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Cyanocobalamin is a synthetic form of vitamin B12 with equivalent
vitamin B12 activity. The chemical name is 5,6-dimethyl-benzimidazolyl
cyanocobamide. The cobalt content is 4.35%. The molecular formula is C63H88CoN14O14P,
which corresponds to a molecular weight of 1355.38 and the following structural
Cyanocobalamin occurs as dark red crystals or orthorhombic needles or crystalline
red powder. It is very hygroscopic in the anhydrous form, and sparingly to moderately
soluble in water (1:80). Its pharmacologic activity is destroyed by heavy metals
(iron) and strong oxidizing or reducing agents (vitamin C), but not by autoclaving
for short periods of time (15-20 minutes) at 121°C. The vitamin B12
coenzymes are very unstable in light.
Nascobal® Nasal Spray is a solution of Cyanocobalamin, USP (vitamin B12)
for administration as a spray to the nasal mucosa. Each bottle of Nascobal (cyanocobalamin) Nasal
Spray contains 2.3 mL of a 500 mcg / 0.1 mL solution of cyanocobalamin with
sodium citrate, citric acid, glycerin and benzalkonium chloride in purified
water. The spray solution has a pH between 4.5 and 5.5. The spray pump unit
must be fully primed (see DOSAGE AND ADMINISTRATION)
prior to initial use. After initial priming, each spray delivers an average
of 500 mcg of cyanocobalamin and the 2.3 mL of spray solution contained in the
bottle will deliver 8 doses of Nascobal (cyanocobalamin) Nasal Spray. The unit must be re-primed
before each dose. (see DOSAGE AND ADMINISTRATION).
Nascobal (cyanocobalamin) 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.
Nascobal (cyanocobalamin) Nasal Spray is also indicated as a supplement for other vitamin B12
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
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
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 (see Drug/Laboratory
Test Interactions), use of a gluten free diet in nontropical 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.
Nascobal (cyanocobalamin) Nasal Spray is not suitable for vitamin B12 absorption
test (Schilling Test).
According to the USDA, there is no difference between a “portion” and a “serving.”See Answer
DOSAGE AND ADMINISTRATION
The recommended initial dose of Nascobal (cyanocobalamin) Nasal Spray is one spray (500 mcg)
administered in ONE nostril once weekly. Nascobal (cyanocobalamin) Nasal Spray should be administered
at least one hour before or one hour after ingestion of hot foods or liquids.
Periodic monitoring of serum B12 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.
See LABORATORY TESTS for monitoring B12
levels and adjustment of dosage.
Nascobal (cyanocobalamin) 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. Nascobal (cyanocobalamin) 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 Nascobal (cyanocobalamin) Nasal Spray
The pharmacist should assemble the Nascobal (cyanocobalamin) Nasal Spray unit prior to dispensing
to the patient, according to the following instructions:
Open the carton and remove the spray actuator and spray solution bottle.
Assemble Nascobal (cyanocobalamin) 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.
Return the Nascobal (cyanocobalamin) Nasal Spray bottle to the carton for dispensing to the
Mfd. for QOL Medical, LLC
Kirland, WA 98033, USA
www.nascobal (cyanocobalamin) .com
3078 Rev. 02/06
FDA rev date: 9/15/2006
Side Effects & Drug Interactions
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 Nascobal (Cyanocobalamin, USP) Gel
for Intranasal Administration (N=24) and intramuscular vitamin B12
(N=25). In the pharmacokinetic study comparing Nascobal (cyanocobalamin) Nasal Spray and Nascobal (cyanocobalamin)
Nasal Gel, the incidence of adverse events was similar.
Table. Adverse Experiences by Body System, Number of Patients
and Number of Occurrences by Treatment Following Intramuscular and Intranasal
Administration of Cyanocobalamin.
Number of Patients (Occurrences)
Vitamin B12 ,
Body as a Whole
Peripheral Vascular Disorder
Nausea & Vomiting
a Sore throat, common cold
* There may be a possible relationship between these adverse experiences
and the study drugs. These adverse experiences could have also been produced
by the patient's clinical state or other concomitant therapy.
The intensity of the reported adverse experiences following the administration
of Nascobal (Cyanocobalamin, 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 Nascobal (Cyanocobalamin,
USP) Gel for Intranasal Administration (one headache, infection, and paresthesia).
The majority of the reported adverse experiences following dosing with Nascobal
(Cyanocobalamin, 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 Nascobal (Cyanocobalamin, USP)
Gel for Intranasal Administration.
The following adverse reactions have been reported with parenteral vitamin
Generalized: Anaphylactic shock and death (See WARNINGS
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.
Drug/Laboratory Test Interactions
Persons taking most antibiotics, methotrexate or pyrimethamine invalidate folic
acid and vitamin B12 diagnostic blood assays.
Colchicine, para-aminosalicylic acid and heavy alcohol intake for longer than
2 weeks may produce malabsorption of vitamin B12.
Heart Healthy Diet: 25 Foods You Should EatSee Slideshow
Patients with early Leber's disease (hereditary optic nerve atrophy) who were
treated with vitamin B12 suffered severe and swift optic atrophy.
Hypokalemia and sudden death may occur in severe megaloblastic anemia which
is treated intensely with vitamin B12. Folic acid is not a substitute
for vitamin B12 although it may improve vitamin B12-deficient
megaloblastic anemia. Exclusive use of folic acid in treating vitamin B12-deficient
megaloblastic anemia could result in progressive and irreversible neurologic
Anaphylactic shock and death have been reported after parenteral vitamin B12
administration. No such reactions have been reported in clinical trials with
Nascobal (cyanocobalamin) Nasal Spray or Nascobal (cyanocobalamin) Nasal Gel.
Blunted or impeded therapeutic response to vitamin B12 may be due
to such conditions as infection, uremia, drugs having bone marrow suppressant
properties such as chloramphenicol, and concurrent iron or folic acid deficiency.
An intradermal test dose of parenteral vitamin B12 is recommended
before Nascobal (cyanocobalamin) Nasal Spray is administered to patients suspected of cyanocobalamin
sensitivity. Vitamin B12 deficiency that is allowed to progress for
longer than three months may produce permanent degenerative lesions of the spinal
cord. Doses of folic acid greater than 0.1 mg per day may result in hematologic
remission in patients with vitamin B12 deficiency. Neurologic manifestations
will not be prevented with folic acid, and if not treated with vitamin B12,
irreversible damage will result.
Doses of vitamin B12 exceeding 10 mcg daily may produce hematologic
response in patients with folate deficiency. Indiscriminate administration may
mask the true diagnosis.
The validity of diagnostic vitamin B12 or folic acid blood assays
could be compromised by medications, and this should be considered before relying
on such tests for therapy.
Vitamin B12 is not a substitute for folic acid and since it might
improve folic acid deficient megaloblastic anemia, indiscriminate use of vitamin
B12 could mask the true diagnosis.
Hypokalemia and thrombocytosis could occur upon conversion of severe megaloblastic
to normal erythropoiesis with vitamin B12 therapy. Therefore, serum
potassium levels and the platelet count should be monitored carefully during
Vitamin B12 deficiency may suppress the signs of polycythemia vera.
Treatment with vitamin B12 may unmask this condition.
If a patient is not properly maintained with Nascobal® (cyanocobalamin) Nasal Spray, intramuscular
vitamin B12 is necessary for adequate treatment of the patient. No
single regimen fits all cases, and the status of the patient observed in follow-up
is the final criterion for adequacy of therapy.
The effectiveness of Nascobal (cyanocobalamin) Nasal Spray in patients with nasal congestion,
allergic rhinitis and upper respiratory infections has not been determined.
Therefore, treatment with Nascobal (cyanocobalamin) Nasal Spray should be deferred until symptoms
Hematocrit, reticulocyte count, vitamin B12, folate and iron levels
should be obtained prior to treatment. If folate levels are low, folic acid
should also be administered. All hematologic parameters should be normal when
beginning treatment with Nascobal® (cyanocobalamin) Nasal Spray.
Vitamin B12 blood levels and peripheral blood counts must be monitored
initially at one month after the start of treatment with Nascobal® (cyanocobalamin) Nasal
Spray, and then at intervals of 3 to 6 months.
A decline in the serum levels of B12 after one month of treatment
with B12 nasal spray may indicate that the dose may need to be adjusted
upward. Patients should be seen one month after each dose adjustment; continued
low levels of serum B12 may indicate that the patient is not a candidate
for this mode of administration.
Patients with pernicious anemia have about 3 times the incidence of carcinoma
of the stomach as in the general population, so appropriate tests for this condition
should be carried out when indicated.
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Long-term studies in animals to evaluate carcinogenic potential have not been
done. There is no evidence from long-term use in patients with pernicious anemia
that vitamin B12 is carcinogenic. Pernicious anemia is associated
with an increased incidence of carcinoma of the stomach, but this is believed
to be related to the underlying pathology and not to treatment with vitamin
Pregnancy Category C: Animal reproduction studies have not been conducted with
vitamin B12. It is also not known whether vitamin B12
can cause fetal harm when administered to a pregnant woman or can affect reproduction
capacity. Adequate and well-controlled studies have not been done in pregnant
women. However, vitamin B12 is an essential vitamin and requirements
are increased during pregnancy. Amounts of vitamin B12 that are recommended
by the Food and Nutrition Board, National Academy of Science - National Research
Council for pregnant women should be consumed during pregnancy.
Vitamin B12 appears in the milk of nursing mothers in concentrations
which approximate the mother's vitamin B12 blood level. Amounts of
vitamin B12 that are recommended by the Food and Nutrition Board,
National Academy of Science-National Research Council for lactating women should
be consumed during lactation.
Intake in pediatric patients should be in the amount recommended by the Food
and Nutrition Board, National Academy of Science-National Research Council.
Please also see PATIENT INFORMATION
Overdosage & Contraindications
No overdosage has been reported with Nascobal Nasal Spray, Nascobal (Cyanocobalamin,
USP) Gel for Intranasal Administration or parenteral vitamin B12.
Sensitivity to cobalt and/or vitamin B12 or any component of the
medication is a contraindication.
General Pharmacology And Mechanism Of Action
Vitamin B12 is essential to growth, cell reproduction, hematopoiesis,
and nucleoprotein and myelin synthesis. Cells characterized by rapid division
(e.g., epithelial cells, bone marrow, myeloid cells) appear to have the greatest
requirement for vitamin B12. Vitamin
B12 can be converted to coenzyme B12 in tissues, and
as such is essential for conversion of methylmalonate to succinate and synthesis
of methionine from homocysteine, a reaction which also requires folate. In the
absence of coenzyme B12, tetrahydrofolate cannot be regenerated from
its inactive storage form, 5- methyltetrahydrofolate, and a functional folate
deficiency occurs. Vitamin B12 also may be involved in maintaining
sulfhydryl (SH) groups in the reduced form required by many SH-activated enzyme
systems. Through these reactions, vitamin B12 is associated with
fat and carbohydrate metabolism and protein synthesis. Vitamin B12
deficiency results in megaloblastic anemia, GI lesions, and neurologic damage
that begins with an inability to produce myelin and is followed by gradual degeneration
of the axon and nerve head.
Cyanocobalamin is the most stable and widely used form of vitamin B12,
and has hematopoietic activity apparently identical to that of the antianemia
factor in purified liver extract. The information below, describing the clinical
pharmacology of cyanocobalamin, has been derived from studies with injectable
Vitamin B12 is quantitatively and rapidly absorbed from intramuscular
and subcutaneous sites of injection. It is bound to plasma proteins and stored
in the liver. Vitamin B12 is excreted in the bile and undergoes some
enterohepatic recycling. Absorbed vitamin B12 is transported via
specific B12 binding proteins, transcobalamin I and II, to the various
tissues. The liver is the main organ for vitamin B12 storage.
Parenteral (intramuscular) administration of vitamin B12 completely
reverses the megaloblastic anemia and GI symptoms of vitamin B12
deficiency; the degree of improvement in neurologic symptoms depends on the
duration and severity of the lesions, although progression of the lesions is
Gastrointestinal absorption of vitamin B12 depends on the presence
of sufficient intrinsic factor and calcium ions. Intrinsic factor deficiency
causes pernicious anemia, which may be associated with subacute combined degeneration
of the spinal cord. Prompt parenteral administration of vitamin B12
prevents progression of neurologic damage.
The average diet supplies about 4 to 15 mcg/day of vitamin B12 in
a protein-bound form that is available for absorption after normal digestion.
Vitamin B12 is not present in foods of plant origin, but is abundant
in foods of animal origin. In people with normal absorption, deficiencies have
been reported only in strict vegetarians who consume no products of animal origin
(including no milk products or eggs).
Vitamin B12 is bound to intrinsic factor during transit through
the stomach; separation occurs in the terminal ileum in the presence of calcium,
and vitamin B12 enters the mucosal cell for absorption. It is then
transported by the transcobalamin binding proteins. A small amount (approximately
1% of the total amount ingested) is absorbed by simple diffusion, but this mechanism
is adequate only with very large doses. Oral absorption is considered too undependable
to rely on in patients with pernicious anemia or other conditions resulting
in malabsorption of vitamin B12.
Colchicine, para-aminosalicylic acid, and heavy alcohol intake for longer than
2 weeks may produce malabsorption of vitamin B12.
A three way crossover study in 25 fasting healthy subjects was conducted to
compare the bioavailability of the B12 nasal spray to the B12
nasal gel and to evaluate the relative bioavailability of the nasal formulations
as compared to the intramuscular injection. The peak concentrations after administration
of intranasal spray were reached in 1.25 +/- 1.9 hours. The average peak concentration
of B12 obtained after baseline correction following administration
of intranasal spray was 757.96 +/- 532.17 pg/mL. The bioavailability of the
nasal spray relative to the intramuscular injection was found to be 6.1%. The
bioavailability of the B12 nasal spray was found to be 10% less than
the B12 nasal gel. The 90% confidence intervals for the loge-transformed
AUC(0-t) and Cmax was 71.71% - 114.19% and 71.6% - 118.66% respectively.
In pernicious anemia patients, once weekly intranasal dosing with 500 mcg B12
gel resulted in a consistent increase in pre-dose serum B12 levels
during one month of treatment (p < 0.003) above that seen one month after
100 mcg intramuscular dose (Figure).
In the blood, B12 is bound to transcobalamin II, a specific B-globulin
carrier protein, and is distributed and stored primarily in the liver and bone
About 3-8 mcg of B12 is secreted into the GI tract daily via the
bile; in normal subjects with sufficient intrinsic factor, all but about 1 mcg
is reabsorbed. When B12 is administered in doses which saturate the
binding capacity of plasma proteins and the liver, the unbound B12
is rapidly eliminated in the urine. Retention of B12 in the body
is dose-dependent. About 80-90% of an intramuscular dose up to 50 mcg is retained
in the body; this percentage drops to 55% for a 100 mcg dose, and decreases
to 15% when a 1000 mcg dose is given.
Figure. Vitamin B12 Serum Trough Levels After Intramuscular Solution (IM) of 100 mcg and Nasal Gel (IN) Administration of 500 mcg Cyanocobalamin After Weekly Doses.
Figure. Vitamin B12 Serum Trough Levels After Intramuscular Solution (IM) of 100 mcg and Nasal Gel (IN) Administration of 500 mcg Cyanocobalamin After Weekly Doses.
Patients with pernicious anemia should be instructed that they will require
weekly intranasal administration of Nascobal (cyanocobalamin) Nasal Spray for the remainder of
their lives. Failure to do so will result in return of the anemia and in development
of incapacitating and irreversible damage to the nerves of the spinal cord.
Also, patients should be warned about the danger of taking folic acid in place
of vitamin B12, because the former may prevent anemia but allow progression
of subacute combined degeneration of the spinal cord.
(Hot foods may cause nasal secretions and a resulting loss of medication; therefore,
patients should be told to administer Nascobal (cyanocobalamin) Nasal Spray at least one hour
before or one hour after ingestion of hot foods or liquids).
A vegetarian diet which contains no animal products (including milk products
or eggs) does not supply any vitamin B12. Therefore, patients following
such a diet should be advised to take Nascobal (cyanocobalamin) Nasal Spray weekly. The need
for vitamin B12 is increased by pregnancy and lactation. Deficiency
has been recognized in infants of vegetarian mothers who were breast fed, even
though the mothers had no symptoms of deficiency at the time.
Because the nasal dosage forms of Vitamin B12 have a lower absorption
than intramuscular dosage, nasal dosage forms are administered weekly, rather
than the monthly intramuscular dosage. As shown in the Figure above, at the
end of a month, weekly nasal administration results in significantly higher
serum Vitamin B12 levels than after intramuscular administration.
The patient should also understand the importance of returning for follow-up
blood tests every 3 to 6 months to confirm adequacy of the therapy.
Careful instructions on the actuator assembly, removal of safety clip, priming
of the actuator and nasal administration of Nascobal (cyanocobalamin) Nasal Spray should be given
to the patient. Although instructions for patients are supplied with individual
bottles, procedures for use should be demonstrated to each patient.
Protect from light. Keep covered in carton until ready to use. Store upright
at controlled room temperature 15°C to 30°C (59°F to 86°F).
Protect from freezing.