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Role of Methycobal in Nerve Repaired► Neuropathic Pain► Diabetic Neuropathic Pain► Post Herpetic Neuralgia► Trigeminal Neuralgia► Management of Neuropathic Pain► Methycobal for Nerve RepairedWhat is 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 memuaskanDiagnosis 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.
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Role of Methycobal in Nerve Role of Methycobal in Nerve RepairedRepaired► ► Neuropathic PainNeuropathic Pain
► ► Diabetic Neuropathic PainDiabetic Neuropathic Pain
► ► Post Herpetic NeuralgiaPost Herpetic Neuralgia
► ► Trigeminal NeuralgiaTrigeminal Neuralgia
► ► Management of Neuropathic Management of Neuropathic PainPain
► ► Methycobal for Nerve Methycobal for Nerve RepairedRepaired
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 Otak3 Talamus : Talamotomy4. Korteks Cerebri : Hipnotisme, Sugesti.
SINAPS NYERI SINAPS NYERI
JENIS – JENIS NYERI / PAINJENIS – 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 PainNyeri dengan
komponen Neuropathic
dan Nociceptive
Contoh : Contoh : Contoh :Perifer :- Diabetic Neuropathy- Post Herpetic Neuralgia- Trigeminal Neuralgia- Post Surgical Neuropathy- Post Traumatic NeuropathyCentral :- Post Stroke PainCommon 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 PainChronic 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 Perbandingan Neuropathic Pain dan Nociceptive Paindan 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
Stimulusdependent 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 PainPain 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 PainPain initiated or caused by
a primary lesion or dysfunction in the central
nervous system
Central Neuropathic Pain
Klasifikasi 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 PainNeuropathic 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 ? 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 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 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 polyneuropathyDemyelinating NeuropathyNeuronopathy (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 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 Emotional and Social Impact of Neuropathic Pain Neuropathic Pain
Q U I ZQ 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 ZQ U I Z
What is the type of this PAIN ?
Is it really PAIN ?
Role of Methycobal in Nerve Role of Methycobal in Nerve RepairedRepaired► ► Neuropathic PainNeuropathic Pain
► ► Diabetic Neuropathic PainDiabetic Neuropathic Pain
► ► Post Herpetic NeuralgiaPost Herpetic Neuralgia
► ► Trigeminal NeuralgiaTrigeminal Neuralgia
► ► Management of Neuropathic Management of Neuropathic PainPain
► ► Methycobal for Nerve Methycobal for Nerve RepairedRepaired
Anatomi Pancreas Anatomi Pancreas Pancreas menghasilkan :• Enzym – enzym pencernaan :
- amilase- tripsin- lipase
• Hormon- insulin (me ↓ glukosa darah)- glukagon (me ↑ glukosa darah)- somatostatin- polipeptida
Pulau Langerhans 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 Fisiologi Pancreas
2 jam Setelah Makan, Gula Darah ↑
Pancreas : sekresi Insulin sedikit/tidak ada
Distribusi Nutrisi dan O2 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 MellitusPatofisiologi Diabetes Mellitus
2 jam Setelah Makan, Gula Darah ↑
Merangsang Pancreas utk mensekresi Insulin
Distribusi Nutrisi dan O2 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 MellitusPatofisiologi Diabetes Mellitus
(Konsensus DM - PERKENI 2006)
• Usia
• Lamanya DM
• Lipotoksisitas
• Glukotoksisitas
• Faktor genetik
• Inflamasi
• Stres oksidatif
• 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
• 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
Asesmen Nyeri Neuropati Diabetika
• Pada “small fiber neuropathy”:
EMG, NCV normal.
Role of Methycobal in Nerve Role of Methycobal in Nerve RepairedRepaired► ► Neuropathic PainNeuropathic Pain
► ► Diabetic Neuropathic PainDiabetic Neuropathic Pain
► ► Post Herpetic NeuralgiaPost Herpetic Neuralgia
► ► Trigeminal NeuralgiaTrigeminal Neuralgia
► ► Management of Neuropathic Management of Neuropathic PainPain
► ► Methycobal for Nerve Methycobal for Nerve RepairedRepaired
Patofisiologi Herpes Zoster 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 Patofisiologi Herpes Zoster
Herpes = anggurBentuknya 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 Treatment for Post Herpetic Neuralgia 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 Role of Methycobal in Nerve RepairedRepaired► ► Neuropathic PainNeuropathic Pain
► ► Diabetic Neuropathic PainDiabetic Neuropathic Pain
► ► Post Herpetic NeuralgiaPost Herpetic Neuralgia
► ► Trigeminal NeuralgiaTrigeminal Neuralgia
► ► Management of Neuropathic Management of Neuropathic PainPain
► ► Methycobal for Nerve Methycobal for Nerve RepairedRepaired
Trigeminal Neuralgia 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 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 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 Diagnosis Trigeminal Neuralgia
Treatment Trigeminal Treatment Trigeminal Neuralgia 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 Role of Methycobal in Nerve RepairedRepaired► ► Neuropathic PainNeuropathic Pain
► ► Diabetic Neuropathic PainDiabetic Neuropathic Pain
► ► Post Herpetic NeuralgiaPost Herpetic Neuralgia
► ► Trigeminal NeuralgiaTrigeminal Neuralgia
► ► Management of Neuropathic Management of Neuropathic PainPain
► ► Methycobal for Nerve Methycobal for Nerve RepairedRepaired
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 neuropathic pain confirme
d?
ALTERNATIVE DIAGNOSIS
Management of
common Neuropathi
c Pain Syndromes
NoYes
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.
Pharmacotherapy1st line agents- TCA- Gabapentin- Pregabalin
2nd 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
Pharmacotherapy1st line agents- Gabapentin- lidocaine patch (preferred for eldery)- Pregabalin- TCA
2nd line agents- Opiods or tramadol
Non-pharmacological therapy- Patient education
Pharmacotherapy1st line agents- Carbamazepine- Oxcarbazepine
2nd line agents- Baclofen- Lamotrigine
Surgical intervention- Consider if refractory to monotherapy & drug combinations
Does patient have adequate pain relief in 2
mth?
Continue treatment
NoExpert referral - Consider referring the patient to a pain medicine specialist
Yes
Based on : MIMS Neurology 2008 page A177
Treatment Neuropathic Pain 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 / weekBased 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 PainPRINSIP 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 Role of Methycobal in Nerve RepairedRepaired► ► Neuropathic PainNeuropathic Pain
► ► Diabetic Neuropathic PainDiabetic Neuropathic Pain
► ► Post Herpetic NeuralgiaPost Herpetic Neuralgia
► ► Trigeminal NeuralgiaTrigeminal Neuralgia
► ► Management of Neuropathic Management of Neuropathic PainPain
► ► Methycobal for Nerve Methycobal for Nerve RepairedRepaired
Struktur MethycobalStruktur Methycobal
CN
Co
OH
Co Co
OH
OHCH2
Perbedaan bentuk struktur dengan Perbedaan bentuk struktur dengan vit. Bvit. B 12 12 lainnya: lainnya:
CyanocobalaminHydroxocobalamin DBCC
Methycobal vit.B12 aktif dengan gugus Methycobal vit.B12 aktif dengan gugus methyl (CHmethyl (CH33) )
- 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.
B12 aktif
Jenis-jenis vit.B12 dan fungsinya Jenis-jenis vit.B12 dan fungsinya
B12 tidak aktif
( di hepar )
( di serum )
Hycobal
Memperbaiki Anemia melalui sintesa heme
Memperbaiki Neuropathy melalui sintesa asam nukleat, protein dan fosfolipid
Neuropathy Perifer
Neuropathy Perifer
B12
CN
Co
OH
Co
CH3
Co
OHOH
CH2
Co
Anemia dan neuropathy yang disebabkan karena defisiensi B12 dan metabolisme yang abnormal dari B12
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
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 Mekanisme kerja Methycobal dalam perbaikan sel sarafperbaikan sel saraf
Methycobal is transported at high levels intoorganelles of nerve cells (Rat model)(Inada et.al.(1981):Symposium on Nervous System and MethylB12, Hakone, Japan)
①
Methycobal enhances synthesis of nucleic acidsand proteins in nerve cells (Mouse model)(Nakazawa et.al. (1970): Vitamin, 42(5), 275)
②
Methycobal stimulates axonal transport(Rat model)Takenaka et.al.: Prog. Med. 2 ( 10 ) ,149-152 ( 1982 )Saito et.al.: Hakone Symposium “Nervous System and Methyl B12”: p 75, 1981
③
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)
④
Methycobal stimulates axonal regeneration(Rat)Onishi A. et.al.:Clinical Pharmacology 18(2): 387 (1987)
⑤
Accelerates early recovery of synapticTransmissionShibuya et. al: Symposium on Nervous System and MethylB12”, Hakone, Japan. 1981)
⑥
Restores diminished neurotransmitter levelsSasaki et. al. Pharmacol.Biochem.Behav.,43,635-639 ( 1992 )
⑦
Sintesa asam nukleat dan protein Sintesa asam nukleat dan protein (Biochemical action - 1)(Biochemical action - 1)
John M. Scott et al: Lancet: 337,1981
Deoxyuridine monophosphateDeoxyuridine monophosphate (( d-UMPd-UMP ))Thymidine monophosphateThymidine monophosphate (( d-TMPd-TMP ))ThymineThymine
DNADNA
CHCH33-- TransmethylationTransmethylation
5,10 methylenetetrahydrofolic acid5,10 methylenetetrahydrofolic acid
5 methyltetrahydrofolic acid5 methyltetrahydrofolic acid
Dihydrofolic acidDihydrofolic acid
Tetrahydrofolic acidTetrahydrofolic acid(( THFTHF ))
MethionineMethionine
Methionine synthetaseMethionine synthetase
HomocysteineHomocysteine
S-adenosylhomocysteineS-adenosylhomocysteine S-adenosylmethionineS-adenosylmethionine
MecobalaminMecobalamin
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
CephalinLecithin
S-adenosylhomocysteine S-adenosylmethionine
Methionine Homocysteine
Mecobalamin
S-adenosylhomocysteine S-adenosylmethionine
Methionine Homocysteine
Mecobalamin
Sintesa fosfolipid Sintesa fosfolipid (Biochemical action - 2)(Biochemical action - 2)
Distribusi Methycobalamin pada Cerebro Distribusi Methycobalamin pada Cerebro Spinal FluidSpinal 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 1000μg
CNB12 1000μg1x pemberian IM
100
0
300
200
400
Pg/ml
Sebelum 1 jam 3 jam 6 jam 12 jam
CNB12
CH3B12
Ko
nse
ntr
asi
B12
pa
da
C
ere
bro
spin
al F
luid
32.4+/-6.7N=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%CNB12
8.1%
0.7%
Serum Cerebro Spinal Fluid
91.2%
73.2% CH3 B12
Methycobalamin
OHB12
DBCC25.9
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 Distribusi Methycobalamin dalam serum dan Cerebro Spinal Fluiddan Cerebro Spinal Fluid
Ampoule
The ready to use - Active Cobalamin The ready to use - Active Cobalamin
for Nerve Damage Repaired 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
DosageRoute of
AdministrationUse 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 byfollow 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 RepairedActive Cobalamin for Nerve Damage Repaired
Covered by insurance because it’s drug
Original product with affordable price
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Blister dengan warna gelap untuk melindungi kapsul dari cahaya
Tercantum no. reg untuk membedakan dengan product palsu
Available on Jan 09
‘ Methycobal jacket ‘ untuk melindungi botol infus dari cahaya pada pemberian Methycobal ampul perdrip