Vitamin B12

Vitamin B12 is a coordination complex of cobalt, which occupies the center of a corrin ligand and is further bound to a benzimidazole ligand and adenosyl group. Several related species behave similarly to function as vitamins. This collection of compounds is sometimes referred to as "cobalamins". These chemical compounds have a similar molecular structure, each of which shows vitamin activity in a vitamin-deficient biological system. They are referred to as vitamers having vitamin activity as a coenzyme, meaning that its presence is required for some enzyme-catalyzed reactions. Cyanocobalamin is the most common form used in dietary supplements and food fortification because cyanide stabilizes the molecule against degradation. Methylcobalamin is also offered as a dietary supplement. It can also be injected intravenously for the purpose of treating cyanide poisoning, as the hydroxyl group is displaced by cyanide, creating a non-toxic cyanocobalamin that is excreted in urine. Pseudovitamins and antivitamins Pseudovitamin B12 refers to compounds that are corrinoids with a structure similar to the vitamin, but without vitamin activity. Antivitamin B12 compounds (often synthetic B12 analogues) not only have no vitamin action, but also actively interfere with the activity of true vitamin B12. The design of these compounds mainly involves the replacement of the metal ion with rhodium, nickel, or zinc, or may have an inactive ligand attached, such as 4-ethylphenyl. These compounds have the potential for use in analyzing B12 pathways or even attacking B12-dependent pathogens. ==Deficiency==

Vitamin B12 deficiency can potentially cause severe and irreversible damage, especially to the brain and nervous system. At levels only slightly below normal, deficiency can result in fatigue, headaches, feeling faint, rapid breathing, pale skin, numbness or tingling, poor appetite, heartburn, poor balance, difficulty walking, poor reflexes, blurred vision, memory problems, depression, irritability, inattention, cognitive decline, dementia, and even psychosis. It has also been linked to optic nerve atrophy and neuritis. The main type of vitamin B12 deficiency anemia is pernicious anemia, characterized by a triad of symptoms: • Anemia with bone marrow promegaloblastosis (megaloblastic anemia). This is due to the inhibition of DNA synthesis (specifically purines and thymidine). • Gastrointestinal symptoms: alteration in bowel motility, such as mild diarrhea or constipation, and loss of bladder or bowel control. These are thought to be due to defective DNA synthesis inhibiting replication in tissue sites with a high turnover of cells. This may also be due to the autoimmune attack on the parietal cells of the stomach in pernicious anemia. There is an association with gastric antral vascular ectasia (which can be referred to as watermelon stomach), and pernicious anemia. • Neurological symptoms: sensory or motor deficiencies (absent reflexes, diminished vibration or soft touch sensation) and subacute combined degeneration of the spinal cord. Deficiency symptoms in children include developmental delay, regression, irritability, involuntary movements and hypotonia. Vitamin B12 deficiency is most commonly caused by malabsorption, but can also result from low intake, immune gastritis, low presence of binding proteins, or use of certain medications. In Hong Kong and India, vitamin B12 deficiency has been found in roughly 80% of the vegan population. As with vegetarians, vegans can avoid this by consuming a dietary supplement or eating B12 fortified food such as cereal, plant-based milks, and nutritional yeast as a regular part of their diet. The elderly are at increased risk because they tend to produce less stomach acid as they age, a condition known as achlorhydria, thereby increasing their probability of B12 deficiency due to reduced absorption. Pregnancy, lactation, and early childhood The U.S. Recommended Dietary Allowance (RDA) for pregnancy is , for lactation . Determination of these values was based on an RDA of for non-pregnant women, plus what will be transferred to the fetus during pregnancy and what will be delivered in breast milk. Low maternal vitamin B12, defined as serum concentration less than 148 pmol/L, increases the risk of miscarriage, preterm birth and newborn low birth weight. Women who consume little animal-sourced food, or who are vegetarian or vegan, are at higher risk of becoming vitamin depleted during pregnancy than those who consume more animal products. This depletion can lead to anemia, and also an increased risk that their breastfed infants become vitamin deficient. Vitamin B12 is not one of the supplements recommended by the World Health Organization for healthy women who are pregnant, however, vitamin B12 is often suggested during pregnancy in a multivitamin along with folic acid especially for pregnant mothers who follow a vegetarian or vegan diet. Low vitamin concentrations in human milk occur in families with low socioeconomic status or low consumption of animal products. Only a few countries, primarily in Africa, have mandatory food fortification programs for either wheat flour or maize flour; India has a voluntary fortification program. For post-operative oral supplementation, may be needed to prevent vitamin deficiency. The vitamin deficiency is typically suspected when a routine complete blood count shows anemia with an elevated mean corpuscular volume (MCV). In addition, on the peripheral blood smear, macrocytes and hypersegmented polymorphonuclear leukocytes may be seen. Diagnosis is supported based on vitamin B12 blood levels below 150–180 pmol/L (200–250 pg/mL) in adults. However, serum values can be maintained while tissue B12 stores are becoming depleted. Therefore, serum B12 values above the cut-off point of deficiency do not necessarily confirm adequate B12 status. and elevated homocysteine is not conclusive, as it is also seen in people with folate deficiency. In addition, elevated methylmalonic acid levels may also be related to metabolic disorders such as methylmalonic acidemia. If nervous system damage is present and blood testing is inconclusive, a lumbar puncture may be carried out to measure cerebrospinal fluid B12 levels. Serum haptocorrin binds 80-90% of circulating B12, rendering it unavailable for cellular delivery by transcobalamin II. This is conjectured to be a circulating storage function. Several serious, even life-threatening diseases cause elevated serum haptocorrin, measured as abnormally high serum vitamin B12, while at the same time potentially manifesting as a symptomatic vitamin deficiency because of insufficient vitamin bound to transcobalamin II which transfers the vitamin to cells. ==Medical uses==

Treatment of deficiency Severe vitamin B12 deficiency is initially corrected with daily intramuscular injections of of the vitamin, followed by maintenance via monthly injections of the same amount or daily oral dosing of . The oral daily dose far exceeds the vitamin requirement because the normal transporter protein-mediated absorption is absent, leaving only very inefficient intestinal passive absorption. Injection side effects include skin rash, itching, chills, fever, hot flushes, nausea and dizziness. There are not enough studies on whether pills are as effective in improving or eliminating symptoms as parenteral treatment. Cyanide poisoning For cyanide poisoning, a large amount of hydroxocobalamin may be given intravenously and sometimes in combination with sodium thiosulfate. The mechanism of action is straightforward: the hydroxycobalamin hydroxide ligand is displaced by the toxic cyanide ion, and the resulting non-toxic cyanocobalamin is excreted in urine. ==Dietary recommendations==

Some research shows that most people in the United States and the United Kingdom consume sufficient vitamin B12. However, other research suggests that the proportion of people with low or marginal levels of vitamin B12 is up to 40% in the Western world. The European Food Safety Authority (EFSA) refers to the collective set of information as "dietary reference values", with population reference intake (PRI) instead of RDA, and average requirement instead of EAR. AI and UL are defined by EFSA the same as in the United States. For women and men over age 18, the adequate intake (AI) is set at 4.0μg/day. AI for pregnancy is 4.5 μg/day, and for lactation 5.0μg/day. For children aged 1–14 years, the AIs increase with age from 1.5 to 3.5μg/day. These AIs are higher than the U.S. RDAs. The Japan National Institute of Health and Nutrition set the RDA for people ages 12 and older at 2.4μg/day. The World Health Organization also uses 2.4μg/day as the adult recommended nutrient intake for this vitamin. For U.S. food and dietary supplement labeling purposes, the amount in a serving is expressed as a "percent of daily value" (%DV). For vitamin B labeling purposes, 100% of the daily value was 6.0μg, but on 27 May 2016, it was revised downward to 2.4μg (see Reference Daily Intake). Compliance with the updated labeling regulations was required by 1 January 2020 for manufacturers with US$10 million or more in annual food sales, and by 1 January 2021 for manufacturers with lower volume food sales. ==Sources==

H2-receptor antagonists and proton-pump inhibitors Gastric acid is needed to release vitamin B12 from protein for absorption. Reduced secretion of gastric acid and pepsin, from the use of H2 blocker or proton-pump inhibitor (PPI) drugs, can reduce the absorption of protein-bound (dietary) vitamin B12, although not of supplemental vitamin B12. H2-receptor antagonist examples include cimetidine, famotidine, nizatidine, and ranitidine. PPIs examples include omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole. Clinically significant vitamin B12 deficiency and megaloblastic anemia are unlikely, unless these drug therapies are prolonged for two or more years, or if in addition, the person's dietary intake is below recommended levels. Symptomatic vitamin deficiency is more likely if the person is rendered achlorhydric (a complete absence of gastric acid secretion), which occurs more frequently with proton pump inhibitors than H2 blockers. Metformin Reduced serum levels of vitamin B12 occur in up to 30% of people taking long-term anti-diabetic metformin. Deficiency does not develop if dietary intake of vitamin B12 is adequate or prophylactic B12 supplementation is given. If the deficiency is detected, metformin can be continued while the deficiency is corrected with B12 supplements. Other drugs Certain medications can decrease the absorption of orally consumed vitamin B12, including colchicine, extended-release potassium products, and antibiotics such as gentamicin, neomycin and tobramycin. Anti-seizure medications phenobarbital, pregabalin, primidone and topiramate are associated with lower than normal serum vitamin concentration. However, serum levels were higher in people prescribed valproate. In addition, certain drugs may interfere with laboratory tests for the vitamin, such as amoxicillin, erythromycin, methotrexate and pyrimethamine. ==Chemistry==

Vitamin B12 is the most chemically complex of all the vitamins. Four of the six coordination sites are provided by the corrin ring and a fifth by a dimethylbenzimidazole group. The sixth coordination site, the reactive center, is variable, being a cyano group (–CN), a hydroxyl group (–OH), a methyl group (–CH3) or a 5′-deoxyadenosyl group. Historically, the covalent carbon–cobalt bond is one of the first examples of carbon-metal bonds to be discovered in biology. The hydrogenases and, by necessity, enzymes associated with cobalt utilization, involve metal-carbon bonds. Animals can convert cyanocobalamin and hydroxocobalamin to the bioactive forms adenosylcobalamin and methylcobalamin by enzymatically replacing the cyano or hydroxyl groups. Methods for the analysis of vitamin B12 in food Several methods have been used to determine the vitamin B12 content in foods including microbiological assays, chemiluminescence assays, polarographic, spectrophotometric, and high-performance liquid chromatography processes. The microbiological assay has been the most commonly used assay technique for foods, utilizing certain vitamin B12-requiring microorganisms, such as Lactobacillus delbrueckii subsp. lactis ATCC7830. Furthermore, this assay requires overnight incubation and may give false results if any inactive vitamin B12 analogues are present in the foods. Currently, radioisotope dilution assay (RIDA) with labeled vitamin B12 and hog IF (pigs) have been used to determine vitamin B12 content in food. Previous reports have suggested that the RIDA method can detect higher concentrations of vitamin B12 in foods compared to the microbiological assay method. ==Biochemistry==

Coenzyme function Vitamin B12 functions as a coenzyme, meaning that its presence is required in some enzyme-catalyzed reactions. Listed here are the three classes of enzymes that sometimes require B12 to function (in animals): • Isomerases • : Rearrangements in which a hydrogen atom is directly transferred between two adjacent atoms with concomitant exchange of the second substituent, X, which may be a carbon atom with substituents, an oxygen atom of an alcohol, or an amine. These use the AdoB12 (adenosylcobalamin) form of the vitamin. In humans, two major coenzyme B12-dependent enzyme families corresponding to the first two reaction types, are known. These are typified by the following two enzymes: Methylmalonyl-CoA mutase Methylmalonyl coenzyme A mutase (MUT) is an isomerase enzyme that uses the AdoB12 form and reaction type 1 to convert L-methylmalonyl-CoA to succinyl-CoA, an important step in the catabolic breakdown of some amino acids into succinyl-CoA, which then enters energy production via the citric acid cycle. This functionality is lost in vitamin B12 deficiency, and can be measured clinically as an increased serum methylmalonic acid (MMA) concentration. The MUT function is necessary for proper myelin synthesis. Based on animal research, it is thought that the increased methylmalonyl-CoA hydrolyzes to form methylmalonate (methylmalonic acid), a neurotoxic dicarboxylic acid, causing neurological deterioration. Methionine synthase Methionine synthase, coded by MTR gene, is a methyltransferase enzyme which uses the MeB12 and reaction type 2 to transfer a methyl group from 5-methyltetrahydrofolate to homocysteine, thereby generating tetrahydrofolate (THF) and methionine. This functionality is lost in vitamin B12 deficiency, resulting in an increased homocysteine level and the trapping of folate as 5-methyl-tetrahydrofolate, from which THF (the active form of folate) cannot be recovered. THF plays an important role in DNA synthesis, so reduced availability of THF results in ineffective production of cells with rapid turnover, in particular red blood cells, and also intestinal wall cells which are responsible for absorption. THF may be regenerated via MTR or may be obtained from fresh folate in the diet. Thus all of the DNA synthetic effects of B12 deficiency, including the megaloblastic anemia of pernicious anemia, resolve if sufficient dietary folate is present. Thus the best-known "function" of B12 (that which is involved with DNA synthesis, cell division, and anemia) is a facultative function that is mediated by B12-conservation of an active form of folate which is needed for efficient DNA production. ==Physiology==

Absorption Vitamin B12 is absorbed by a B12-specific transport proteins or via passive diffusion. Upon leaving the stomach the hydrochloric acid of the chyme is neutralized in the duodenum by bicarbonate, and pancreatic proteases release the vitamin from HC, making it available to be bound by IF, which is a protein secreted by gastric parietal cells in response to the presence of food in the stomach. IF delivers the vitamin to receptor proteins cubilin and amnionless, which together form the cubam receptor in the distal ileum. The receptor is specific to the IF-B12 complex, and so will not bind to any vitamin content that is not bound to IF. Malabsorption Individuals with pernicious anemia do not have the ability to produce intrinsic factor. Individuals who lack intrinsic factor have no ability to absorb vitamin B12. The lack of intrinsic factor is most commonly due to autoimmune gastritis, which causes an autoimmune attack on the parietal cells that create it in the stomach. Antacid drugs that neutralize stomach acid, as well as acid-suppressing agents such as proton-pump inhibitors, can inhibit the absorption of vitamin B12 by preventing its release from food in the stomach. Other causes of B12 malabsorption include bariatric surgery, pancreatic insufficiency, obstructive jaundice, tropical sprue, celiac disease, inherited intrinsic factor deficiency, and radiation enteritis affecting the distal ileum. The ability to absorb vitamin B12 declines with age, particularly in individuals over 60. Cellular reprogramming Vitamin B12 through its involvement in one-carbon metabolism plays a key role in cellular reprogramming and tissue regeneration and epigenetic regulation. Cellular reprogramming is the process by which somatic cells can be converted to a pluripotent state. Vitamin B12 levels affect the histone modification H3K36me3, which suppresses illegitimate transcription outside of gene promoters. Mice undergoing in vivo reprogramming were found to become depleted in B12 and show signs of methionine starvation while supplementing reprogramming mice and cells with B12 increased reprogramming efficiency, indicating a cell-intrinsic effect. ==Synthesis==

Biosynthesis Vitamin B12 is derived from a tetrapyrrolic structural framework created by the enzymes deaminase and cosynthetase which transform aminolevulinic acid via porphobilinogen and hydroxymethylbilane to uroporphyrinogen III. The latter is the first macrocyclic intermediate common to heme, chlorophyll, siroheme and B12 itself. Later steps, especially the incorporation of the additional methyl groups of its structure, were investigated using 13C methyl-labelled S-adenosyl methionine. It was not until a genetically engineered strain of Pseudomonas denitrificans was used, in which eight of the genes involved in the biosynthesis of the vitamin had been overexpressed, that the complete sequence of methylation and other steps could be determined, thus fully establishing all the intermediates in the pathway. Species from the following genera and the following individual species are known to synthesize B12: Propionibacterium shermanii, Pseudomonas denitrificans, Streptomyces griseus, Acetobacterium, Aerobacter, Agrobacterium, Alcaligenes, Azotobacter, Bacillus, Clostridium, Corynebacterium, Flavobacterium, Lactobacillus, Micromonospora, Mycobacterium, Nocardia, Proteus, Rhizobium, Salmonella, Serratia, Streptococcus and Xanthomonas. Streptomyces griseus, a bacterium once thought to be a fungus, was the commercial source of vitamin B12 for many years. The species Pseudomonas denitrificans and Propionibacterium freudenreichii subsp. shermanii are more commonly used today. Propionibacterium, the other commonly used bacteria, produce no exotoxins or endotoxins and are generally recognized as safe (have been granted GRAS status) by the Food and Drug Administration of the United States. The total world production of vitamin B12 in 2008 was 35,000 kg (77,000 lb). Laboratory The complete laboratory synthesis of B12 was achieved by Robert Burns Woodward and Albert Eschenmoser in 1972. The work required the effort of 91 postdoctoral fellows (mostly at Harvard) and 12 PhD students (at ETH Zurich) from 19 nations. The synthesis constitutes a formal total synthesis, since the research groups only prepared the known intermediate cobyric acid, whose chemical conversion to vitamin B12 was previously reported. This synthesis of vitamin B12 is of no practical consequence due to its length, taking 72 chemical steps and giving an overall chemical yield well under 0.01%. Although there have been sporadic synthetic efforts since 1972, the Eschenmoser–Woodward synthesis remains the only completed (formal) total synthesis. ==History==

Descriptions of deficiency effects Between 1849 and 1887, Thomas Addison described a case of pernicious anemia, William Osler and William Gardner first described a case of neuropathy, Hayem described large red cells in the peripheral blood in this condition, which he called "giant blood corpuscles" (now called macrocytes), Paul Ehrlich identified megaloblasts in the bone marrow, and Ludwig Lichtheim described a case of myelopathy. Identification of liver as an anti-anemia food During the 1920s, George Whipple discovered that ingesting large amounts of raw liver seemed to most rapidly cure the anemia of blood loss in dogs, and hypothesized that eating liver might treat pernicious anemia. Edwin Cohn prepared a liver extract that was 50 to 100 times more potent in treating pernicious anemia than the natural liver products. William Castle demonstrated that gastric juice contained an "intrinsic factor" which when combined with meat ingestion resulted in absorption of the vitamin in this condition. Identification of the active compound While working at the Bureau of Dairy Industry, U.S. Department of Agriculture, Mary Shaw Shorb was assigned work on the bacterial strain Lactobacillus lactis Dorner (LLD), which was used to make yogurt and other cultured dairy products. The culture medium for LLD required liver extract. Shorb knew that the same liver extract was used to treat pernicious anemia (her father-in-law had died from the disease), and concluded that LLD could be developed as an assay method to identify the active compound. While at the University of Maryland, she received a small grant from Merck, and in collaboration with Karl Folkers from that company, developed the LLD assay. This identified "LLD factor" as essential for the bacteria's growth. Shorb, Folker and Alexander R. Todd, at the University of Cambridge, used the LLD assay to extract the anti-pernicious anemia factor from liver extracts, purify it, and name it vitamin B12. In 1955, Todd helped elucidate the structure of the vitamin. The complete chemical structure of the molecule was determined by Dorothy Hodgkin based on crystallographic data and published in 1955 and 1956, for which, and for other crystallographic analyses, she was awarded the Nobel Prize in Chemistry in 1964. Hodgkin went on to decipher the structure of insulin. Commercial production Industrial production of vitamin B12 is achieved through fermentation of selected microorganisms. As noted above, the completely synthetic laboratory synthesis of B12 was achieved by Robert Burns Woodward and Albert Eschenmoser in 1972, though this process has no commercial potential, requiring more than 70 steps and having a yield well below 0.01%. ==Society and culture==

In the 1970s, John A. Myers, a physician residing in Baltimore, developed a program of injecting vitamins and minerals intravenously for various medical conditions. The formula included of cyanocobalamin. This came to be known as the Myers' cocktail. After he died in 1984, other physicians and naturopaths took up prescribing "intravenous micronutrient therapy" with unsubstantiated health claims for treating fatigue, low energy, stress, anxiety, migraine, depression, immunocompromised, promoting weight loss, and more. However, other than a report on case studies Healthcare practitioners at clinics and spas prescribe versions of these intravenous combination products, but also intramuscular injections of just vitamin B12. A Mayo Clinic review concluded that there is no solid evidence that vitamin B12 injections provide an energy boost or aid weight loss. There is evidence that for elderly people, physicians often repeatedly prescribe and administer cyanocobalamin injections inappropriately, evidenced by the majority of subjects in one large study either having had normal serum concentrations or having not been tested before the injections. == See also ==