B vitamins in high doses: notes from a practitioner

pharmachologic effect

Manufacturer: Verwag Pharma, Germany
Release form: solution for injection, dragee

Active ingredient: thiamine (benfotiamine), pyridoxine, cyanocobalamin (in ampoules)

Synonyms: Neuromultivit, Neurobex, Neurorubin, Vitaxon, Neurobion, Combilipen, Combigamma

The drug Milgamma belongs to the combined B vitamins. Different mechanisms of action of the drug provide an effect on many functions of the nervous system:

• prevention of degenerative disorders in the nervous system;
• prevention of motor dysfunctions;
• elimination of inflammation in nerve tissues;
• correction of hypovitaminosis caused by deficiencies of B vitamins;
• pain relief;
• improving the functioning of the nervous system;
• stimulation of blood circulation and activation of hematopoiesis;
• acceleration of rehabilitation after neurological pathologies;
• normalization of carbohydrate metabolism.

Milgamma injections or tablets (dragees) - which is better and more effective

The composition of the drug in ampoules differs from Milgamma compositum tablets in the presence of cyanocobalamin. When administering the medicine in injections, the range of actions will be greater. The rate of onset of effects is higher when using solutions for intramuscular administration. The duration of therapy with this form of the drug is shorter than when treating pills.

Oral use of the drug is indicated for uncomplicated disease or after acute symptoms have been relieved with injections.

Binavit

Binavit is available in injections for injection into the muscle, the therapeutic effect of which is explained by vitamins B1, B6, B 12 and lidocaine.

In addition to them, the medicine contains the following inactive substances:

• Water.
• E1519.
• E452.
• E524.
• E536.

The injection solution is a clear red liquid with a specific odor.

B vitamins have a positive effect in inflammatory and degenerative pathologies of the nervous and musculoskeletal systems.

Vitamin B1 or thiamine is necessary for proper carbohydrate metabolism; it takes part in the Krebs cycle and in the transmission of nerve signals.

Vitamin B6 or pyridoxine is important for the metabolism of proteins, fats and carbohydrates, the normal functioning of the peripheral and central nervous system, hematopoiesis, the biosynthesis of catecholamines, and the transmission of nerve impulses.

Thiamine and pyridoxine enhance the effect of each other and have a positive effect on the heart and blood vessels, nervous system, and neuromuscular connection.

Vitamin B12 or cyanocobalamin takes part in the formation of nucleotides and myelin, in the metabolism of folic acid, it is necessary for normal growth and proper development of epithelial cells. Its deficiency leads to anemia.

Lidocaine has an analgesic effect at the site of needle insertion, dilates blood vessels, and improves the absorption of vitamins. It blocks the transmission of pain signals along nerve fibers.

After an injection, vitamin B1 is quickly absorbed into the blood, its maximum concentration is observed after 15 minutes . It is not deposited in the body, so it must be supplied with food daily. It is excreted in the urine within 2 days. Vitamin B1 is metabolized in the body.

Vitamin B6 is quickly absorbed at the injection site, about 80% of the administered dosage is bound to proteins. Pyridoxine is metabolized in the liver. It is excreted in urine 2-5 hours after absorption.

Up to 90% of vitamin B12 is bound to proteins, its highest concentration is reached an hour after the injection. Passing through the liver, vitamin B12 is metabolized. Excreted in urine and bile; if kidney function is impaired, it can be completely excreted through the intestines.

After injection into the muscle, the highest concentration of lidocaine is observed after a maximum of 15 minutes . Up to 80% of the dosage is bound to plasma proteins. Lidocaine is metabolized in the liver and excreted in the urine.

All active components of the drug penetrate the blood-brain barrier and placenta and are excreted in breast milk.

Indications for use of Milgamma

According to the instructions for use of Milgamma, the medicine is used for a variety of neurological disorders:

• neuritis;
• neuralgia;
• destructive spinal pathologies: hernias, protrusions, osteochondrosis, radiculitis;
• deficiencies of B vitamins with various manifestations;
• chronic stress, depression;
• sciatica;
• disorders in the roots due to spinal injuries;
• increasing athletes' tolerance to physical activity;
• herpes infection as part of complex therapy;
• complex treatment of chronic inflammatory diseases of joints and muscles - myalgia, arthritis, arthrosis;
• multiple sclerosis;
• paresis;
• neuropathy.

As a rule, Milgamma is prescribed as part of a complex treatment of these diseases, often in combination with anti-inflammatory drugs such as Meloxicam, Movalis, Diclofenac sodium, Mydocalm, etc.

B vitamins in high doses: notes from a practitioner

A quarter of a century has passed since, as a teenager, I leafed through A.A.’s old university textbook. Markosyan in physiology and eagerly peered at the black and white photographs. They still come easily to mind, those “faded” patients with pellagra, beriberi, cheilitis and night blindness. Fantasy depicted real meetings with these sufferers when “I grow up and become a doctor.” I knew Markosyan’s text almost by heart and was sure that even in a crowd I could recognize such a characteristic patient...

What kind of marginal cases has professional life encountered? But I saw only one vitamin deficiency (albeit many times): Addison-Birmer pernicious anemia. And not one more and never...

But if the study of vitamin deficiencies will very soon become the prerogative of departments of the history of medicine, then general practitioners quite often encounter varying degrees of hypovitaminosis. For us, their external causes are obvious (from the dubious quality of many of our food products to direct antagonism between some, say, medications taken by a person and food vitamins), and endogenous (atrophic processes in the mucous membranes of the gastrointestinal tract, enzymatic deficiency, consequences of previous intestinal infections, etc.). By the way, a new scourge has emerged for fat-soluble vitamins: the general craze for low-fat foods and diets. Against the background of an appropriate diet, muscle weakness (vitamin E deficiency), deterioration in skin quality (vitamin A deficiency), and in especially advanced cases, a tendency to osteopenia (vitamin D deficiency) often appear.

But it should be noted that the use of vitamins is not limited only to situations associated with their deficiency. Actively participating in enzymatic metabolic processes, they are able to have a pronounced regulatory effect on the functional state of various human organs and systems. Their action is manifested in increasing the resistance properties of the body, in the activation of immunological and metabolic processes. These effects of vitamins make it possible to use them as a complex pathogenetic therapy and, among other things, to stimulate the immune system (ascorbic acid), to improve blood circulation (nicotinic acid), etc.

However, more often than others, preparations of B vitamins are used for parenteral administration. Although the main “users” are neurologists, general practitioners have long been using thiamine and pyridoxine in the complex treatment of patients with radiculitis, encephalopathy and neuropathy of various origins. Since the mid-twentieth century, in many countries, including the USSR, they began to be considered as effective analgesics. It is well known that B vitamins are neurotropic substances and significantly affect the transmission of excitation along nerve fibers, metabolism, and the metabolism of mediators in the nervous system. Clinical experience shows that parenteral use of a combination of vitamins B1, B6 and B12 relieves pain well, stimulating the natural antinociceptive system at the level of the spinal cord, normalizes reflex reactions, and eliminates sensitivity disorders. In addition, studies conducted in recent years have shown that B vitamins influence the course of various pathological conditions, including cancer, in the human body and are able to prevent their development.

Moreover, in contrast to situations with hypo- and avitaminosis, in which it is necessary to administer exactly the vitamin whose deficiency provoked the corresponding symptom complex, in our patients with discirculatory encephalopathy, in patients with radicular syndrome with discopathy, in persons suffering from toxic disorders of sensitivity and motor skills against the background of alcoholism, with various neuropathic complaints in diabetics, we require almost all B vitamins, the pharmacotherapeutic effects of which can cover a wide range of clinical manifestations. This is due to the fact that, being synergists, vitamins exhibit their properties more actively when administered in a complex manner. But from our college days we remember that they cannot be mixed in one syringe. That's why we had to prescribe them either alternating every other day, or test the patient's tolerance by giving several injections at a time.

The only product whose manufacturing technology made it possible to combine all three substances together, while maintaining their stability and biological activity, turned out to be Milgamma®. And we, clinicians, can only rejoice: during the time we have been using this drug, we have been convinced of its powerful therapeutic effect and high safety.

Thiamine, controlling the most important energy processes, primarily related to the utilization of glucose, is also involved in the conduction of nerve impulses and axonal transport, improves the regeneration of nervous tissue and neuromuscular transmission. By creating high concentrations of vitamin B1 in the blood, one can obtain vivid clinical manifestations of its neurotropic effect, in particular, a decrease in pain associated with pathological processes in the nerves. This effect is also facilitated by its antioxidant activity, which is related to the effect of thiamine on glutathione metabolism.

Pyridoxine serves as a cofactor for more than 100 enzymes. It affects the structure and function of nervous tissue, primarily regulating the metabolism of amino acids, which ensures the normalization of protein metabolism, and prevents the accumulation of excess amounts of neurotropic poison - ammonia. Vitamin B6 is involved in the synthesis of various mediators: catecholamines, histamine and the inhibitory mediator GABA - β-aminobutyric acid. In addition, it increases intracellular reserves of magnesium, which plays an important role in metabolic, in particular energy, processes and in the activity of the nervous system.

Finally, cyanocobalamin, which stimulates nucleic metabolism through the activation of folic acid and thus participates in the maintenance of hematopoiesis and almost all types of plastic metabolism, is indicated not only in the presence of Addison-Birmer disease. For example, for the correction of metabolic disorders that occur in diabetes mellitus, the anabolic function of vitamin B12 plays an important role, and in the treatment of neuropathy, its ability to restore the structure of the myelin sheath and reduce peripheral neurogenic nociception is most significant.

Milgamma® and Milgamma® compositum are true medicinal products with a good evidence base. Randomized, double-blind studies (BAP I, BEDIP, BENDIP) have produced very remarkable results. Thus, regular use of the drug in patients with symmetrical distal sensory polyneuropathy due to diabetes mellitus leads not only to a slowdown in the progression of the disease, but also to the restoration of the function of peripheral nerve fibers. This is evidenced by an improvement in vibration sensitivity and an increase in the speed of nerve impulse transmission along peripheral nerves.

I think general practitioners should be more confident in prescribing Milgamma® when working with patients who have concomitant neurological symptoms. I have successfully used this drug in elderly patients during day hospital treatment, especially if they have diabetes. The course of treatment consists of 10 intramuscular injections of Milgamma® (100 mg of thiamine, 100 mg of pyridoxine, 1000 mcg of cyanocobalamin), which are practically painless due to the presence of 20 mg of lidocaine and a small volume of solution in an ampoule (2 ml). Then the patient switches to oral administration of Milgamma® compositum tablets, 1 tablet 3 times a day for 6 weeks, which allows to enhance and prolong the effect of the course of injections. Preventive courses of therapy with Milgamma® compositum are recommended every 6 months.

Milgamma - instructions for use

Ampoules

Milgamma should be administered only intramuscularly slowly. The solution in ampoules is ready for administration and has a red color. The medicine must be injected into the gluteal muscle.

In acute conditions, Milgamma is administered deeply intramuscularly 1 time/day in a dose of 2 ml. The duration of treatment is determined by the doctor. As maintenance therapy, 2 ml of Milgamma is administered 2-3 times a week for 1 month. Further treatment continues with the use of the drug in pill form.

Dragee

The drug Milgamma compositum is taken orally, 1 tablet per day. If necessary, the daily dose can be increased to 3 tablets. The duration of treatment is selected by the doctor taking into account the severity of the disease. The average duration of treatment is 30 days. If it is necessary to continue treatment, the doctor should reduce the dosage of the drug.

How to take Milgamma tablets (dragees) - before or after meals

The prescribed dosage of the drug in tablets (dragées) is taken orally only after meals. You should drink at least 50–60 ml of water. The medicine should not be chewed or pre-crushed.

It is recommended to administer Milgamma in injections once in the morning. The solution contains lidocaine, which reduces the pain of the drug upon administration.

The drug is usually well tolerated. Side effects may occur with prolonged use or overdose. Among these symptoms, the most common are allergies, dizziness, excitability, dyspepsia, feeling hot, and convulsions.

Milgamma is not used to treat children under 16 years of age. And also among the contraindications: heart rhythm disturbances, oncological pathologies of the blood, kidney and liver diseases (the use of ampoules is undesirable due to the lidocaine content).

The medicine should be stored in ampoules in the refrigerator at a temperature of +2–8⁰С.

Comparisons and differences

Binavit and Milgamma have the following differences:

Milgamma's analogues

Complete analogues of the drug Milgamma in terms of active ingredients are the following generics:

• Neuromultivitis;
• Binavit;
• Neurolon;
• Neurorubin;
• Combigamma;
• Kombilipen - domestic analogue;
• Nerviplex;
• Larigama;
• Neurol;
• BoriVit (Belarus);
• Neurobex;
• Neuraxin B;
• Vitagamma;
• Vitaxon;
• Trigamma;
• Compligam;
• Neurobion;
• Neuromax.

Milgamma differs from substitutes in the manufacturer, the raw materials used, the composition of excipients and the dosages of some active substances. The replacement can be carried out by a doctor under control of the dynamics of the patient’s condition. A direct analogue of Milgamma compositum is Benfo-Binavit in tablets, which also does not contain cyanocobalamin.

There are a number of action analogues that, in addition to B vitamins, contain other active components:

• Clodifene Neuro (with diclofenac sodium);
• Pentovit (with nicotinamide);
• Cocarnit;
• Cyanocobilamine;
• Neurodiclovit;
• Magne B6;
• Magnelis forte;
• Pyridoxine hydrochloride;
• Berocca-plus;
• Angiovit (with folic acid);
• Neuromidin;
• Mexidol.

List of Milgamma analogues with prices

Milgamma or Combilipen injections - which is better and more effective, what is the difference

Manufacturer: Pharmstandard, Russia
Release form: tablets, injection solution

Active ingredient: benfotiamine (thiamine), pyridoxine, cyanocobalamin

Synonyms: Milgamma, Larigama, Kopmligam

Combilipen is a complete domestic analogue of Milgamma. The difference between drugs is in the manufacturers, the complex of excipients. In terms of effects and action, the products are identical. Combilipen tablets, unlike Milgamma compositum, contain cyanocobalamin, which expands the range of actions of this substitute.

Taking Combilipen is permitted from the age of 18. This analogue is not prescribed to pregnant and lactating women due to the lack of safety data. Dosage and treatment regimens do not differ from Milgamma.

How are the products similar?

Binavit and Milgamma have common indications for use; they are prescribed in the presence of the following pathologies:

1. Damage to the nervous system of various origins, including neuralgia, Bell's palsy, neuritis, ganglion damage, plexitis, neuropathy, polyneuropathy.
2. Muscle cramps that occur at night.
3. Back pain.
4. Radiculitis.
5. Sciatica.
6. Radicular syndrome, which is caused by degenerative changes in the spinal column.

Both medications are not used in pediatrics and should not be used by pregnant or breastfeeding women. They are contraindicated in the presence of the following pathologies:

• Intolerance to the composition of the injection solution.
• Acute and uncompensated chronic heart failure.

When using injection solutions, the following adverse reactions may occur:

1. Allergies, including rashes, anaphylaxis, angioedema, difficulty breathing.
2. Dizziness, impaired consciousness.
3. Increased and decreased heart rate, heart rhythm disturbances.
4. Vomit.
5. Excessive sweating, acne, itching and urticaria.
6. Cramps.
7. Irritation at the injection site.

If therapeutic dosages are exceeded, both medications can cause intoxication, which is manifested by the following symptoms:

• Vomit.
• Decrease in heart rate.
• Arrhythmia.
• Vertigo.
• Impaired consciousness.
• Cramps.

If signs of poisoning appear, multivitamins should be discontinued and go to the hospital, where, if necessary, symptomatic therapy will be prescribed.

Since the injections may cause dizziness, you must be careful when driving.

Milgamma or Mydocalm - which is better?

Manufacturer: Gedeon Richter, Hungary
Release form: tablets, injection solution

Active ingredient: tolperisone

Synonyms: Tolperisone, Tolisor, Lidamitol

Mydocalm is a remedy that relaxes muscles. It has a central effect, helps reduce muscle spasm. It is often used in combination with B vitamins. The drug Mydocalm cannot be a replacement for Milgamma, since the composition and effects on the body of the drugs are different. The products complement each other perfectly, but are not analogues in terms of the effects they provide.

Mydocalm can be taken orally or administered intramuscularly, depending on the severity of the disease. Not for use in children under 18 years of age. The drug is contraindicated for use in nursing and pregnant women.

Reviews about Milgamma

There are numerous reviews about Milgamma, which are left by both patients who have undergone such treatment and specialists. Reviews note that intramuscular injections are quite painful, and sometimes there is irritation at the site where the injection was administered. But more often a positive effect is described in the treatment of neuralgia , neuritis and other diseases that were noted after the patient was given injections of Milgamma. Reviews from doctors contain information that during treatment, patients must lead a correct lifestyle and follow all recommendations, since the remedy only eliminates the symptoms, but not the cause of the disease.

The effectiveness of the drug in complex therapy is also often noted, for which not only this drug is prescribed, but also other drugs. For example, a good effect can be obtained if Movalis and Milgamma are prescribed simultaneously. Movalis is a non-steroidal anti-inflammatory drug that has a pronounced positive effect on diseases of the musculoskeletal system.

Milgamma or Neurobion injections - which is better and more effective

Manufacturer: DR.
Reddis, Austria Release form: tablets, injection solution

Active ingredient: thiamine, pyridoxine, cyanocobalamin

Synonyms: Neuromultivit, Compligam, Milgamma, Combilipen, Larigama

Neurobion is a complete analogue in composition. Both drugs in injections have the same effects. The difference is in the manufacturers and the presence of cyanocobalamin in the Neurobion tablets. The effectiveness of the products has been proven, and the quality is high, because... both drugs are produced by European companies.

If, for a number of reasons, a doctor is looking for something to replace Milgamma in injections, then Neurobion may be an ideal option. Treatment regimens and methods of administration of this analogue are identical. Children over 16 years of age are allowed to take the medicine. As a rule, treatment begins with injections of Neurobion with a further transition to taking this analogue in tablets.

Side effects

Side effects of Milgamma appear, as a rule, in rare cases.

In particular, the following side effects are rarely possible:

• Immune system: allergic manifestations.
• Nervous system: impaired consciousness, dizziness .
• Cardiovascular system: tachycardia , arrhythmia , bradycardia.
• Digestive system: vomiting.
• Skin: severe sweating, itching , acne .
• Musculoskeletal and connective tissue: cramps .

Sometimes after Milgamma is administered intravenously to a patient, he may experience irritation in the area where the solution was injected. Systemic reactions can occur only with very rapid administration or in case of overdose.

If any other side effects occur or the negative effects described above are aggravated, you should immediately tell a specialist about this, who will give recommendations on how to inject the ampoules, or replace the drug.

Milgamma or Neuromultivit tablets - which is better?

Manufacturer: GLPHARMA, GmbH, Austria
Release form: tablets

Active ingredient: thiamine, pyridoxine, cyanocobalamin

Synonyms: Neurobion, Milgamma, Compligam, Larigama, Combilipen

Neuromultivit is an analogue of European quality with an identical composition. Both drugs have the same effects and treatment regimens. Neuromultivit tablets, unlike Milgamma, are available only in tablet form and are intended for internal use in children over 18 years of age. The price category of the drugs is practically the same.

Adverse reactions may include allergic reactions, dyspepsia, headaches, and excessive excitability. This analogue is not recommended for nursing and pregnant women.

Milgamma or Binavit - which is better?

Manufacturer: Binergia, Russia
Release form: tablets, injection solution

Active ingredient: thiamine, pyridoxine, cyanocobalamin

Synonyms: Neuromultivit, Neurobion, Milgamma, Larigama, Combilipen

Binavit is a Russian substitute for Milgamma, which is produced in tablets and ampoules. If you are looking for a more budget-friendly option for B vitamins, this product is ideal. The proven effectiveness of the generic along with its low cost will help ensure complete treatment.

Used in children over 18 years of age and adults. It is recommended to start using the product in acute conditions with ampoules. Subsequently, as directed by the doctor, the patient is transferred to oral administration of this analogue in tablet form.

With an overdose or very long-term use of this analogue, allergies, stool disorders, nausea, and headaches may develop.

Milgamma or Larigama - which is better?

Manufacturer: Grotex, Russia
Release form: injection solution, tablets

Active ingredient: thiamine (benfotiamine), pyridoxine, cyanocobalamin

Synonyms: Milgamma, Kombilipen, Neuromultivit, Compligam

Larigama is an analogue of Milgama in ampoules and tablets made in Russia, which costs less. The properties and effects of the drugs are the same.

Differences in manufacturers, quality of raw materials, as well as in the composition of auxiliary ingredients. According to doctors, the first effects appear faster when using such products in ampoules. Further transition to taking pills allows you to maintain and consolidate the effects obtained.

The medicine, like most analogues, is used in children over 18 years of age. Research shows that the drug can negatively affect the development of the fetus, and also quickly penetrates into mother's milk. Therefore, it is not recommended to prescribe the drug to nursing and pregnant women.

Milgamma or Compligam injections - which is better

Manufacturer: Sotex, Russia
Release form: tablets, injection solution

Active ingredient: thiamine (benfotiamine), pyridoxine, cyanocobalamin

Synonyms: Milgamma, Larigama, Comibilipen, Neurobion, Binavit, Neuromultivit

Compligam is an inexpensive domestic analogue with an identical composition. The effectiveness and pharmacological properties of drugs in all forms of release are the same. Differences in manufacturers explain the different costs of the products, as well as differences in the composition of additional ingredients used in production.

The use of Compligam is permitted only for children over 18 years of age. Like other analogues and generics, the medicine is not prescribed during pregnancy and lactation. The drug is well tolerated when used in doses specified by the manufacturer.

Milgamma compositum analogues

Manufacturer: Verwag Pharma, Germany
Release form: pills

Active ingredient: benfotiamine, pyridoxine

Synonyms: Larigama, Combilipen, Neurobion, Neuromultivit

Milgamma compositum is the trade name of the drug, which is produced in pills. A complete analogue in composition is Benfo-Binavit. Their composition, unlike other products, does not contain cyanocobalamin.

All products containing thiamine and pyridoxine can be considered substitutes for their effects. They additionally contain vitamin B12 (cyanocobalamin). Such analogues in tablets include:

• Larigama;
• Compligam;
• Neurobion;
• Neuromultivitis;
• Binavit;
• Combilipen.

The listed medications are often prescribed by doctors as substitutes for Milgamma. This is justified by the almost identical properties and indications for use of the products.

Compound

The composition of Milgamma in the form of a solution for intramuscular administration includes several active substances. In particular, the ampoules contain: pyridoxine hydrochloride , thiamine hydrochloride , cyanocobalamin and lidocaine hydrochloride .
Also, Milgamma injections contain additional substances: benzyl alcohol, potassium hexacyanoferrate, sodium hydroxide, sodium polyphosphate, water for injection.

Vitamins in tablets contain benfotiamine , pyridoxine hydrochloride , and also contain anhydrous colloidal silicon dioxide, croscarmellose sodium, microcrystalline cellulose, talc, povidone K30, and partial long-chain glycerides.

Milgamma or Milgamma compositum - which is better

Both drugs are analogues produced by the same manufacturer. Intended for the treatment of children over 16 years of age and adults.

Milgamma compositum does not contain cyanocobalamin (vitamin B12), unlike the injection form. Therefore, the most rational treatment regimens begin with injections. After eliminating acute symptoms, the patient is transferred to taking pills. This approach will ensure maximum effectiveness of treatment and maintenance of results for a long time.

Answers on questions

Are Milgamma injections painful or not?

When administering the drug, pain may occur in the injection area. To reduce this, the injection solution contains lidocaine as an anesthetic.

Is Milgamma possible for oncology or not?

The drug and its analogues are contraindicated for blood cancer.

When is it better to inject Milgamma: in the morning or in the evening?

The medicine is recommended to be administered in the morning.

Is Milgamma injected every day or every other day?

The medication is administered daily until acute symptoms are eliminated, then once every 2-3 days.

Does Milgamma increase or decrease blood pressure?

The drug and its analogues do not affect blood pressure.

Milgamma injections with a prescription or not?

The solution for injection is dispensed from pharmacies only with doctor's prescriptions.