Thursday, March 6, 2008

19 - vitamin B6 ( pyridoxine )

Vitamin B6

Vitamin B6 is a water-soluble vitamin that was first isolated in the 1930s. There are three traditionally considerd forms of vitamin B6: pyridoxal (PL), pyridoxine (PN), pyridoxamine (PM). The phosphate ester derivative pyridoxal 5'-phosphate (PLP) is the principal coenzyme form and has the most importance in human metabolism .


Vitamin B6 must be obtained from the diet because humans cannot synthesize it. PLP plays a vital role in the function of approximately 100 enzymes that catalyze essential chemical reactions in the human body . For example, PLP functions as a coenzyme for glycogen phosphorylase, an enzyme that catalyzes the release of glucose from stored glycogen. Much of the PLP in the human body is found in muscle bound to glycogen phosphorylase. PLP is also a coenzyme for reactions used to generate glucose from amino acids, a process known as gluconeogenesis .

Nervous system function

In the brain, the synthesis of the neurotransmitter, serotonin, from the amino acid, tryptophan, is catalyzed by a PLP-dependent enzyme. Other neurotransmitters, such as dopamine, norepinephrine and gamma-aminobutyric acid (GABA), are also synthesized using PLP-dependent enzymes .

Red blood cell formation and function

PLP functions as a coenzyme in the synthesis of heme, an iron-containing component of hemoglobin. Hemoglobin is found in red blood cells and is critical to their ability to transport oxygen throughout the body. Both PL and PLP are able to bind to the hemoglobin molecule and affect its ability to pick up and release oxygen. However, the impact of this on normal oxygen delivery to tissues is not known .

Niacin formation

The human requirement for another B vitamin, niacin, can be met in part by the conversion of the essential amino acid, tryptophan, to niacin, as well as through dietary intake. PLP is a coenzyme for a critical reaction in the synthesis of niacin from tryptophan; thus, adequate vitamin B6 decreases the requirement for dietary niacin .

Hormone function

Steroid hormones, such as estrogen and testosterone, exert their effects in the body by binding to steroid hormone receptors in the nucleus of the cell and altering gene transcription. PLP binds to steroid receptors in a manner that inhibits the binding of steroid hormones, thus decreasing their effects. The binding of PLP to steroid receptors for estrogen, progesterone, testosterone, and other steroid hormones suggests that the vitamin B6 status of an individual may have implications for diseases affected by steroid hormones, including breast cancer and prostate cancers .

Nucleic acid synthesis

PLP serves as a coenzyme for a key enzyme involved in the mobilization of single-carbon functional groups (one-carbon metabolism). Such reactions are involved in the synthesis of nucleic acids. The effect of vitamin B6 deficiency on the function of the immune system may be partly related to the role of PLP in one-carbon metabolism (see Disease Prevention).


Severe deficiency of vitamin B6 is uncommon. Alcoholics are thought to be most at risk of vitamin B6 deficiency due to low dietary intakes and impaired metabolism of the vitamin. In the early 1950s, seizures were observed in infants as a result of severe vitamin B6 deficiency caused by an error in the manufacture of infant formula. Abnormal electroencephalogram (EEG) patterns have been noted in some studies of vitamin B6 deficiency. Other neurologic symptoms noted in severe vitamin B6 deficiency include irritability, depression, and confusion; additional symptoms include inflammation of the tongue, sores or ulcers of the mouth, and ulcers of the skin at the corners of the mouth .

The Recommended Dietary Allowance (RDA)

Because vitamin B6 is involved in many aspects of metabolism, several factors are likely to effect an individual's requirement for vitamin B6. Of those factors, protein intake has been the most studied. Increased dietary protein results in an increased requirement for vitamin B6, probably because PLP is a coenzyme for many enzymes involved in amino acid metabolism . Unlike previous recommendations, the Food and Nutrition Board (FNB) of the Institute of Medicine did not express the most recent RDA for vitamin B6 in terms of protein intake, although the relationship was considered in setting the RDA . The current RDA was revised by the Food and Nutrition Board (FNB) in 1998 and is presented in the table below.

Recommended Dietary Allowance (RDA) for Vitamin B6

Life Stage


Males (mg/day)

Females (mg/day)


0-6 months

0.1 (AI)

0.1 (AI)


7-12 months

0.3 (AI)

0.3 (AI)


1-3 years




4-8 years




9-13 years




14-18 years




19-50 years




51 years and older




all ages




all ages



Disease Prevention

Homocysteine and cardiovascular disease

Even moderately elevated levels of homocysteine in the blood have been associated with increased risk for cardiovascular disease, including heart disease and stroke . During protein digestion, amino acids, including methionine, are released. Homocysteine is an intermediate in the metabolism of methionine. Healthy individuals utilize two different pathways to metabolize homocysteine. One pathway converts homocysteine back to methionine and is dependent on folic acid and vitamin B12. The other pathway converts homocysteine to the amino acid cysteine and requires two vitamin B6(PLP)-dependent enzymes. Thus, the amount of homocysteine in the blood is regulated by at least three vitamins: folic acid, vitamin B12, and vitamin B6 (diagram). Several large observational studies have demonstrated an association between low vitamin B6 intake or status with increased blood homocysteine levels and increased risk of cardiovascular diseases. A large prospective study found the risk of heart disease in women who consumed, on average, 4.6 mg of vitamin B6 daily was only 67% of the risk in women who consumed an average of 1.1 mg daily . Another large prospective study found higher plasma levels of PLP were associated with a decreased risk of cardiovascular disease independent of homocysteine levels . Further, several studies have reported that low plasma PLP status is a risk factor for coronary artery disease . In contrast to folic acid supplementation, studies supplementing individuals with only vitamin B6 have not resulted in significant decreases in basal (fasting) levels of homocysteine. However, one study found that vitamin B6 supplementation was effective in lowering blood homocysteine levels after an oral dose of methionine (methionine load test) was given , suggesting vitamin B6 may play a role in the metabolism of homocysteine after meals.

Immune function

Low vitamin B6 intake and nutritional status have been associated with impaired immune function, especially in the elderly. Decreased production of immune system cells known as lymphocytes, as well as decreased production of an important immune system protein called interleukin-2, have been reported in vitamin B6 deficient individuals . Restoration of vitamin B6 status has resulted in normalization of lymphocyte proliferation and interleukin-2 production, suggesting that adequate vitamin B6 intake is important for optimal immune system function in older individuals . However, one study found that the amount of vitamin B6 required to reverse these immune system impairments in the elderly was 2.9 mg/day for men and 1.9 mg/day for women; these vitamin B6 requirements are higher than the current RDA .

Cognitive function

A few studies have associated cognitive decline in the elderly or Alzheimer's disease with inadequate nutritional status of folic acid, vitamin B12, and vitamin B6 and thus, elevated levels of homocysteine . One observational study found that higher plasma vitamin B6 levels were associated with better performance on two measures of memory, but plasma vitamin B6 levels were unrelated to performance on 18 other cognitive tests . Similarly, a double-blind, placebo-controlled study in 38 healthy elderly men found that vitamin B6 supplementation improved memory but had no effect on mood or mental performance (19). Further, a placebo-controlled trial in 211 healthy younger, middle-aged, and older women found that vitamin B6 supplementation (75 mg/day) for five weeks improved memory performance in some age groups but had no effect on mood (20). Recently, a systematic review of randomized trials concluded that there is inadequate evidence that supplementation with vitamin B6, vitamin B12, or folic acid improves cognition in those with normal or impaired cognitive function . Because of mixed findings, it is presently unclear whether supplementation with B vitamins might blunt cognitive decline in the elderly. Further, it is not known if marginal B vitamin deficiencies, which are relatively common in the elderly, even contribute to age-associated declines in cognitive function, or whether both result from processes associated with aging and/or disease.

Kidney stones

A large prospective study examined the relationship between vitamin B6 intake and the occurrence of symptomatic kidney stones in women. A group of more than 85,000 women without a prior history of kidney stones were followed over 14 years and those who consumed 40 mg or more of vitamin B6 daily had only two thirds the risk of developing kidney stones compared with those who consumed 3 mg or less . However, in a group of more than 45,000 men followed over six years, no association was found between vitamin B6 intake and the occurrence of kidney stones . Limited data have shown that supplementation of vitamin B6 at levels higher than the tolerable upper intake level (100 mg/day) decreases elevated urinary oxalate levels, an important determinant of calcium oxalate kidney stone formation in some individuals. However, it is less clear that supplementation actually resulted in decreased formation of calcium oxalate kidney stones. Presently, the relationship between vitamin B6 intake and the risk of developing kidney stones requires further study before any recommendations can be made.

Disease Treatment

Vitamin B6 supplements at pharmacologic doses (i.e., doses much larger than those needed to prevent deficiency) have been used in an attempt to treat a wide variety of conditions, some of which are discussed below. In general, well designed, placebo-controlled studies have shown little evidence that large supplemental doses of vitamin B6 are beneficial .

Side effects of oral contraceptives

Because vitamin B6 is required for the metabolism of the amino acid tryptophan, the tryptophan load test (an assay of tryptophan metabolites after an oral dose of tryptophan) was used as a functional assessment of vitamin B6 status. Abnormal tryptophan load tests in women taking high-dose oral contraceptives in the 1960s and 1970s suggested that these women were vitamin B6 deficient. Abnormal results in the tryptophan load test led a number of clinicians to prescribe high doses (100-150 mg/day) of vitamin B6 to women in order to relieve depression and other side effects sometimes experienced with oral contraceptives. However, most other indices of vitamin B6 status were normal in women on high-dose oral contraceptives, and it is unlikely that the abnormality in tryptophan metabolism was due to vitamin B6 deficiency . A more recent placebo-controlled study in women on the lower dose oral contraceptives, which are commonly prescribed today, found that doses up to 150 mg/day of vitamin B6 (pyridoxine) had no benefit in preventing side effects, such as nausea, vomiting, dizziness, depression, and irritability .

Premenstrual syndrome (PMS)

The use of vitamin B6 to relieve the side effects of high-dose oral contraceptives led to the use of vitamin B6 in the treatment of premenstrual syndrome (PMS). PMS refers to a cluster of symptoms, including but not limited to fatigue, irritability, moodiness/depression, fluid retention, and breast tenderness, that begin sometime after ovulation (mid-cycle) and subside with the onset of menstruation (the monthly period). A review of 12 placebo-controlled double-blind trials on vitamin B6 use for PMS treatment concluded that evidence for a beneficial effect was weak . A more recent review of 25 studies suggested that supplemental vitamin B6, up to 100 mg/day, may be of value to treat PMS; however, only limited conclusions could be drawn because most of the studies were of poor quality .


Because a key enzyme in the synthesis of the neurotransmitters serotonin and norepinephrine is PLP-dependent, it has been suggested that vitamin B6 deficiency may lead to depression. However, clinical trials have not provided convincing evidence that vitamin B6 supplementation is an effective treatment for depression , though vitamin B6 may have therapeutic efficacy in premenopausal women .

Morning sickness (nausea and vomiting in pregnancy)

Vitamin B6 has been used since the 1940s to treat nausea during pregnancy. Vitamin B6 was included in the medication Bendectin, which was prescribed for the treatment of morning sickness and later withdrawn from the market due to unproven concerns that it increased the risk of birth defects. Vitamin B6 itself is considered safe during pregnancy and has been used in pregnant women without any evidence of fetal harm . The results of two double-blind, placebo-controlled trials that used 25 mg of pyridoxine every eight hours for three days or 10 mg of pyridoxine every eight hours for five days suggest that vitamin B6 may be beneficial in alleviating morning sickness. Each study found a slight but significant reduction in nausea or vomiting in pregnant women. A recent systematic review of placebo-controlled trials on nausea during early pregnancy found vitamin B6 to be somewhat effective . However, it should be noted that morning sickness also resolves without any treatment, making it difficult to perform well-controlled trials.

Carpal tunnel syndrome

Carpal tunnel syndrome causes numbness, pain, and weakness of the hand and fingers due to compression of the median nerve at the wrist. It may result from repetitive stress injury of the wrist or from soft tissue swelling, which sometimes occurs with pregnancy or hypothyroidism. Several early studies by the same investigator suggested that vitamin B6 status was low in individuals with carpal tunnel syndrome and that supplementation with 100-200 mg/day over several months was beneficial . A recent study in men not taking vitamin supplements found that decreased blood levels of PLP were associated with increased pain, tingling, and nocturnal wakening, all symptoms of carpal tunnel syndrome . Studies using electrophysiological measurements of median nerve conduction have largely failed to find an association between vitamin B6 deficiency and carpal tunnel syndrome. While a few trials have noted some symptomatic relief with vitamin B6 supplementation, double-blind, placebo-controlled trials have not generally found vitamin B6 to be effective in treating carpal tunnel syndrome .


Food sources

Surveys in the U.S. have shown that dietary intake of vitamin B6 averages about 2 mg/day for men and 1.5 mg/day for women. A survey of elderly individuals found that men and women over 60 years old consumed about 1.2 mg/day and 1.0 mg/day, respectively; both intakes are lower than the current RDA. Certain plant foods contain a unique form of vitamin B6 called pyridoxine glucoside; this form of vitamin B6 appears to be only about half as bioavailable as vitamin B6 from other food sources or supplements. Vitamin B6 in a mixed diet has been found to be approximately 75% bioavailable . In most cases, including foods in the diet that are rich in vitamin B6 should supply enough to prevent deficiency. However, those who follow a very restricted vegetarian diet might need to increase their vitamin B6 intake by eating foods fortified with vitamin B6 or by taking a supplement. Some foods that are relatively rich in vitamin B6 and their vitamin B6 content in milligrams (mg) are listed in the table below. For more information on the nutrient content of specific foods, search the USDA food composition database.



Vitamin B6 (mg)

Fortified cereal

1 cup



1 medium


Salmon, wild, cooked

3 ounces*


Turkey, without skin, cooked

3 ounces


Chicken, light meat without skin, cooked

3 ounces


Potato, Russet, baked, with skin

1 medium


Spinach, cooked

1 cup


Hazelnuts, dry roasted

1 ounce


Vegetable juice cocktail

6 ounces


*A 3-ounce serving of meat or fish is about the size of a deck of cards.


Vitamin B6 is available as pyridoxine hydrochloride in multivitamin, vitamin B-complex, and vitamin B6 supplements .



Because adverse effects have only been documented from vitamin B6 supplements and never from food sources, safety concerning only the supplemental form of vitamin B6 (pyridoxine) is discussed. Although vitamin B6 is a water-soluble vitamin and is excreted in the urine, long-term supplementation with very high doses of pyridoxine may result in painful neurological symptoms known as sensory neuropathy. Symptoms include pain and numbness of the extremities and in severe cases, difficulty walking. Sensory neuropathy typically develops at doses of pyridoxine in excess of 1,000 mg per day. However, there have been a few case reports of individuals who developed sensory neuropathies at doses of less than 500 mg daily over a period of months. Yet, none of the studies in which an objective neurological examination was performed reported evidence of sensory nerve damage at intakes below 200 mg pyridoxine daily . To prevent sensory neuropathy in virtually all individuals, the Food and Nutrition Board of the Institute of Medicine set the tolerable upper intake level (UL) for pyridoxine at 100 mg/day for adults (see table below) . Because placebo-controlled studies have generally failed to show therapeutic benefits of high doses of pyridoxine, there is little reason to exceed the UL of 100 mg/day.

Tolerable Upper Intake Level (UL) for Vitamin B6

Age Group

UL (mg/day)

Infants 0-12 months

Not possible to establish*

Children 1-3 years


Children 4-8 years


Children 9-13 years


Adolescents 14-18 years


Adults 19 years and older


*Source of intake should be from food and formula only.

Drug interactions

Certain medications interfere with the metabolism of vitamin B6; therefore, some individuals may be vulnerable to a vitamin B6 deficiency if supplemental vitamin B6 is not taken. Anti-tuberculosis medications, including isoniazid and cycloserine, the metal chelator penicillamine, and antiparkinsonian drugs including L-dopa, all form complexes with vitamin B6 and thus create a functional deficiency. Additionally, the efficacy of other medications may be altered by high doses of vitamin B6. For instance, high doses of vitamin B6 have been found to decrease the efficacy of two anticonvulsants, phenobarbital and phenytoin, as well as L-dopa .

Linus Pauling Institute Recommendation

Metabolic studies suggest that young women require 0.02 mg of vitamin B6 per gram of protein consumed daily . Using the upper boundary for acceptable levels of protein intake for women (100 grams/day), the daily vitamin B6 requirement for young women would be calculated at 2.0 mg daily. Older adults may also require at least 2.0 mg/day. For these reasons, the Linus Pauling Institute recommends that all adults consume at least 2.0 mg of vitamin B6 daily. Following the Linus Pauling Institute recommendation to take a daily multivitamin-mineral supplement containing 100% of the Daily Value for vitamin B6 will ensure an intake of at least 2.0 mg/day of vitamin B6. Although a vitamin B6 intake of 2.0 mg daily is slightly higher than the most recent RDA, it is 50 times less than the tolerable upper intake level (UL) set by the Food and Nutrition Board (see Safety).

Older adults (65 years and older)

Metabolic studies have indicated that the requirement for vitamin B6 in older adults is approximately 2.0 mg daily ; this requirement could be even higher if the effect of marginally deficient vitamin B6 intakes on immune function and homocysteine levels are clarified. Despite evidence that the requirement for vitamin B6 may be slightly higher in older adults, several surveys have found that over half of individuals over age 60 consume less than the current RDA (1.7 mg/day for men and 1.5 mg/day for women). For these reasons, the Linus Pauling Institute recommends that older adults take a multivitamin/multimineral supplement, which generally provides at least 2.0 mg of vitamin B6 daily.

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