Vitamin A


Article Author:
Emily Chea


Article Editor:
Harold Milstein


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
10/21/2019 11:55:58 AM

Indications

Vitamin A is a general term that encompasses various fat-soluble substances such as retinol, retinyl palmitate, and beta-carotene. Its various metabolites are essential for vision, cellular differentiation, epithelial barrier function, and immune function.[1]

Vitamin A is obtained through diet in two forms. Preformed vitamin A (retinol and retinyl ester) is derived from animal sources such as meat, dairy products, and fish. Provitamin A (beta-carotenoid) is derived from colorful fruits and vegetables. Both ingested forms of vitamin A must be converted to retinal and retinoic acid after absorption to support biologic processes.[1]

Deprivation of vitamin A replaces normal epithelium with stratified, keratinizing epithelium in the eyes, periocular glands, respiratory tract, alimentary tract, and genitourinary tract. [2] Excess vitamin A results in acute and chronic deleterious effects on health. Vitamin A deficiency is far more prevalent worldwide than vitamin A toxicity. The World Health Organization (WHO) estimates that 3 million children develop clinical vitamin A deficiency annually compared to an estimated 200 cases of vitamin A toxicity diagnosed annually. [3]

Globally, vitamin A deficiency is an important public health problem. Supplementation is considered a key intervention to greatly reducing the rate of child morbidity and mortality due to preventable diseases in countries with high under-five mortality. It is recognized as one of the most cost-effective interventions to improve childhood survival rates.

Vitamin A supplementation is offered for treatment of measles, xerophthalmia, severe malnutrition, and to prevent deficiency in pregnant women living in areas endemic to vitamin A deficiency. Treatment of xerophthalmia is of special interest because it is one of the only diseases due to vitamin deficiency to reach epidemic levels. Its response to vitamin A supplementation to the eye has been well established and can prevent night blindness, a major problem in developing countries. 

Vitamin A's involvement in cell morphogenesis, differentiation, and proliferation is essential to gene regulation. Additionally, its function as an antioxidant decreases free radical damage to DNA[4]. A deficiency in vitamin A is believed to play a role in neoplastic transformation and carcinogenesis[4].

Studies thus far have not revealed sufficient data to indicate a strong correlation between vitamin A and cancer prevention in all populations. Supplementation in vitamin A sufficient populations have not suggested any added benefit for cancer prevention. However, supplementation in vitamin A deficient populations, such as malnourished or tobacco-dependent groups, may reduce the incidence of cancer[4]

Vitamin A also modulates a broad range of immune processes. It is involved in helper T cell and B cell development, thereby important for adaptive immunity. Its contribution to mucosal epithelial regeneration and neutrophil, macrophage, and natural killer cell functioning label it important for innate immunity, as well. Vitamin A deficiency and infectious diseases that transiently suppress serum retinol concentrations impair normal immune function. In particular, vitamin A deficiency is recognized as a risk factor for the measles virus, a major cause of childhood morbidity and mortality. Megadoses (200,000 IU for two days) of vitamin A has been shown to lower the overall incidence of death related to measles.[3]

Mechanism of Action

In the liver, retinol is esterified to retinyl esters and stored in the stellate cells. In the tissues, both retinol and beta-carotene are oxidized to retinal and retinoic acid, which are essential for vision and gene regulation, respectively. These active metabolites bind nuclear receptors of the RAR family to control gene expression.[1][5][6][7][1]

Administration

Vitamin A supplementation may be administered orally or intramuscularly. Absorption of oral vitamin A enhanced by a fatty meal due to its lipophilic nature.[1]

Adverse Effects

Excess natural or synthetic vitamin A levels may result in a wide array of adverse effects. Vitamin A toxicity, also known as hypervitaminosis A, is more commonly associated with abuse of vitamin A supplements than with health intervention programs. Toxic reactions may also be provoked by consuming liver products rich in vitamin A or excess administration of vitamin A preparations. The amount of vitamin A required to cause toxicity among individuals varies depending on age and hepatic function.

Acute vitamin A toxicity may occur with a single ingestion of 25,000 IU/kg or more. Signs and symptoms include nausea, vomiting, diarrhea, dizziness, lethargy, drowsiness, increased intracranial pressure, and skin changes such as erythema, pruritus, or desquamation.

Chronic vitamin A toxicity may occur with excessive ingestion of 4000 IU/kg or more daily for 6-15 months. Signs and symptoms include low-grade fever, headache, fatigue, anorexia, intestinal disturbances, hepatosplenomegaly, anemia, hypercalcemia, subcutaneous swelling, nocturia, joint and bone pain, and skin changes such as yellowing, dryness, alopecia, and photosensitivity. 

Vitamin A is highly teratogenic if taken during pregnancy. Retinoids affect the expression of homeobox gene Hoxb-1, which regulates axial patterning of the embryo. Birth abnormalities include craniofacial, cardiac, and central nervous system malformations. Therefore, treatment with vitamin A should be avoided in pregnant patients except in areas where vitamin A deficiency is prevalent. In this circumstance, supplementation should not exceed 10,000 IU daily.[8]

Of note, mild adverse effects have been observed with vitamin A given with immunization. Symptoms include loose stools, headache, irritability, fever, nausea, and vomiting. These side effects are rare and typically resolved within 24 to 48 hours.

Contraindications

Vitamin A is contraindicated in pregnancy, breastfeeding patients, and patients with hypersensitivity to this class of drugs. It should be prescribed with caution to patients with hepatic disease, renal disease, alcoholism, and acne vulgaris. 

Monitoring

Isotretinoin is an oral medication derived from vitamin A that is primarily used to treat severe acne. Its package insert recommends baseline lipid and hepatic panels followed by repeat testing weekly or biweekly until the response has been established. However, a recent meta-analysis demonstrated that increases in triglycerides or cholesterol levels typically occur within the first 8 weeks of therapy with minimal to no change after that. The data was not sufficient enough to conclude an early rise in liver function tests, although it was determined that elevated liver function values were rarely high risk. Based on these findings, evidence from the meta-analysis does not support monthly laboratory testing for standard doses of oral isotretinoin.

Toxicity

Symptoms of toxicity may resolve within several weeks after discontinuing vitamin A and instituting supportive therapy. Patients with increased intracranial pressure may require lumbar punctures or medications such as mannitol and diuretics for therapy. Patients with hypercalcemia may require intravenous fluids and additional therapy such as calcitonin and corticosteroids. [8]

Congenital disabilities caused by vitamin A are irreversible. 

Enhancing Healthcare Team Outcomes

Healthcare workers including nurses and pharmacists should know that empirical dispensing of vitamin A is not recommended.  Unless there is a defciency, patients should not be encouraged to take excess amounts of this vitamin as it is known to cause toxicity. Instead, patients should be urged to eat a healthy diet rather than reply on supplements.


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Vitamin A - Questions

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Which of the following foods are low in vitamin A?



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Which organ is responsible for the storage of vitamin A?



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What vitamin form is retinol?



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Which vitamin deficiency affects night vision?



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Which of the following foods that is high in vitamin A will encourage tissue repair?



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Beta-carotene is a precursor for which one of the following?



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Excessive amounts of which vitamin may result in teratogenicity?



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Derivatives of which vitamin are commonly used for acne treatment?



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Vitamin A - References

References

Delivery of retinoid-based therapies to target tissues., Moise AR,Noy N,Palczewski K,Blaner WS,, Biochemistry, 2007 Apr 17     [PubMed]
TISSUE CHANGES FOLLOWING DEPRIVATION OF FAT-SOLUBLE A VITAMIN., Wolbach SB,Howe PR,, The Journal of experimental medicine, 1925 Nov 30     [PubMed]
Vitamin A for treating measles in children., Huiming Y,Chaomin W,Meng M,, The Cochrane database of systematic reviews, 2005 Oct 19     [PubMed]
The importance of vitamin A in nutrition., Dawson MI,, Current pharmaceutical design, 2000 Feb     [PubMed]
Teratogenicity of high vitamin A intake., Challem JJ,, The New England journal of medicine, 1996 May 2     [PubMed]
Kilby K,Mathias H,Boisvenue L,Heisler C,Jones JL, Micronutrient Absorption and Related Outcomes in People with Inflammatory Bowel Disease: A Review. Nutrients. 2019 Jun 20;     [PubMed]
Meléndez-Martínez AJ, An Overview of Carotenoids, Apocarotenoids and Vitamin A in Agro-Food, Nutrition, Health and Disease. Molecular nutrition     [PubMed]
Elmadfa I,Meyer AL, The Role of the Status of Selected Micronutrients in Shaping the Immune Function. Endocrine, metabolic     [PubMed]

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