injection should be used where rapid restoration of Thiamine nitrate (Liver 4) is necessary, as in Wernicke’s encephalopathy, infantile beriberi with acute collapse, cardiovascular disease due to Thiamine nitrate (Liver 4) deficiency, or neuritis of pregnancy if vomiting is severe. It is also indicated when giving IV dextrose to individuals with marginal Thiamine nitrate (Liver 4) status to avoid precipitation of heart failure.

Thiamine nitrate (Liver 4) Hydrochloride Injection is also indicated in patients with established Thiamine nitrate (Liver 4) deficiency who cannot take Thiamine nitrate (Liver 4) orally due to coexisting severe anorexia, nausea, vomiting, or malabsorption. Thiamine nitrate (Liver 4) Hydrochloride Injection is not usually indicated for conditions of decreased oral intake or decreased gastrointestinal absorption, because multiple vitamins should usually be given.

Cyanocobalamin (Liver 4) nasal spray contains Cyanocobalamin (Liver 4), a man-made form of vitamin B12. Vitamin B12 is important for growth, cell reproduction, blood formation, and protein and tissue synthesis.

Cyanocobalamin (Liver 4) nasal spray is used to treat vitamin B12 deficiency in people with pernicious anemia and other conditions.

Cyanocobalamin (Liver 4) nasal spray is usually given after treatment with an injection form of this medicine.

Cyanocobalamin (Liver 4) may also be used for purposes not listed in this medication guide.

Pyridoxine HCl (Liver 4) is vitamin B6. Vitamins occur naturally in foods such as meat, poultry, nuts, whole grains, bananas, and avocados. Vitamin B6 is important for many processes in the body.

Pyridoxine HCl (Liver 4) is used to treat or prevent vitamin B6 deficiency. It is also used to treat a certain type of anemia (lack of red blood cells). Pyridoxine HCl (Liver 4) injection is also used to treat some types of seizure in babies.

Pyridoxine HCl (Liver 4) taken by mouth (oral) is available without a prescription. Injectable Pyridoxine HCl (Liver 4) must be given by a healthcare professional.

Pyridoxine HCl (Liver 4) may also be used for purposes not listed in this medication guide.

Vitamins are compounds that you must have for growth and health. They are needed in small amounts only and are usually available in the foods that you eat. Riboflavin (Liver 4) (vitamin B 2) is needed to help break down carbohydrates, proteins, and fats. It also makes it possible for oxygen to be used by your body.

Lack of Riboflavin (Liver 4) may lead to itching and burning eyes, sensitivity of eyes to light, sore tongue, itching and peeling skin on the nose and scrotum, and sores in the mouth. Your doctor may treat this condition by prescribing Riboflavin (Liver 4) for you.

Some conditions may increase your need for Riboflavin (Liver 4). These include:

• Alcoholism
• Burns
• Cancer
• Diarrhea (continuing)
• Fever (continuing)
• Illness (continuing)
• Infection
• Intestinal diseases
• Liver disease
• Overactive thyroid
• Serious injury
• Stress (continuing)
• Surgical removal of stomach

In addition, Riboflavin (Liver 4) may be given to infants with high blood levels of bilirubin (hyperbilirubinemia).

Increased need for Riboflavin (Liver 4) should be determined by your health care professional.

Claims that Riboflavin (Liver 4) is effective for treatment of acne, some kinds of anemia (weak blood), migraine headaches, and muscle cramps have not been proven.

Oral forms of Riboflavin (Liver 4) are available without a prescription.

Vitamins are compounds that you must have for growth and health. They are needed in small amounts only and are usually available in the foods that you eat. Thiamine nitrate (Liver 4) (vitamin B 1) is needed for the breakdown of carbohydrates.

Some conditions may increase your need for Thiamine nitrate (Liver 4). These include:

• Alcoholism
• Burns
• Diarrhea (continuing)
• Fever (continuing)
• Illness (continuing)
• Intestinal disease
• Liver disease
• Overactive thyroid
• Stress (continuing)
• Surgical removal of stomach

Also, the following groups of people may have a deficiency of Thiamine nitrate (Liver 4):

• Patients using an artificial kidney (on hemodialysis)
• Individuals who do heavy manual labor on a daily basis

Increased need for Thiamine nitrate (Liver 4) should be determined by your health care professional.

Lack of Thiamine nitrate (Liver 4) may lead to a condition called beriberi. Signs of beriberi include loss of appetite, constipation, muscle weakness, pain or tingling in arms or legs, and possible swelling of feet or lower legs. In addition, if severe, lack of Thiamine nitrate (Liver 4) may cause mental depression, memory problems, weakness, shortness of breath, and fast heartbeat. Your health care professional may treat this by prescribing Thiamine nitrate (Liver 4) for you.

Thiamine nitrate (Liver 4) may also be used for other conditions as determined by your health care professional.

Claims that Thiamine nitrate (Liver 4) is effective for treatment of skin problems, chronic diarrhea, tiredness, mental problems, multiple sclerosis, nerve problems, and ulcerative colitis (a disease of the intestines), or as an insect repellant or to stimulate appetite have not been proven.

Injectable Thiamine nitrate (Liver 4) is administered only by or under the supervision of your health care professional. Other forms of Thiamine nitrate (Liver 4) are available without a prescription.

Once a medicine or dietary supplement has been approved for marketing for a certain use, experience may show that it is also useful for other medical problems. Although this use is not included in product labeling, Thiamine nitrate (Liver 4) is used in certain patients with the following medical conditions:

• Enzyme deficiency diseases such as encephalomyelopathy, maple syrup urine disease, pyruvate carboxylase, and hyperalaninemia

The recommended initial dose of Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray is one spray (500 mcg) administered in ONE nostril once weekly. Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray should be administered at least one hour before or one hour after ingestion of hot foods or liquids. Periodic monitoring of serum B levels should be obtained to establish adequacy of therapy.

Priming (Activation) of Pump

Before the first dose and administration, the pump must be primed. Remove the clear plastic cover and the plastic safety clip from the pump. To prime the pump, place nozzle between the first and second finger with the thumb on the bottom of the bottle. Pump the unit firmly and quickly until the first appearance of spray. Then prime the pump an additional 2 times. Now the nasal spray is ready for use. The unit must be re-primed before each dose. Prime the pump once immediately before each administration of doses 2 through 8.

How supplied

Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray is available as a spray in 3 mL glass bottles containing 2.3 mL of solution. It is available in a dosage strength of 500 mcg per actuation (0.1 mL/actuation). A screw-on actuator is provided. This actuator, following priming, will deliver 0.1 mL of the spray. Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray is provided in a carton containing a nasal spray actuator with dust cover, a bottle of nasal spray solution, and a package insert. One bottle will deliver 8 doses (NDC 67871-773-35).

Pharmacist Assembly Instructions For Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray

The pharmacist should assemble the Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray unit prior to dispensing to the patient, according to the following instructions:

1. Open the carton and remove the spray actuator and spray solution bottle.
2. Assemble Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray by first unscrewing the white cap from the spray solution bottle and screwing the actuator unit tightly onto the bottle. Make sure the clear dust cover is on the pump unit.
3. Return the Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)) Nasal Spray bottle to the carton for dispensing to the patient.

Mfd. for QOL Medical, LLC

Kirland, WA 98033, USA

1.866.469.3773

www.Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4)).com

3078 Rev. 02/06

FDA rev date: 9/15/2006

Usual Adult Dose for Drug Induced Vitamin/Mineral Deficiency:

Drug Induced Neuritis:

Cycloserine: 100 to 300 mg/day orally in divided doses.

Isoniazid or penicillamine: 100 to 200 mg/day orally for 3 weeks or 25 to 100 mg/day for prophylaxis.

Oral contraceptives: 25 to 30 mg/day orally.

Acute Intoxication:

Hydralazine: 25 mg/kg. One-third of the dose should be administered IM and the remainder administered as an IV infusion over 3 hours.

Isoniazid: 1 to 4 grams IV as a first dose, then 1 g IM every 30 minutes until the total required dose has been administered (given with other anticonvulsants as needed). The total dose administered should equal the amount of isoniazid ingested.

Mushroom ingestion (genus Gyromitra): 25 mg/kg IV infused over 15 to 30 minutes. Repeat as needed to a maximum total daily dose of 15 to 20 g.

Usual Adult Dose for Dietary Supplement:

Pyridoxine HCl (Liver 4) Deficiency:

10 to 25 mg/day orally, IM, or IV for 3 weeks followed by 2 to 5 mg/day from a multivitamin product.

Usual Adult Dose for Anemia:

Sideroblastic, hereditary: 200 to 600 mg orally daily. If adequate response obtained, dose may be decreased to 30 to 50 mg orally daily.

If therapeutic response is not obtained after 1 to 2 months of Pyridoxine HCl (Liver 4) therapy, a different therapy should be considered.

Usual Adult Dose for Nausea/Vomiting:

Nausea and vomiting of Pregnancy:

25 mg orally every 8 hours.

Usual Pediatric Dose for Drug Induced Vitamin/Mineral Deficiency:

Drug Induced Neuritis (cycloserine, isoniazid, hydralazine, penicillamine) :

Treatment: 10 to 50 mg/day.

Prophylaxis: 1 to 2 mg/kg/day

Acute Intoxication:

Hydralazine: 25 mg/kg: One-third of the dose should be administered IM and the remainder administered as an IV infusion over 3 hours.

Isoniazid: Acute ingestion of known amount: Initial: A total dose of Pyridoxine HCl (Liver 4) equal to the amount of isoniazid ingested (maximum dose: 70 mg/kg, up to 5 g); administer at a rate of 0.5 to 1 g/minute until seizures stop or the maximum initial dose has been administered; may repeat every 5 to 10 minutes as needed to control persistent seizure activity and/or CNS toxicity. If seizures stop prior to the administration of the calculated initial dose, infuse the remaining Pyridoxine HCl (Liver 4) over 4 to 6 hours. Acute ingestion of unknown amount: Initial: 70 mg/kg (maximum dose: 5 g); administer at a rate of 0.5 to 1 g/minute; may repeat every 5 to 10 minutes as needed to control persistent seizure activity and/or CNS toxicity.

Mushroom ingestion (genus Gyromitra): 25 mg/kg IV. Repeat as needed up to a maximum total dose of 15 to 20 g.

Usual Pediatric Dose for Dietary Supplement:

Pyridoxine HCl (Liver 4) Deficiency:

5 to 25 mg/day orally, IM, or IV for 3 weeks followed by 1.5 to 2.5 mg/day from a multivitamin product.

Usual Pediatric Dose for Seizures:

Pyridoxine HCl (Liver 4)-dependent seizures:

10 to 100 mg PO, IM, or IV initially, followed by 2 to 100 mg orally daily.

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule,

Oral:

B-2-400: 400 mg

Generic: 50 mg

Tablet,

Oral:

Generic: 25 mg, 50 mg, 100 mg

Dosing: Adult

Dietary supplement:

Oral: 100 mg once or twice daily

Prevention of migraine headache (off-label use):

Oral: 400 mg once daily (Rahimdel 2015; Schoenen 1998)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Dietary supplement: Infants, Children, and Adolescents: A multivitamin preparation is most commonly used for the provision of Riboflavin (Liver 4) supplementation in pediatric patients; the use of a single-ingredient Riboflavin (Liver 4) product as a daily supplement for the prevention of deficiency in pediatric patients is very rare. If single-ingredient Riboflavin (Liver 4) supplement is necessary, consult product labeling for appropriateness of product in infants and young children in particular.

Migraine headache, prevention: Limited data available, efficacy results variable: Children ≥ 8 years and Adolescents:

Oral: 200 to 400 mg once daily; dosing based on a retrospective study of 41 patients (ages 8 to 18 years) who received 200 mg/day (n=21) or 400 mg/day (n=20) as prophylaxis for migraine and migraine-type headaches; results showed significant reduction in primary endpoint of frequency of headache attack; 68.4% of patients had a ≥50% decrease in headache frequency during treatment (Condò 2009). However, in a prospective, placebo-controlled study of 48 patients (ages 5 to 15 years), patients received 200 mg/day (n=27) or placebo (n=21) and in the treatment group (Riboflavin (Liver 4)) no benefit compared to placebo for migraine frequency or intensity was observed; a high placebo responder rate was also reported (MacLennan 2008).

Severe cases 140 mg tid for 4-6 wk. In all other cases 70 mg tid for 4-6 wk.

Usual Adult Dose for Beriberi

10 to 20 mg IM three times daily for up to 2 weeks. Thereafter, use an oral therapeutic multivitamin preparation containing 5 to 10 mg Thiamine nitrate (Liver 4) daily for one month. A complete and balanced diet should follow.

Neuritis of pregnancy:

If vomiting severe to preclude oral therapy, give 5 to 10 mg IM daily.

'Wet' with myocardial failure:

Treat as an emergency cardiac condition. Thiamine nitrate (Liver 4) is administered slowly by the IV route.

Usual Adult Dose for Thiamine nitrate (Liver 4) Deficiency

If dextrose administered: to patients with marginal Thiamine nitrate (Liver 4) status, give 100 mg in each of the first few liters of IV fluid to avoid precipitating heart failure.

Usual Adult Dose for Vitamin/Mineral Supplementation

50 to 100 mg orally once a day

Usual Adult Dose for Wernicke's Encephalopathy

100 mg IV as an initial dose followed by 50 to 100 mg/day IM or IV until the patient is on a regular, balanced, diet.

Usual Pediatric Dose for Beriberi

10 to 25 mg IM or IV daily (if critically ill), or 10 to 50 mg orally every day for 2 weeks, then 5 to 10 mg orally daily for 1 month. If collapse occurs: 25 mg IV. Administer with caution.

Usual Pediatric Dose for Thiamine nitrate (Liver 4) Deficiency

If dextrose administered: to patients with marginal Thiamine nitrate (Liver 4) status, give 100 mg in each of the first few liters of IV fluid to avoid precipitating heart failure.

Usual Pediatric Dose for Vitamin/Mineral Supplementation

Infants: 0.3 to 0.5 mg orally once a day; children: 0.5 to 1 mg orally once a day.

Renal Dose Adjustments

Data not available

Liver Dose Adjustments

Data not available

Dose Adjustments

If hypersensitivity to Thiamine nitrate (Liver 4) is suspected, administer a skin test: one-hundredth of the dose intradermally and observe patient for at least 30 minutes. If no reaction occurs, full dose can be administered.

Precautions

Serious hypersensitivity/anaphylactic reactions have been reported, especially after repeated administration. A skin test should be performed on patients who are suspected of drug allergies or previous reactions to Thiamine nitrate (Liver 4), and any positive responders should not receive Thiamine nitrate (Liver 4) by injection.

Deaths have been reported after the use of IV or IM administration of Thiamine nitrate (Liver 4).

Thiamine nitrate (Liver 4) injection contains aluminum. Toxic levels of aluminum may occur if prolonged parenteral administration is used in patients with kidney impairment.

Dialysis

Data not available

Other Comments

Oral Thiamine nitrate (Liver 4) may be given with or without food.

Parenteral Thiamine nitrate (Liver 4) should be administered IM or by slow IV injection.

Dietary sources of Thiamine nitrate (Liver 4) include pork, beef, whole grains, yeast, fresh vegetables and legumes.

Recommended Dietary Allowances (RDA) in Adults:

Males: 1.2 mg daily

Female: 1.1 mg daily

Recommended Daily Allowance (RDA) in Pediatrics:

1 to 3 years: 0.5 mg/day

4 to 8 years: 0.6 mg/day

9 to 13 years: 0.9 mg/day

Males -14 to 18 years: 1.2 mg/day

Females - 14 to 18 years: 1.0 mg/day

Average Adequate Intake (AI) for healthy breast-fed infants:

0 to 6 months: 0.2 mg/day

7 to 12 months: 0.3 mg/day

See also:
What is the most important information I should know about Cyanocobalamin (Liver 4)?

You should not use this medication if you are allergic to cobalt, or if you have Leber's disease. Cyanocobalamin (Liver 4) can lead to optic nerve damage (and possibly blindness) in people with Leber's disease.

To treat pernicious anemia, you will have to use this medication on a regular basis for the rest of your life. Not using the medication can lead to irreversible nerve damage in your spinal cord.

Pernicious anemia is also treated with folic acid to help maintain red blood cells. However, folic acid will not treat Vitamin B12 deficiency and will not prevent possible damage to the spinal cord. Use all of your medications as directed.

Avoid eating or drinking hot foods or liquids within 1 hour before or after using the nasal form of this medication.

Tell your doctor if you develop nasal congestion, a cold, or allergies. The nasal spray may not work as well if you are congested.

Your dose needs may change if you become pregnant, if you breast-feed, or if you eat a vegetarian diet. Tell your doctor about any changes in your diet or medical condition.

See also:
What is the most important information I should know about Pyridoxine HCl (Liver 4)?

Contraindications for Vitamin B6 (Pyridoxine HCl (Liver 4))

Vitamin B6 is contraindicated in those hypersensitive to any component of a vitamin B6-containing product.

See also:
What is the most important information I should know about Riboflavin (Liver 4)?

None well documented.

Hypersensitivity, pregnancy, lactation.

See also:
What is the most important information I should know about Thiamine nitrate (Liver 4)?

A history of sensitivity to Thiamine nitrate (Liver 4) or to any of the ingredients in this drug is a contraindication.

Use Cyanocobalamin (Liver 4) (b12) spray as directed by your doctor. Check the label on the medicine for exact dosing instructions.

• An extra patient leaflet is available with Cyanocobalamin (Liver 4) (b12) spray. Talk to your pharmacist if you have questions about this information.
• Cyanocobalamin (Liver 4) (b12) spray is used in the nose.
• Follow the directions provided by your doctor or other health care provider. If you are unsure how to use Cyanocobalamin (Liver 4) (b12) spray, contact your doctor or other health care provider.
• Do not use Cyanocobalamin (Liver 4) (b12) spray within 1 hour before or after eating or drinking hot foods or liquids.
• Prime the pump before the first use. Place the nozzle between the first and second finger with the thumb on the bottom. Point the nozzle away from yourself and others. Pump the unit firmly and quickly until the medicine sprays out, then spray two more times.
• Re-prime the pump before each dose. Point the nozzle away from yourself and others, then spray once.
• Use Cyanocobalamin (Liver 4) (b12) spray in only 1 nostril each week.
• To use Cyanocobalamin (Liver 4) (b12) spray, sit down and tilt your head back slightly. Place the tip of the spray container into the nose. Using a finger from your other hand, press against the opposite nostril to close it off. Breath gently through the open nostril and spray a dose of medicine from the container. After using the medicine, rinse the tip of the spray unit in hot water and dry with a clean tissue to prevent contamination.
• Cyanocobalamin (Liver 4) (b12) spray is usually used 1 time per week. Do not use it more often than 1 time per week without checking with your doctor.
• This bottle contains 8 doses. Do not continue to use this bottle after 8 doses have been used. It may not give the correct amount of medicine.
• Continue to use Cyanocobalamin (Liver 4) (b12) spray even if you feel well. Do not miss any doses.
• If you miss a dose of Cyanocobalamin (Liver 4) (b12) spray, use it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not use 2 doses at once.

Ask your health care provider any questions you may have about how to use Cyanocobalamin (Liver 4) (b12) spray.

Use Pyridoxine HCl (Liver 4) (vitamin b6) as directed by your doctor. Check the label on the medicine for exact dosing instructions.

• Pyridoxine HCl (Liver 4) (vitamin b6) is usually administered as an injection at your doctor's office, hospital, or clinic. If you are using Pyridoxine HCl (Liver 4) (vitamin b6) at home, carefully follow the injection procedures taught to you by your health care provider.
• If Pyridoxine HCl (Liver 4) (vitamin b6) contains particles or is discolored, or if the vial is cracked or damaged in any way, do not use it.
• Keep this product, as well as syringes and needles, out of the reach of children and away from pets. Do not reuse needles, syringes, or other materials. Dispose of properly after use. Ask your doctor or pharmacist to explain local regulations for proper disposal.
• If you miss a dose of Pyridoxine HCl (Liver 4) (vitamin b6) and you are taking it regularly, take it as soon as possible. If several hours have passed or if it is nearing time for the next dose, do not double the dose to catch up, unless advised by your health care provider. Do not take 2 doses at once.

Ask your health care provider any questions you may have about how to use Pyridoxine HCl (Liver 4) (vitamin b6).

A surgeon or other healthcare provider will give you this medicine as part of your corneal collagen crosslinking procedure.

You will be given numbing eyedrops to prepare you for the procedure. You may also be given a sedative or anesthesia to help you relax. Although you will most likely be awake during the procedure, you should feel little or no discomfort. A special device will be placed around your eyelids to keep them open during the procedure.

Your eye surgeon will place Riboflavin (Liver 4) ophthalmic drops into your eyes about every 2 minutes during the procedure.

After the procedure, the surgeon will place a contact lens on the treated eye to protect it for a short time.

Call your doctor right away if the contact lens falls out or feels like it is out of place inside your eye.

You may also need to use antibiotic or steroid eyedrops to prevent infection and reduce swelling after your procedure. Carefully follow all after-care instructions and do not miss any follow-up appointments.

Use Thiamine nitrate (Liver 4) as directed by your doctor. Check the label on the medicine for exact dosing instructions.

• Thiamine nitrate (Liver 4) is usually given as an injection at your doctor's office, hospital, or clinic. If you will be using Thiamine nitrate (Liver 4) at home, a health care provider will teach you how to use it. Be sure you understand how to use Thiamine nitrate (Liver 4). Follow the procedures you are taught when you use a dose. Contact your health care provider if you have any questions.
• Do not use Thiamine nitrate (Liver 4) if it contains particles, is cloudy or discolored, or if the vial is cracked or damaged.
• Keep this product, as well as syringes and needles, out of the reach of children and away from pets. Do not reuse needles, syringes, or other materials. Ask your health care provider how to dispose of these materials after use. Follow all local rules for disposal.
• If you miss a dose of Thiamine nitrate (Liver 4), contact your doctor to find out what to do.

Ask your health care provider any questions you may have about how to use Thiamine nitrate (Liver 4).

How to use Cyanocobalamin (Liver 4) nasal

Pyridoxine HCl (Liver 4) (vitamin B6) is used to prevent or treat low levels of vitamin B6 in people who do not get enough of the vitamin from their diets. Most people who eat a normal diet do not need extra vitamin B6. However, some conditions (such as alcoholism, liver disease, overactive thyroid, heart failure) or medications (such as isoniazid, cycloserine, hydralazine, penicillamine) can cause low levels of vitamin B6. Vitamin B6 plays an important role in the body. It is needed to maintain the health of nerves, skin, and red blood cells.

Pyridoxine HCl (Liver 4) has been used to prevent or treat a certain nerve disorder (peripheral neuropathy) caused by certain medications (such as isoniazid). It has also been used to treat certain hereditary disorders (such as xanthurenic aciduria, cystathioninuria, hyperoxaluria, homocystinuria).

How to use Pyridoxine HCl (Liver 4)

Take this vitamin by mouth with or without food, usually once daily. Follow all directions on the product package, or take as directed by your doctor. If you are uncertain about any of the information, consult your doctor or pharmacist.

If you are taking the extended-release capsules, swallow them whole. Do not crush or chew extended-release capsules or tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Also, do not split extended-release tablets unless they have a score line and your doctor or pharmacist tells you to do so. Swallow the whole or split tablet without crushing or chewing.

If you are taking the powder, mix it thoroughly in the proper amount of liquid and stir well. Drink all of the liquid right away. Do not prepare a supply for future use.

Dosage is based on your medical condition and response to treatment.

Use this vitamin regularly to get the most benefit from it. To help you remember, take it at the same time each day.

Tell your doctor if your condition persists or worsens. If you think you may have a serious medical problem, seek immediate medical attention.

Riboflavin (Liver 4) (Riboflavin (Liver 4)) supplementation is used to prevent and treat Riboflavin (Liver 4) deficiency. Riboflavin (Liver 4) may prevent migraine headaches at high doses and be useful for prevention of eye conditions such as cataract, glaucoma and tired eyes (fatigue). Riboflavin (Liver 4) is also used for boosting of immune system, and maintenance of healthy hair, skin, nails and mucous membranes.

Silymarin (Liver 4) is a liver protectant and antioxidant. Treatment with Silymarin (Liver 4) has shown slightly improved liver function, and showed improvement in patients with type 2 diabetes and diabetic nephropathy (kidney disease).

It is a vitamin used to treat patients with deficiencies due to increased dietary requirements, reduced intakes, reduced absorption or increased excretion. It is used as a supplement in alcholic patients.

See also:
What other drugs will affect Cyanocobalamin (Liver 4)?

The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly. These drug interactions are possible, but do not always occur. Your doctor or pharmacist can often prevent or manage interactions by changing how you use your medications or by close monitoring.

To help your doctor and pharmacist give you the best care, be sure to tell your doctor and pharmacist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products) before starting treatment with this product. While using this product, do not start, stop, or change the dosage of any other medicines you are using without your doctor's approval.

Some products that may interact with this drug include: drugs that affect the bone marrow (such as chloramphenicol), vitamins/supplements that contain intrinsic factor.

Certain medications can decrease the absorption of vitamin B12, including: colchicine, metformin, extended-release potassium products, antibiotics (such as gentamicin, neomycin, tobramycin), anti-seizure medications (such as phenobarbital, phenytoin, primidone), medications to treat heartburn (such as H2 blockers including cimetidine/famotidine, proton pump inhibitors such as omeprazole/lansoprazole).

Vitamin B12 is an ingredient found in many combination vitamin and nutritional products. Tell your doctor or pharmacist if you are taking other products that contain Cyanocobalamin (Liver 4), vitamin B12, or hydroxocobalamin.

Cyanocobalamin (Liver 4) may interfere with certain laboratory tests (including intrinsic factor, blood tests for other types of anemia), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.

Certain drugs may interfere with laboratory tests for vitamin B12 levels, possibly causing false results. Tell laboratory personnel and all your doctors if you take any of the following: antibiotics (such as amoxicillin, erythromycin), methotrexate, pyrimethamine.

This document does not contain all possible drug interactions. Keep a list of all the products you use. Share this list with your doctor and pharmacist to lessen your risk for serious medication problems.

See also:
What other drugs will affect Pyridoxine HCl (Liver 4)?

The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly. These drug interactions are possible, but do not always occur. Your doctor or pharmacist can often prevent or manage interactions by changing how you use your medications or by close monitoring.

To help your doctor and pharmacist give you the best care, be sure to tell your doctor and pharmacist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products) before starting treatment with this product. While using this product, do not start, stop, or change the dosage of any other medicines you are using without your doctor's approval.

Some products that may interact with this vitamin include: altretamine, cisplatin, phenobarbital, phenytoin.

This vitamin may interfere with certain laboratory tests (including urine test for urobilinogen), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this vitamin.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

See also:
What other drugs will affect Riboflavin (Liver 4)?

Interactions for Riboflavin (Liver 4) (Riboflavin (Liver 4))

Alcohol - impairs the intestinal absorption of riboflavi

Antidepressants (tricyclics or phenothiazines) - requirements for Riboflavin (Liver 4) may be increased in patients receiving these medications

Probenecid - concurrent use decreases gastrointestinal absorption of Riboflavin (Liver 4); requirements for Riboflavin (Liver 4) may be increased in patients receiving probenecid.

See also:
What other drugs will affect Thiamine nitrate (Liver 4)?

With the simultaneous use with inducers of microsomal liver enzymes, means having hepatotoxic effect, increasing the risk of hepatotoxic action of paracetamol.

With the simultaneous use of anticoagulants may be slight to moderate increase in prothrombin time.

With the simultaneous use of anticholinergics may decrease absorption of paracetamol.

With the simultaneous use of oral contraceptives accelerated excretion of paracetamol from the body and may reduce its analgesic action.

With the simultaneous use with urological means reduced their effectiveness.

With the simultaneous use of activated charcoal reduced bioavailability of paracetamol.

When Thiamine nitrate (Liver 4) applied simultaneously with diazepam may decrease excretion of diazepam.

There have been reports about the possibility of enhancing mielodepression effect of zidovudine while applying with paracetamol. A case of severe toxic liver injury.

Described cases of toxic effects of paracetamol, while the use of isoniazid.

When applied simultaneously with carbamazepine, phenytoin, phenobarbital, primidonom decreases the effectiveness of paracetamol, which is caused by an increase in its metabolism and excretion from the body. Cases of hepatotoxicity, while the use of paracetamol and phenobarbital.

In applying cholestyramine a period of less than 1 h after administration of paracetamol may decrease of its absorption.

At simultaneous application with lamotrigine moderately increased excretion of lamotrigine from the body.

With the simultaneous use of metoclopramide may increase absorption of paracetamol and its increased concentration in blood plasma.

When applied simultaneously with probenecid may decrease clearance of paracetamol, with rifampicin, sulfinpyrazone - may increase clearance of paracetamol due to increasing its metabolism in the liver.

At simultaneous application of Thiamine nitrate (Liver 4) with ethinylestradiol increases absorption of paracetamol from the gut.

Enhances the effect of indirect anticoagulants (coumarin derivatives and indandione). Antipyretic and analgesic activity of caffeine increases, reduce - rifampicin, phenobarbital and alcohol (accelerated biotransformation, inducing microsomal liver enzymes).

See also:
What are the possible side effects of Cyanocobalamin (Liver 4)?

The incidence of adverse experiences described in the Table below are based on data from a short-term clinical trial in vitamin B12 deficient patients in hematologic remission receiving Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4), USP) Gel for Intranasal Administration (N=24) and intramuscular vitamin B12 (N=25). In the pharmacokinetic study comparing Cyanocobalamin (Liver 4) Nasal Spray and Cyanocobalamin (Liver 4) Nasal Gel, the incidence of adverse events was similar.

The intensity of the reported adverse experiences following the administration of Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4), USP) Gel for Intranasal Administration and intramuscular vitamin B12 were generally mild. One patient reported severe headache following intramuscular dosing. Similarly, a few adverse experiences of moderate intensity were reported following intramuscular dosing (two headaches and rhinitis; one dyspepsia, arthritis, and dizziness), and dosing with Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4), USP) Gel for Intranasal Administration (one headache, infection, and paresthesia).

The majority of the reported adverse experiences following dosing with Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4), USP) Gel for Intranasal Administration and intramuscular vitamin B12 were judged to be intercurrent events. For the other reported adverse experiences, the relationship to study drug was judged as "possible" or "remote". Of the adverse experiences judged to be of "possible" relationship to the study drug, anxiety, incoordination, and nervousness were reported following intramuscular vitamin B12 and headache, nausea, and rhinitis were reported following dosing with Cyanocobalamin (Liver 4) (Cyanocobalamin (Liver 4), USP) Gel for Intranasal Administration.

The following adverse reactions have been reported with parenteral vitamin B12:

Generalized: Anaphylactic shock and death.

Cardiovascular: Pulmonary edema and congestive heart failure early in treatment; peripheral vascular thrombosis.

Hematological: Polycythemia vera.

Gastrointestinal: Mild transient diarrhea.

Dermatological: Itching; transitory exanthema.

Miscellaneous: Feeling of swelling of the entire body.

See also:
What are the possible side effects of Pyridoxine HCl (Liver 4)?

Pyridoxine HCl (Liver 4) usually has no side effects when used in recommended doses.

If your doctor has prescribed this medication, remember that he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Pyridoxine HCl (Liver 4) can cause side effects when taken in large doses for a long time. Tell your doctor right away if any of these unlikely but serious side effects occur: headache, nausea, drowsiness, numbness/tingling of arms/legs.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US -

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

See also:
What are the possible side effects of Riboflavin (Liver 4)?

Adverse Reactions

Frequency not defined: Genitourinary: Urine discoloration (yellow-orange)

Occasional laxative effects. Abdominal bloating, diarrhoea, flatulence, loss of appetite, anorexia, nausea, stomach upset.

See also:
What are the possible side effects of Thiamine nitrate (Liver 4)?

Pulmonary edema, Angioedema (swelling of deeper layers of skin), Cyanosis (bluish discoloration of the skin), Flushing, Gastrointestinal bleeding, Gastrointestinal disturbance, Hemorrhage, Decreased white blood cell count, Nausea, Restlessness, Urticaria, Itching