4. Management of Vitamin B Complex Deficiencies in IBD Patients and

Recommendations

Nutrition support should be considered as an important element of a multidimensional

management of all IBD patients. Although no specific recommendations exist, clinicians

involved in the management of patients with inflammatory bowel disease should regularly

assess the diet and the nutritional status of these patients. Every effort should be made to

always maintain these patients in a well-balanced diet that is rich in nutrients.

Usually, the nutritional needs can be met by food alone together or not with a

multivitamin supplement. Nutritional support as adjunctive therapy should be employed in

any malnourished patient, in those with complications due to specific nutrient deficiencies

and in those who have difficulty in maintaining a normal nutritional status. Special nutritional

considerations are required for specific groups of patients including children, adolescents,

candidates for surgery and those with: severe active disease, severe disease complications

(fistulas, stenoses), and extensive bowel resection with or without short bowel syndrome.

In regard to the “vitamin B complex”, the major concern is to identify and treat the

vitamin B6, vitamin B12 and folate deficiencies, since they are associated with severe

complications in IBD patients (anemia, thrombosis and colon cancer). The other “vitamin B

complex” members’ deficiencies observed in some studies did not have any specific clinical

impact, although some clinical syndromes due to their deficiency have been rarely described.

Nutritional Issues in Inflammatory Bowel Disease… 71

Multivitamin supplements contain adequate amounts for daily requirements of watersoluble B vitamins, and can be used for the prophylaxis against deficiencies of these

micronutrients.

Treatment of macrocytic anemia in IBD patients does not differ from the general

population (intramuscular injections of hydroxycobalamin in vitamin B12 deficiency or

folinic acid orally in folate deficiency).

Hyperhomocysteinemia may be present in IBD patients and has been associated with

thromboembolic complications. Cattaneo et al. [131] found that hyperhomocysteinemia in

IBD patients could be corrected by the administration of folate, vitamin B12 and vitamin B6.

Many other studies assessing the homocysteine and “vitamin B complex” status in IBD

patients suggested the daily administration of folate, vitamin B12 and vitamin B6 for

prophylaxis against hyperhomocysteinemia and thrombotic complications [17,21,39], since

studies have shown a lowering effect on serum homocysteine levels by daily administration

of “vitamin B complex” supplements [132-135]. It is hoped that lowering homocysteine

towards normal serum levels would reduce the risk for thrombosis, but a recent study, the

VITRO trial [135], showed that homocysteine lowering by “vitamin B complex”

supplementation did not prevent recurrent venous thrombosis.

Finally, previous studies have linked folate deficiency with increased cancer risk in UC

patients [104-106]. Evidence from small clinical studies suggests that folate supplementation

in UC patients may have a protective effect against colorectal cancer since it has been

associated with a dose-dependent reduced risk [106] or with an improvement of surrogate

markers of colorectal cancer (DNA repair defects or rectal cell hyperproliferation) [136,137].

However, folate supplementation for colorectal neoplasia chemoprevention should be

regarded with great caution. Animal studies have shown that the protective effect of folate is

dose and timing related, since folate supplementation reduces the risk of colorectal cancer in

normal colorectal mucosa, whereas folate supplementation has a promoting effect on the

progression of established microscopic neoplasmatic foci in the colorectal mucosa and

colorectal neoplasms [138]. Large prospective studies are needed to clarify the

chemopreventive role of folate against colorectal cancer in ulcerative colitis.

CONCLUSION

• Nutrition-related issues are important components of the global assessment in the

management of patients with inflammatory bowel disease.

• Several nutrient deficiencies, including the “vitamin B complex” members, are

frequently observed in IBD patients. The aetiology of nutrient deficiencies is

multifactorial and clinicians should be aware of the malnutrition existence and its

clinical consequences in IBD patients.

• Nutritional status and nutrient intake should be regularly assessed in all IBD patients.

Children, adolescents, perioperative patients, patients with severe disease or

complications and patients with extended small bowel resection, need special

attention.

72 Petros Zezos and Georgios Kouklakis

• Any specific nutrient deficiency should be corrected together with diet adjustment

and prophylactic polyvitamin supplementation when appropriate.

• “Vitamin B complex” supplements protect against macrocytic anemia,

hyperhomocysteinemia and their complications in IBD patients.

• Folate supplementation may have a protective role against colorectal cancer in IBD

patients.

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