Role of Methycobal in Nerve Repaired

Neuropathic Pain

Diabetic Neuropathic Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Management of Neuropathic Pain

Methycobal for Nerve Repaired
1. Neuron Cornu Post. Medulla Spinalis.
2. Talamus.
3. Korteks Lobus Parietalis Hemisfer Cerebri

Hambatan nyeri:
1. Tingkat Spinal:
Neurotransmitter:
GABA, serotonin, norepinefrin.
2. Tingkat Batang Otak
3 Talamus : Talamotomy
4. Korteks Cerebri : Hipnotisme, Sugesti.
SINAPS NYERI
JENIS JENIS NYERI / PAIN
Neuropathic Pain Nociceptive Pain
Nyeri disebabkan karena
kerusakan pada sistem
saraf (susunan saraf
perifer ataupun pusat)
Nyeri disebabkan karena
adanya luka pada
jaringan tubuh (otot,
tulang, kulit, viseral)
Mixed Pain
Nyeri dengan
komponen
Neuropathic
dan
Nociceptive
Contoh :
Contoh : Contoh :
Perifer :
- Diabetic Neuropathy
- Post Herpetic Neuralgia
- Trigeminal Neuralgia
- Post Surgical Neuropathy
- Post Traumatic Neuropathy
Central :
- Post Stroke Pain
Common descriptions :
- Burning
- Tingling
- Hypersensitivity to touch or cold

- Low back pain with
radiculopathy
- Cervical radiculopathy
- Cancer pain
- Carpal Tunnel Syndrome
- Pain due to inflammation
- Limb pain after a fracture
- Joint pain in Osteoarthritis
- Post Operative Visceral Pain

Common descriptions :
- Aching
- Sharp
- Throbbing

Neuropathic Pain Nociceptive Pain
Chronic pain (months/years) Acute pain (hours or days)
Caused by injury or disease to nerves Caused by injury or inflammation that
affects both the muscles and joints
Mild to excruciating pain that can last
indefinitely
Moderate to severe pain that
disappears when the injury heals
Causes extreme sensitivity to touch
simply wearing light clothing is painful
Causes sore, achy muscles
Sufferers can become depressed or
socially withdrawn because they see no
relief in sight and may experience sleep
problems
Sufferers can become anxious and
distressed but optimistic about relief
from pain

Wall PD. Textbook of Pain. 4th ed; 1999; Jude EB. Clin in Pod Med and Surg.1999;16:81-97;
Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997: Goldman L.
Cecil Textbook of Medicine. 21st ed; 2000
Perbandingan Neuropathic Pain dan
Nociceptive Pain
Woolf CJ, Mannion RJ. Neuropathic Pain: Etiology, symptoms, mechanisms, and
management. Lancet, 1999;353:1959-64.
Syndrome

Symptoms


Patophysiology


Etiology
Neuropathic pain
Stimulus-
independent pain
Stimulus
dependent pain
Mechanisms
Nerve damage
Traumatic
Toxic
Infectious
Metabolic
Hereditary Compression
Ischaemic
Th/ Pain killer, eg :
gabapentin,
pregabalin
Th/ Based on etiology
Ex : Oral Anti Diabetic,
Steroid, Anti biotics,
etc.
Immune - mediated
Th/ nerve repaired
Methycobal active cobalamin
Neuropathic Pain
Pain initiated or caused by a primary lesion
or dysfunction in the nervous system
Pain initiated or caused by a
primary lesion or dysfunction in
the peripheral nervous system
Peripheral Neuropathic Pain
Pain initiated or caused by a
primary lesion or dysfunction in
the central nervous system
Central Neuropathic Pain
Klasifikasi Neuropathic Pain
Disebabkan kerusakan myelin sheet,
yang berakibat :
1. impuls yang lewat akan menyebar
ke sel saraf lainnya,
sehingga timbul nyeri
2. penghantaran implus ke sel saraf
berikutnya menjadi terhambat
timbul gangguan sensorik.

Neuropathic Pain
Pain disebabkan oleh kerusakan pada SSP atau SST
Keluhan Pain biasanya : rasa geli, rasa rasa tertusuk, rasa
tersengat listrik, rasa terbakar dan disertai dengan rasa
kesemutan atau rasa baal.
Pain timbul sepanjang teritori yang persarafi oleh nervus ybs
(nervus, plexus, radix, spinal cord, brain)
Biasanya kronik (e.g. postherpetic neuralgia, poststroke pain)
Bila di terapi dengan NSAID hasilnya kurang memuaskan
What is Neuropathic Pain ?
Jutaan nervus saling berhubungan di
dalam tubuh :
Nerves menghubungkan otak dan
tubuh utk berkomunikasi
If you accidentally grab a hot iron,
nerves in your hand send a
message to the brain that you are
touching something hot. As a
result, your hand feels a burning
pain

Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997
How Neuropathic Pain Occurs
Jika nerves rusak atau terluka maka fungsinya
terganggu :
Dapat mengirimkan sinyal yang salah ke otak
Nervus yang rusak dapat memberitahu otak bahwa
ada rasa terbakar pada telapak kaki walaupun tidak
menapak pada suatu yang panas.

Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997
How Neuropathic Pain Happens
Polyneuropathy is caused by the degeneration of axon terminals and results in symmetric
distal sensory loss with shading to normal sensation. A compression neuropathy often
results in demyelination with the axon left relatively intact. Sensory loss follows a radicular
pattern. When the neuronal cell body dies the condition is called "neuronopathy." If the cell
body is in the sensory ganglion the condition is often referred to as "ganglionopathy." The
pattern is usually random
Axonal polyneuropathy Demyelinating Neuropathy Neuronopathy (Ganglionopathy)
Up to 7.7 % of people in Europe have neuropathic pain

3 million people, or 7.5% in the United Kingdom
2.5 million people, or 6.4% in France
3.5 million people, or 6.0% in Germany
2.1 million people, or 7.7% in Spain

It often is under-diagnosed and under-treated
Bennett G. Hosp Pract. 1998;95-114; Patient Flow Study. Mercer
Management Consulting; July 2, 2002; Dickinson T. Trends in
Pharmacol Sci. 2003;24:555-557.
Incidence / Prevalence
People with neuropathic pain report:
Difficulty sleeping
A lack of energy
Drowsiness
Difficulty concentrating

Strained relationships with family and friends
An inability to work, walk, or even wear clothes as the
contact with their skin can cause an unbearable burning
pain
Meyer-Rosberg K. Euro J of Pain. 2001;5:379-389; Berger A.. Pain. 2004;5(3):143-9
Emotional and Social Impact of
Neuropathic Pain
Q U I Z
Are Men really stronger than women ?
Women produced estrogen that will
increased threshold of pain
But woman report more pain throught
their life time
and
woman feel pain in more pain of theirs
body and for longer durations
Q U I Z
What is the type of this PAIN ?
Is it really PAIN ?
Role of Methycobal in Nerve Repaired
Neuropathic Pain

Diabetic Neuropathic Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Management of Neuropathic Pain

Methycobal for Nerve Repaired
Anatomi Pancreas
Pancreas menghasilkan :
Enzym enzym pencernaan :
- amilase
- tripsin
- lipase
Hormon
- insulin (me glukosa darah)
- glukagon (me glukosa darah)
- somatostatin
- polipeptida
Pulau Langerhans
2 jam Setelah Makan, Gula Darah
Pancreas mensekresi Insulin
Insulin mengubah Glukosa menjadi Glikogen

(dalam darah)
(di otot & hati)
Gula Darah
Fisiologi Pancreas
2 jam Setelah Makan, Gula Darah
Pancreas : sekresi Insulin sedikit/tidak ada
Distribusi Nutrisi dan O
2
ke jaringan terganggu
Glukosa tetap tinggi dalam darah
Fungsi otot & saraf terganggu, timbul nyeri neuropathy
Glukosa tidak dapat berubah menjadi Glikogen

(dalam darah) (di otot & hati)
Patofisiologi Diabetes Mellitus
2 jam Setelah Makan, Gula Darah
Merangsang Pancreas utk mensekresi Insulin
Distribusi Nutrisi dan O
2
ke jaringan membaik
Glukosa dalam darah
Fungsi otot & saraf membaik, nyeri neuropathy berkurang
OAD
Glukosa berubah menjadi Glikogen

(dalam darah) (di otot & hati)
Patofisiologi Diabetes Mellitus
Nyeri Neuropati Diabetika
Keluhan nyeri sering dijumpai pada
Neuropati Diabetika.

Prevalensi : Sepertiga dari pasien DM.

Nyeri Neuropati Diabetika sukar diobati.
Komplikasi DM
Mikroangiopati
- Neuropati
- Retinopati
- Nefropati

Makroangiopati
- Stroke
- Akut Miokard Infark
- Penyakit Pembuluh Darah Perifer




Kriteria Diagnosis DM
(Konsensus DM - PERKENI 2006)

Gula darah puasa 126mg/dl
Gula darah sewaktu 200mg/dl
Keluhan Klinis DM (+)



Patofisiologi
Neuropati Diabetika adalah Polineuropati Simetris.
Melibatkan serabut besar (A ) & serabut kecil (C-Fiber).
Serabut A dengan Glutamat pada Na
+
channel.
Serabut C dengan neurotransmitter substansia P.
Nyeri neuropati Diabetika banyak melibatkan C Fiber.
Pengendalian gula darah penting dalam prevalensi nyeri
neuropati diabetika.
Usia
Lamanya DM
Lipotoksisitas
Glukotoksisitas
Faktor genetik
Inflamasi
Stres oksidatif


Gejala Klinis
Pola nyeri di kaki
Nyeri seperti terbakar
Nyeri seperti tertembak
Disestesia
Keluhan penyerta yang mungkin terjadi
Rasa baal
Alodinia
Hiperalgesia
Cenderung lebih nyeri pada malam hari

Nyeri Tanpa Stimulus
(Nyeri Spontan)
Nyeri seperti
terbakar
(burning)
Nyeri seperti
tersayat
(lacinating)
Nyeri seperti
tersetrum
(electric shock)
Disestesia
Parestesia Rasa baal
Alodinia
Hiperalgesia
Hipoalgesia
Hiperpati
NYERI DENGAN STIMULUS
(EVOKED PAIN)
Diagnosis
Anamnesis Nyeri pada Nyeri
Neuropati Diabetika :
1. Riwayat nyeri : Lokasi, kualitas, awitan, etc.
2. Macamnya nyeri
3. Durasi nyeri
4. Intensitas nyeri
5. Komorbid (gangguan tidur, cemas, depresi)
Pemeriksaan
Pemeriksaan Fisik
Pemeriksaan Neurologik :
- Motorik
- Sensorik
- Otonom
Pemeriksaan penunjang :
- EMG, USG, MRI, fMRI
- Quantitative Sensory Testing
- Pemeriksaan Laboratorium
- Biopsi




Pemeriksaan Neurologi
Motorik :
- Kekuatan, Tonus, Refleks

Sensorik :
Serabut Saraf Besar :
Vibrasi
Tekanan
Posisi

Otonom :
Kardiovaskular
Gastrointestinal
Urogenital



Serabut saraf Kecil :
Rasa nyeri
Termal

Respirasi
Sudomotor

Sensasi nyeri

Sensasi termal

Vibrasi

Rasa tekanan

Posisi

Pemeriksaan kekuatan

Pemeriksaan refleks



Metabolik
Vaskuler
Infeksi
Luka
Tekanan
(Konsensus DM - PERKENI 2006)
Visual Anologue Scale (VAS)
Numeric Pain Rating Scale (NPRS)
Faces Pain Rating Scale (anak)
Long Form
KUESIONER NYERI NEUROPATIK McGILL
Short Form

Anamnesis & Pemeriksaan.
Diagnosis DM
Menentukan Gambaran Klinis
Menentukan Neuropati
- Skrining : Garpu tala & monofilamen
- Skala nyeri
Evaluasi Komorbid : depresi, gangguan tidur,
ulcerasi kaki.

Asesmen Nyeri
Neuropati Diabetika
Pemeriksaan Konfirmatif

Pemeriksaan Penghantaran Saraf (EMG)

Tes sensorik kwantitatif.
Pada small fiber neuropathy:
EMG, NCV normal.
Terapi Nyeri Neuropati Diabetika
(Guidelines Mayo Clinic 2006)
Lini Pertama :
Duloxetin, Oxycodone, Pregabalin,
Anti depresan Trisiklik
Lini Kedua :
Carbamazepin, Gabapentin, Lamotrigine,
Tramadol, Venlafaxine
Terapi Nyeri Neuropati Diabetika
(EFNS Guideline 2006)
Terapi Lini Pertama :
Pregabalin , Gabapentin, Anti depresan
Trisiklik.
Lini Kedua :
Duloxetine, Venlafaxine
Role of Methycobal in Nerve Repaired
Neuropathic Pain

Diabetic Neuropathic Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Management of Neuropathic Pain

Methycobal for Nerve Repaired
Patofisiologi Herpes Zoster
Pasca infeksi Varicella Zoster
Virus Varicella Zoster dormant pada spinal
ganglion sekitar tulang belakang
Pada saat imunitas tubuh , virus Varicella Zoster aktif
kembali menjadi virus Herpes Zoster dan menginfeksi
serabut saraf mengikuti dermatom
serabut saraf yang terinfeksi mengalami
kerusakan myelin dan timbul Post Herpetic
Neuralgia (tidak hilang hingga 2 6 bulan pasca
Herpes)
Patofisiologi Herpes Zoster
Herpes = anggur
Bentuknya vesikel (berisi cairan) bergerombol
seperti anggur dan disertai kemerahan
Progression of herpes zoster. A cluster of small bumps (1) turns into blisters (2).
The blisters fill with lymph, break open (3), crust over (4), and finally disappear.
Postherpetic neuralgia can sometimes occur due to nerve damage (5),
Treatment for Post Herpetic Neuralgia
1. For acute Herpes Zoster :
- Acyclovir 5 x 800 mg / day 7 days

2. For acute and cronic Post Herpetic Neuralgia :
Pain killer :
- Gabapentin 3 x 300 mg/day 3 x 1200 mg/day 2 6
months
- NSAID 1 2 weeks

3. For Nerve Repaired :
- Methycobal injection 3 x 500 mcg / week (im)


Role of Methycobal in Nerve Repaired
Neuropathic Pain

Diabetic Neuropathic Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Management of Neuropathic Pain

Methycobal for Nerve Repaired
Trigeminal Neuralgia
Ada sekitar 15,000 kasus baru yang
didiagnosa dlm setahun dan 90%
kasus timbul pada usia di atas 40 th.
Prevalensi sekitar 12 juta pasien
dengan ratio : 1.5:1.
Keluhan : nyeri mendadak,
Stabbing (rasa tertusuk), shooting
(rasa perih,panas), electric shock-like
pain (rasa tersengat listrik) di
sepanjang area maxillary and
mandibular, sesisi.
Rasa nyeri timbul spontan atau
terstimuli dgn sentuhan, air dingin,
mengunyah, berbicara, gerakan
wajah, menyikat gigi atau stress
emosional, dan berulang.
Trigeminal neuralgia juga menyebabkan chepalgia yang berat dan intermittent (hilang timbul).
Trigger zones biasanya di daerah pusat wajah dan sekitar hidung dan bibir dan ukurannya
kecil (1-2 mm).
Penyebab Trigeminal Neuralgia karena demyelinisasi dan irritasi pada nervus trigeminal.
Anatomi Nervus V
- Trigeminal neuralgia (TN) = tic douloureux adalah suatu kondisi yang mengenai
nervus trigeminal (N.V).
- Nervus ini adalah salah satu nervus terbesar di kepala dan berfungsi untuk
menyalurkan impuls rabaan, tekanan, suhu, dari area wajah, rahang, gusi, dahi,
sekitar mata.
Cause of trigeminal neuralgia
- The exact cause of trigeminal neuralgia is controversial, but it is suggested
that an area of vascular compression where the trigeminal nerve enters the
brain may be the culprit.
- This compression may cause damage to the myelin sheath (the insulating
cover of a nerve fiber) that surrounds the trigeminal nerve. Other precipitating
factors include multiple sclerosis and hypertension.
Etiologi Trigeminal Neuralgia
- Pemeriksaan Neurologis biasanya normal.
- Yang harus dipikirkan adalah sesuatu yang lebih dari sekedar trigeminal
Neuralgia misal : multiple sclerosis atau tumor.
- MRI dgn atau tanpa kontras tetap normal jika tidak ada lesi.
- Biasanya diagnosa Trigeminal Neuralgia ditegakkan berdasarkan anamnesa dan
therapeutic trial.
- Sering terjadi pasien tidak diterapi dengan benar karena diagnosanya sulit
ditegakkan.
- Penyakit lain yang menyerupai Trigeminal Neuralgia : dental disorders, sinus
infections, temporal arteritis, migraine headaches, and psychological disorders.
- Jika salah diagnosa maka bisa menyebabkan : ekstraksi gigi yang tidak perlu,
terapi root canals, operasi sinus, biopsi dan terapi antibiotik.
Diagnosis Trigeminal Neuralgia
Treatment Trigeminal Neuralgia
- Medical management : CBZ, PHT, GBP, LTG
- Mekanisme kerja dari obat obat tsb adl menghambat impuls nyeri dengan
memblok masuknya ion Natrium atau Calcium ke dalam sel.
- Surgical or radiosurgical therapy is generally only considered after treatment
with medications has failed.
Role of Methycobal in Nerve Repaired
Neuropathic Pain

Diabetic Neuropathic Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Management of Neuropathic Pain

Methycobal for Nerve Repaired

Patient presents with symptoms
suggestive of neuropathic pain
DIAGNOSIS
Clinical History
Determine if manisfestations are part of
common neuropathic pain syndromes
Physical Exam
Should include a full neurological exam
Ancillary Tests
1
2
3
4
Is
neuropathi
c pain
confirmed
?
ALTERNATIVE
DIAGNOSIS
Management
of common
Neuropathic
Pain
Syndromes
No Yes
Based on : MIMS Neurology 2008 page A177
Management of common
Neuropathic Pain
Syndromes
Painful Diabetic Peripheral
Neuropathy (DPN)
Postherpetic Neuralgia
(PHN)
Trigeminal Neuralgia (TN)
Non-pharmacological therapy
- Patient education
- Optimize glycemic control
- proper foot care
- transcutaneous electrical nerve stimulation
(TENS)
- Alternative therapy: acupuncture,
biofeedback, magnet therapy.

Pharmacotherapy
1
st
line agents
- TCA
- Gabapentin
- Pregabalin

2
nd
line agents
- Lamotrigine
- Opiods or tramadol
- Serotonin-noradrenaline reuptake inhibitors
(Duloxetine, Venlafaxine)

Other agents :
- Capsaicin - SSRI
- Oxcarbazepine - Topiramate
Non-pharmacological
therapy
- Patient education
- Psychosocial counseling
- TENS

Pharmacotherapy
1
st
line agents
- Gabapentin
- lidocaine patch (preferred for
eldery)
- Pregabalin
- TCA

2
nd
line agents
- Opiods or tramadol
Non-pharmacological therapy
- Patient education

Pharmacotherapy
1
st
line agents
- Carbamazepine
- Oxcarbazepine

2
nd
line agents
- Baclofen
- Lamotrigine

Surgical intervention
- Consider if refractory to monotherapy &
drug combinations
Does patient
have adequate
pain relief in 2
mth?
Continue treatment
No
Expert referral
- Consider referring the
patient to a pain medicine
specialist
Yes
Based on : MIMS Neurology 2008 page A177
Treatment Neuropathic Pain
1. Based on Etiology
- Diabetic Neuropathy Oral Anti Diabetic, Insulin.
- Post Herpetic Neuralgia Anti Viral
- Trigeminal Neuralgia steroid
2. Pain Killer
- Anticonvulsants
- Tri Cyclic Antidepresant
- Tramadol
- Opioid
3. Nerve Repaired
- Methycobal Ampoule 3 x 500 mcg / week
Based on : MIMS Neurology 2008 page A177
Penderita
Diabetic
Neuropatic Pain
Oral Anti
Diabetic

-Anticonvulsants
(gabapentin/
pregabalin)
Vit B1,B6,
B12
- Gol. Sulfonilurea
- Gol. Biguanid
- Gol. Glitazone
PRINSIP Therapy pada Diabetic Neuropatic Pain
Kontrol
Gula
Darah
Hilangkan
Neuropati
c Pain
Memperbaiki
mielin
(mielinisasi)
Based on : MIMS Neurology 2008 page A177
Role of Methycobal in Nerve Repaired
Neuropathic Pain

Diabetic Neuropathic Pain

Post Herpetic Neuralgia

Trigeminal Neuralgia

Management of Neuropathic Pain

Methycobal for Nerve Repaired
Struktur Methycobal
CN
Co
OH
Co
Co
OH
OH
CH2
Perbedaan bentuk struktur dengan vit. B
lainnya:
Cyanocobalamin Hydroxocobalamin DBCC
Methycobal vit.B12 aktif dengan gugus methyl (CH
3
)
- Methycobal adalah bentuk vit B12 aktif karena mempunyai gugus CH3.
- Di dalam tubuh, semua bentuk vit. B12 akan diubah menjadi bentuk
Methycobalamin sebelum digunakan dalam proses metabolisme tubuh.
B
12
aktif
Jenis-jenis vit.B12 dan fungsinya
B
12
tidak
aktif
di hepar
di serum
Hycobal
Memperbaiki Anemia
melalui sintesa heme
Memperbaiki Neuropathy
melalui sintesa asam
nukleat, protein dan
fosfolipid
Neuropathy
Perifer
B12
CN
Co
OH
Co
CH3
Co
OH
OH
CH2
Co
Anemia dan neuropathy yang
disebabkan karena defisiensi
B12 dan metabolisme yang
abnormal dari B12
Anemia dan neuropathy
yang disebabkan karena
defisiensi B1,B6,B12 dan
metabolisme yang
abnormal dari B1,B6,B12
Vit B kompleks
B1, B6, B12
Cyanocobalamin
Hydroxocobalamin
Methycobal
Mekanisme kerja Methycobal dalam perbaikan sel saraf
Methycobal is transported at high levels into
organelles of nerve cells (Rat model)
(Inada et.al.(1981):Symposium on Nervous System and Methyl
B12, Hakone, Japan)

Methycobal enhances synthesis of nucleic acids
and proteins in nerve cells (Mouse model)
(Nakazawa et.al. (1970): Vitamin, 42(5), 275)

Methycobal stimulates axonal transport
(Rat model)
Takenaka et.al.: Prog. Med. 210,149-1521982
Saito et.al.: Hakone Symposium Nervous System and
Methyl B12: p 75, 1981

Promotes myelinization- Synthesis of Lipids
(in vitro)
(Yonezawa T. et al.: Hakone Symposium Nervous System and
Methyl B12, p49-53, 1981
Nakazawa T. et.al.: Hakone Symposium Nervous System and
Methyl B12, 54-60, 1981)

Methycobal stimulates axonal regeneration
(Rat)
Onishi A. et.al.:Clinical Pharmacology 18(2): 387 (1987)

Accelerates early recovery of synaptic
Transmission
Shibuya et. al: Symposium on Nervous System and Methyl
B12, Hakone, Japan. 1981)

Restores diminished neurotransmitter levels
Sasaki et. al. Pharmacol.Biochem.Behav.,43,635-6391992

Sintesa asam nukleat dan protein
(Biochemical action - 1)
John M. Scott et al: Lancet: 337,1981
Deoxyuridine monophosphated-UMP Thymidine monophosphated-TMP
Thymine
DNA
CH
3
- Transmethylation
5,10 methylenetetrahydrofolic acid
5 methyltetrahydrofolic acid
Dihydrofolic acid
Tetrahydrofolic acid
THF
Methionine
Methionine synthetase
Homocysteine
S-adenosylhomocysteine S-adenosylmethionine
Mecobalamin
Methycobal mengaktivasi sintesa DNA di sel saraf dan membantu sintesa protein
Shinichi Tashiro : Hakone Symposium The Nervous System and Methyl B12 p.30, 1981.
Methycobal mensintesa lecithin, komponen utama dari selubung myelin
Transmethylation
Ethanolamine Choline
Cephalin
Lecithin
S-adenosylhomocysteine S-adenosylmethionine
Methionine Homocysteine
Mecobalamin
S-adenosylhomocysteine S-adenosylmethionine
Methionine Homocysteine
Mecobalamin
Sintesa fosfolipid
(Biochemical action - 2)
Distribusi Methycobalamin pada Cerebro Spinal Fluid
Nobuo Tanaka et al. : Hakone Symposium "The Nervous System and Vitamin B12" P.5,1981.
Tujuan
Metode
Mengevaluasi distribusi Methycobalamin pada Cerebro Spinal Fluid
CH3B12 1000g
CNB12 1000g
1x pemberian IM
100
0
300
200
400
Pg/ml
Sebelum 1 jam 3 jam 6 jam 12 jam
CNB12
CH
3
B
12
K
o
n
s
e
n
t
r
a
s
i

B
1
2

p
a
d
a


C
e
r
e
b
r
o
s
p
i
n
a
l

F
l
u
i
d


32.4+/-6.7
N=17
Konsentrasi Methycobalamin lebih tinggi daripada cyanocobalamin dalam CSF
Hasil
Haruto Uchino et al. :Vitamins 42(3):198,1970.
Haruto Uchino et al. :Kyoto Symposium "Peripheral Neuropathy and Methycobal," p.1,1978.
Metode
0.9%
CNB
12
8.1%
0.7%
Serum
Cerebro Spinal Fluid
91.2%
73.2%
CH
3
B
12
Methycobalamin
OHB
12
DBCC
25.9
Perbandingan konsentrasi vit. B12 di dalam serum dan Cerebro
Spinal Fluid pada orang sehat.

Konsentrasi Methycobalamin lebih tinggi daripada vit B12 lainnya di serum dan CSF
Hasil
Distribusi Methycobalamin dalam serum dan Cerebro
Spinal Fluid
Ampoule
The ready to use - Active Cobalamin
for Nerve Damage Repaired

Garis robek
Masing-masing ampul Methycobal Injeksi dikemas dalam bungkus
aluminium bag agar terlindung dari cahaya dan dirancang dengan
garis tempat merobek tepat pada leher ampul, sehingga badan ampul
tetap berada di dalam agar tidak terpapar cahaya.

Methycobal merupakan preparat
yang light sensitive
Methycobal merupakan obat dan di cover oleh asuransi kesehatan
Dosage
Route of
Administration
Use for
Ampoule 500 mcg 3 times/week i.m. or i.v. Hospitalized Patients
Capsules 500 mcg 3 times/day per oral out patients
follow by
Special cover design to protect from light, both capsules & ampoules
Small capsule, easy to swallow
Contain 1 ml, more convenient, no pain in injection
Active Cobalamin for Nerve Damage Repaired
Covered by insurance because its drug
Original product with affordable price
Blister dengan warna gelap untuk
melindungi kapsul dari cahaya
Tercantum no. reg untuk
membedakan dengan product palsu
Methycobal jacket untuk melindungi botol infus dari
cahaya pada pemberian Methycobal ampul perdrip