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      Is intravenous vitamin C contraindicated in patients with G6PD deficiency?

      editorial
      Critical Care
      BioMed Central
      Vitamin C, G6PD deficiency, Sepsis, Septic shock, Clinical trials

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          Abstract

          There is increasing interest in the use of intravenous vitamin C as adjunctive treatment in the management of patients with sepsis and septic shock. Currently, there are at least 20 randomized controlled trials worldwide testing this intervention in patients with sepsis. Almost all of these trials list glucose-6-phosphate dehydrogenase (G6PD) deficiency as an exclusion criterion. This is based on a handful of cases of hemolysis in patients with G6PD deficiency who received large pharmacologic doses of IV vitamin C (> 60 g) [1]. However, the reality is that low-moderate dose intravenous vitamin C may be the treatment of choice for drug-induced hemolysis in patients with G6PD deficiency. In vitro data dating back to 1979 has demonstrated that vitamin C in plasma concentrations up to 5 mmol/l inhibited the oxidation of oxyhemoglobin and Heinz body formation in G6PD-deficient red cells incubated with acetylphenylhydrazine (a strong oxidizing drug) [2]. Serum concentrations of vitamin C are typically in the range of 200–600 umol/l when dosed with 1.5 g IV q 6 hourly. Furthermore, case reports and case series have demonstrated a dramatic reduction of methemoglobinemia and hemolysis in patients treated with intravenous vitamin C in a dose between 1 and 10 g q 6 hourly [3, 4]. Indeed, intravenous vitamin C may be the treatment of choice in G6PD-deficient patients with drug-induced hemolysis, as methyl blue is contraindicated in these patients [3]. These data suggest that in the dosage currently under investigation (6 g/day), vitamin C should not be considered contraindicated in patients with known or suspected G6PD deficiency. This is important, as GDPD deficiency is not uncommon in patients of African and Mediterranean descent [5]. Furthermore, sepsis per se may cause methemoglobinemia in both G6PD-deficient patients and those with normal G6PD function.

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          Ascorbic acid for the treatment of methemoglobinemia: the experience of a large tertiary care pediatric hospital.

          The purpose of reporting this series of patients is to illustrate the role of ascorbic acid in the treatment of severe acquired methemoglobinemia (metHb), especially when methylene blue is not available. Medical records of affected patients were reviewed to collect history of exposures, food ingestion, physical examination, pulse oximetry, blood gas, and co-oximetry results, and outcomes. Five cases of acquired metHb are presented here, all of whom received treatment with ascorbic acid and fully recovered after 24 hours of treatment. Our series emphasizes that ascorbic acid is an effective alternative in the management of acquired metHb if methylene blue is unavailable and suggests that ascorbic acid infusion may be indicated in patients with glucose-6-phosphatase dehydrogenase deficiency.
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            Severe acute haemolytic anaemia associated with severe methaemoglobinaemia in a G6PD-deficient man

            Methaemoglobin is a form of haemoglobin in which the ferrous (Fe 2+ ) ion contained in the iron–porphyrin complex of haem is oxidised to its ferric (Fe 3+ ) state. Methaemoglobinaemia, the presence of methaemoglobin in the blood, is most commonly treated with methylene blue. However, methylene blue cannot be used in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency as it is ineffective in such patients and it can worsen G6PD deficiency haemolysis. We report the case of a 30-year-old man who presented with clinical features of G6PD deficiency-associated haemolysis and was found to have severe methaemoglobinaemia (35%). He was administered blood transfusions and intravenous ascorbic acid. His methaemoglobinaemia resolved within 24 hours. This case demonstrates the successful management of a patient with severe methaemoglobinaemia in the setting of G6PD deficiency haemolysis. Emergency physicians should be aware of the possible co-occurrence of severe methaemoglobinaemia in a patient with G6PD deficiency haemolysis.
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              Ascorbic Acid-Induced Hemolysis in G-6-PD Deficiency

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                Author and article information

                Contributors
                marikpe@evms.edu
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                3 April 2019
                3 April 2019
                2019
                : 23
                : 109
                Affiliations
                ISNI 0000 0001 2182 3733, GRID grid.255414.3, Division of Pulmonary and Critical Care Medicine, , Eastern Virginia Medical School, ; 825 Fairfax Av, Suite 410, Norfolk, VA 23507 USA
                Article
                2397
                10.1186/s13054-019-2397-6
                6448313
                30944032
                e3895320-9f95-424f-9d44-f0050ce12aaf
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 4 March 2019
                : 18 March 2019
                Categories
                Editorial
                Custom metadata
                © The Author(s) 2019

                Emergency medicine & Trauma
                vitamin c,g6pd deficiency,sepsis,septic shock,clinical trials
                Emergency medicine & Trauma
                vitamin c, g6pd deficiency, sepsis, septic shock, clinical trials

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