Low-dose Oral Administration Research Articles

Effect of low-dose cisapride on gastric emptying and QTc interval in preterm infants

UNLABELLED The aim of the study was a prospective survey of the effects of low-dose cisapride on gastric emptying and QTc interval in very low birthweight infants. Twenty low birthweight infants were studied: mean (SD) gestation 30.5 (2.2) wk; birthweight 1320 (150)g. Gastric emptying was assessed ultrasonically in 15 of these infants, in a randomized blind crossover study, following 24-h low-dose oral cisapride administration (0.1 mg/kg given 8 hourly), or placebo. The QTc interval was also determined in all 20 infants following a 7-d course of cisapride or placebo. CONCLUSIONS Cisapride significantly shortened both gastric emptying time and QTc interval (p < 0.05) compared to placebo. All infants completed the study without any apparent adverse effects. In conclusion, low-dose cisapride administration significantly improves gastric emptying without increasing the QTc interval.

Breakdown of mucosal immunity in gut by 2,3,7,8-tetraclorodibenzo-p-dioxin (TCDD)

Mucosal immunity plays a pivotal role for body defense against infection and allergy. The aim of this study was to clarify the effects of 2,3,7,8-tetraclorodibenzo-p-dioxin (TCDD) on mucosal immunity in the gut. Fecal IgA level and oral tolerance induction were examined in TCDD-treated mice. Flow cytometric and histological analyses were also performed. Single oral administration of low dose 2,3,7,8-TCDD resulted in a marked decrease in IgA secretion in the gut without any effects on the cellular components of gut-associated lymphoid tissues (GALT) including Peyer's patches (PPs) and mesenteric lymph nodes (LNs). Decressed IgA secretion by TCDD was not observed in aryl hydrocarbon receptor (AhR)-deficient mice. Flow cytometric analysis revealed that IgA B cells in PPs and the mesenteric LNs remained unchanged in the TCDD-treated mice. An immunofluorescence study also demonstrated that a significant number of cytoplasmic IgA cells were present in the lamina propria of the gut in the TCDD-treated mice. Furthermore, oral tolerance induction by ovalbumin (OVA) was impaired in the TCDD-treated mice and OVA-specific T cell proliferation occurred in the peripheral lymphoid tissues including the spleen and LNs. These results suggest that a relatively low dose of TCDD impairs mucosal immunity in the gut and induces systemic sensitization by oral antigens.

DNA Microarray Technology in the Evaluation of Weight Management Potential of a Novel Calcium-Potassium Salt of (—)-Hydroxycitric Acid

Quality and quantity of diet and nutrients are key factors of human health and disease prevention. Molecular diagnostics and cellular signaling play a fundamental role in the usefulness of novel nutraceuticals and functional foods. Increasing knowledge of the genes and molecules involved in the development of obesity is creating new methods of obesity regulation. Traditional herbal medicines may have some potential in weight management. Botanical dietary supplements often contain complex mixtures of phytochemicals that have additive or synergistic interactions. Evidence from numerous human and animal dietary studies has demonstrated the potential therapeutic effects of traditional herbal medicines in controlling obesity. We analyzed the effects of low-dose oral administration of calcium-potassium salt of (-)-hydroxycitric acid (HCA-SX) on the body weight and abdominal fat transcriptome in rats. HCA-SX restricted body weight gain in rats and lowered abdominal fat leptin expression. High-density microarray analysis of 9960 genes and ESTs present in the fat tissue identified a small set of specific genes sensitive to dietary HCA-SX. Mitochondrial/nuclear proteins necessary for fundamental support of the tissue were not affected by HCA-SX, further demonstrating its safety. Functional characterization of HCA-SX sensitive genes revealed that up-regulation of genes encoding serotonin receptors represents a distinct effect of HCA-SX on appetite suppression.

Effect of Low-Dose Oral Administration of Natural Human Interferon Alpha in Preventing Diarrhea and Enhancing Growth in Suckling Piglets

Effect of Low-Dose Oral Administration of Natural Human Interferon Alpha in Preventing Diarrhea and Enhancing Growth in Suckling Piglets

Long-term low-dose oral administration of dehydroepiandrosterone modulates adrenal response to adrenocorticotropic hormone in early and late postmenopausal women

Objective. The aging process is associated with a decline in the circulating Δ5-androgen dehydroepiandrosterone (DHEA) and its sulfate ester, dehydroepiandrosterone sulfate (DHEAS). The present study aimed to evaluate the effects of a long-term (12 months) oral DHEA administration (25 mg/day) on adrenal function, before and after 3, 6 and 12 months of treatment.Method. Postmenopausal women belonging to two age groups, 50–55 years (n = 10) and 60–65 years (n = 10), were studied. Adrenal function was assessed in basal conditions, after suppression with dexamethasone (DXM) and following a stimulation test with adrenocorticotropic hormone (ACTH) (10 μg bolus). Serum levels of DHEA, DHEAS, androstenedione (Δ4-A), allopregnanolone, 17-hydroxyprogesterone (17-OHP) and cortisol were measured and the effects of DHEA supplementation on specific adrenal enzymatic pathways were evaluated by calculating precursor/product ratios (17-OHP/cortisol, 17-OHP/Δ4-A, DHEA/Δ4-A and DHEA/DHEAS).Results. DHEA supplementation annulled the age-related differences in DHEA and DHEAS levels and induced a marked increase in all steroids, except for cortisol, after 3–6 months of treatment. Serum cortisol levels decreased from the 3rd month, both in younger and older subjects. DHEA supplementation did not affect DXM-induced suppression of adrenal steroidogenesis. During the treatment period all adrenal androgens and progestins showed a significant increase in their response to ACTH, while the cortisol response decreased significantly. The results suggest a significant DHEA-induced change in adrenal enzymatic activities, as also evidenced by the change in precursor/product ratios during therapy.Conclusion. Chronic DHEA administration is capable of modifying circulating levels of androgens and progestins in both early and late postmenopausal women by modulating the age-related changes in adrenal function.

Rationale and Design of the Enoximone Clinical Trials Program

Background Chronic heart failure is a disease syndrome characterized in its advanced stages by a poor quality of life, frequent hospitalizations, and a high risk of mortality. In advanced and ultra-advanced chronic heart failure, many treatment options, such as cardiac transplantation and mechanical devices, are severely limited by availability and cost. Short-term Phase II clinical trials suggest that low-dose oral inotropic therapy with enoximone may improve hemodynamics and exercise capacity, without adversely affecting mortality, in selected subjects with advanced chronic heart failure. Based on these data, the ability of enoximone to deliver safe and efficacious palliative treatment of advanced/ultra-advanced chronic heart failure is being evaluated in Phase III clinical trials. Methods and Results The Enoximone Clinical Trials Program is a series of 4 clinical trials designed to evaluate the safety and efficacy of oral enoximone in advanced chronic heart failure. ESSENTIAL I and II (The Studies of Oral Enoximone Therapy in Advanced Heart Failure) will investigate the effects of oral enoximone on all-cause mortality and cardiovascular hospitalization, submaximal exercise capacity, and quality of life in subjects with New York Heart Association Class III/IV chronic heart failure. EMOTE (Oral Enoximone in Intravenous Inotrope-Dependent Subjects) will evaluate the potential of oral enoximone to wean subjects with ultra-advanced chronic heart failure from chronic intravenous inotropic therapy to which they have been shown to be dependent. EMPOWER (Enoximone Plus Extended-Release Metoprolol Succinate in Subjects with Advanced Chronic Heart Failure) will explore the potential of enoximone to increase the tolerability of continuous release metoprolol in subjects shown previously to be hemodynamically intolerant to β-blocker treatment. Conclusion These studies are Phase III, multicenter, randomized, double-blinded, placebo-controlled trials designed to test the general hypothesis that chronic oral administration of low doses of enoximone can produce beneficial effects in subjects with advanced or ultra-advanced chronic heart failure.

Down-regulation of vascular endothelial growth factor in renal cell carcinoma cells by glucocorticoids

Metastatic renal cell carcinomas (RCC) remain highly resistant to systemic therapy. RCCs are highly vascular tumors, which overproduce angiogenic peptides such as vascular endothelial growth factor (VEGF) even under normoxic conditions. A potential suggested role of antiangiogenic therapeutic strategies is the treatment of RCC by inhibiting VEGF production. The down-regulation of VEGF expression by glucocorticoids has recently been demonstrated in several cells. In this study, the direct effects of glucocorticoids on VEGF production by RCC cells were evaluated. Four RCC cell lines A498, RCC270, Caki1, and ACHN were treated with dexamethasone (DEX), hydrocortisone (HC), 5-α-dihydrotestosterone (DHT), or estradiol (E2). RU486 was used as a glucocorticoid receptor (GR) antagonist. Cell growth was studied with MTS assays. VEGF mRNA and protein were evaluated with quantitative real-time RT-PCR and ELISA, respectively, and GR expression was examined using RT-PCR and immunocytochemistry. All four RCC cell lines expressed GR. DEX at 100 nM down-regulated VEGF secretions by more than 50% in three lines (A498, RCC270, and Caki1) and had a weak inhibitory effect on ACHN cells. The effect of DEX on reducing VEGF mRNA levels in A498 cells was concentration-dependent and maximal at 100 nM (80% inhibition). HC had similar but weaker effects on VEGF production in the RCC cells, but E2 and DHT had no effect. RU486 reversed the effects of DEX. DEX at 1–1000 nM did not affect cell growth in any of the four RCC cell lines. This is the first study showing that glucocorticoids, at concentrations achievable in vivo by oral administration of low doses of DEX, have an inhibitory effect on VEGF mRNA expression and protein secretion of RCC cells possibly through the GR pathway. Furthermore, DEX might have a potential role in antiangiogenic therapeutic strategies by inhibiting VEGF production during metastatic RCC treatment.

Effect of a gamma-aminobutyric acid-enriched dairy product on the blood pressure of spontaneously hypertensive and normotensive Wistar-Kyoto rats.

We investigated the blood-pressure-lowering effects of gamma-aminobutyric acid (GABA) and a GABA-enriched fermented milk product (FMG) by low-dose oral administration to spontaneously hypertensive (SHR/Izm) and normotensive Wistar-Kyoto (WKY/Izm) rats. FMG was a non-fat fermented milk product produced by lactic acid bacteria, and the GABA contained in FMG was made from the protein of the milk during fermentation. A single oral dose of GABA or FMG (5 ml/kg; 0.5 mg GABA/kg) significantly (P<0.05) decreased the blood pressure of SHR/Izm from 4 to 8 h after administration, but did not increase that of WKY/Izm rats. The hypotensive activity of GABA was dose-dependent from 0.05 to 5.00 mg/kg in SHR/Izm. During the chronic administration of experimental diets to SHR/Izm, a significantly slower increase in blood pressure with respect to the control group was observed at 1 or 2 weeks after the start of feeding with the GABA or FMG diet respectively (P<0.05) and this difference was maintained throughout the period of feeding. The time profile of blood-pressure change due to administration of FMG was similar to that of GABA. FMG did not inhibit angiotensin 1-converting enzyme. Furthermore, an FMG peptide-containing fraction from reverse-phase chromatography lacked a hypotensive effect in SHR/Izm rats. The present results suggest that low-dose oral GABA has a hypotensive effect in SHR/Izm and that the hypotensive effect of FMG is due to GABA.

Effect of oral administration of low doses of pentobarbital on the induction of cytochrome P450 isoforms and cytochrome P450-mediated reactions in immature Beagles.

To determine the effect of oral administration of low doses of pentobarbital on cytochrome P450 (CYP) isoforms and CYP-mediated reactions in immature Beagles. 42 immature (12-week-old) Beagles. Dogs were grouped and treated orally as follows for 8 weeks: low-dose pentobarbital (50 microg/d; 4 males, 4 females), mid-dose pentobarbital (150 microg/d; 4 males, 4 females), high-dose pentobarbital (500 microg/d; 4 males, 4 females), positive-pentobarbital control (10 mg/kg/d; 2 males, 2 females), positive-phenobarbital control (10 mg/kg/d; 2 males, 2 females), and negative control (saline 10.9% NaCl] solution; 5 males, 5 females). Serum biochemical and hematologic values were monitored. On necropsy examination, organ weights were determined, and histologic evaluation of tissue sections of liver, kidney, small intestine, testes, epididymis, and ovaries was performed. Hepatic and intestinal drug-metabolizing enzyme activities were measured, and relative amounts of CYP isoforms were determined by western blot analysis. The amount of a hepatic CYP2A-related isoform in dogs from the high-dose pentobarbital treatment group was twice that of dogs from the negative control group. CYP2C was not detectable in small intestinal mucosa of dogs from the negative control group; measurable amounts of CYP2C were found in dogs from the various (low-, mid-, and high-dose) pentobarbital treatment groups and from positive-pentobarbital and positive phenobarbital control groups. Several CYP-mediated reactions increased in a dose-dependent manner. The lowest calculated effective dose of pentobarbital ranged from 200 to 450 microg/d. Several CYP isoforms and their associated reactions were induced in dogs by oral administration of low amounts of pentobarbital.

The management of coumarin-induced over-anticoagulation Annotation.

The management of coumarin-induced over-anticoagulation Annotation.

Acute Herpes zoster Neuralgia: Retrospective Analysis of Clinical Aspects and Therapeutic Responsiveness

Background: Although the efficacy of modern antiviral agents for the treatment of herpes zoster is unquestioned, their ability to affect the associated pain remains controversial. Objective: We have therefore evaluated the inpatient hospital records of 550 patients with herpes zoster with regard to pain-related clinical aspects and therapeutic responsiveness. Methods: Intensity of pain was quantified by calculating a daily pain equivalence index (PEI) on the basis of different classes of pain medication and the number of tablets used in each category. Results: The mean age of patients was 66.7 years, cranial segments were predominantly involved (55%), 64% of patients suffered from associated diseases and 77% experienced herpes-related pain. The PEI was 0.90 in the entire patient population, with significantly higher values in women and in patients with 3 or more associated diseases. It was lower in sacral and cranial nerve involvement, and it decreased rapidly in patients prior to discharge from hospital. Although there were significant differences in hospital stay between patients who received aciclovir and those who did not (mean 20.3 vs. 23.8 days), and for high- versus low-dose oral or intravenous administration, no significant differences were noted between the two groups for initial PEI values and during the course of observation, irrespective of the route of administration or the dose of aciclovir and the individual patient’s PEI value. The groups were otherwise closely similar with regard to basic demographic and clinical data. 23.3% predominantly aged female patients with more associated diseases than the total patient population had a persistently elevated PEI and stayed in hospital beyond 21 days (mean 35.1 days), representing patients who went on to postherpetic neuralgia. Conclusion: These data further delineate clinical aspects of acute herpes zoster neuralgia, underline the unsolved therapeutic problems associated with this condition despite otherwise effective antiviral treatment, and characterise a subgroup of patients at risk to develop postherpetic neuralgia.

DETERMINATION OF TRIFLUSAL IN HUMAN PLASMA BY HIGH PERFORMANCE LIQUID CHROMATOGRAPHY WITH AUTOMATED COLUMN SWITCHING SYSTEM

An analytical method of triflusal in human plasma was developed using semi-microbore HPLC equipped with automated column switching system. p-Toluic acid which is the structural analogue of triflusal, was used as an internal standard and 2 M HCl was employed as a stabilizer. The load phase and mobile phase were prepared using acetonitrile and 20 mM KH2PO4 with the volume ratios of 10:90 (pH 2.5) and 43:57 (pH 2.3), respectively. The signals were monitored by a UV detector at 275 nm with flow-rate of load phase, 500 μL/min, and mobile phase, 100 μL/min, respectively. The retention time of triflusal and p-toluic acid was about 20.2 min and 16.4 min, respectively. The detection limit of triflusal in human plasma was 0.01 μg/mL and the limit of quantitative analysis was 0.05 μg/mL. The accuracy of the assay was from 97.76% to 116.51% while the intra-day and inter-day coefficient of variation of the same concentration range was less than 15%. This analytical method demonstrated excellent sensitivity, reproducibility, specificity, and speed using the plasma sample. This method could be successfully applied to evaluate the bioavailability of triflusal in human subjects without time-consuming sample clean-up after oral administration of low dose.

Progressive development of a Th1-type hepatic cytokine profile in rats with experimental cholangitis.

Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are presumed autoimmune chronic cholestatic liver diseases characterized by cholangitis and progressive loss of bile ducts. Cytokines have been postulated to be involved in the progression of these diseases, but their role is poorly defined. Our objectives were to characterize a rat model of cholangitis and to determine Type 1/Type 2 (Th1/Th2) cytokine profile shifts in this model. Cholangitis was induced in Sprague-Dawley rats (200 to 225 g) by low-dose oral administration of the biliary toxin alpha-naphthylisothiocyanate (ANIT) (1 g/kg powdered rat chow ad libitum) for 4, 7, and 14 days. Cholestasis was observed in ANIT-treated animals. Liver histology of ANIT-treated rats showed hepatic inflammation centered on damaged bile ducts, significant bile duct proliferation, and progressive fibrosis. Immunohistochemistry showed enhanced staining of hepatic major histocompatibility complex (MHC) II, CD4, and CD8 in portal areas of ANIT-treated animals. In addition, the hepatic cytokine profile became increasingly Th1 in nature with progressive ANIT treatment. In summary, experimental cholangitis biochemically and histologically mimics human chronic cholangitis and furthermore, is associated with a progressive shift to a more Th1-dominant hepatic cytokine profile. Therefore, this model may be useful for examining the role of cytokines in the progression of chronic cholangitic diseases.

Altered Dopamine Turnover in Murine Hypothalamus after Low-dose Continuous Oral Administration of Aluminum

Aluminum, a known neurotoxic substance, has been suggested as a possible contributing factor in the pathogenesis of Alzheimer's disease. Ground-water pollution by aluminum has been recently reported. In the current study groups of 5 male BALB/c mice were administered aluminum ammonium sulfate in drinking water ad libitum at 0, 5, 25, and 125 mg/L aluminum for 4 weeks. At the termination of aluminum exposure, their brains were removed and dissected into cerebrum, cerebellum, medulla oblongata, midbrain, corpus striatum, and hypothalamus. The concentration of norepinephrine (NE), dopamine (DA), dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), serotonin (5-HT), and 5-hydroxyindoleacetic acid (5-HIAA), were determined in each brain area. DA, DOPAC, and HVA levels were lower in the hypothalamus of aluminum-treated mice, most notably in the low-dose group, as compared with control. No marked alterations in NE, 5-HT, and 5-HIAA levels were detected in any brain region. Changes in the concentration of DA and its metabolites measured in the hypothalamus suggest an inhibition of DA synthesis by aluminum.

Suppression of late asthmatic response by low-dose oral administration of interferon-beta in the guinea pig model of asthma.

We investigated the anti-asthmatic effects of low-dose oral and subcutaneous administration of interferon-beta (IFN-beta) on an ovalbumin (OVA)-sensitized and challenged guinea pig model of asthma. Subcutaneous administration of IFN-beta suppressed the eosinophil infiltration by 14.2% of the control and the respiratory resistance (Rrs) by 58.2% at 2.0 MIU/kg. Oral administration of IFN-beta inhibited the late asthmatic response (LAR) by suppressing the increase of Rrs by 29% of the control at 1 IU/ml and the eosinophil infiltration into the trachea and lung by 34.6% at the optimum dosage of 10 IU/ml. Both subcutaneous and oral administration could not inhibit the early asthmatic response (EAR). Additionally we found 2',5'-oligoadenylate synthetase (2',5'-OAS) induction by low-dose oral administration (LDOA) of IFN-beta to the same extent as by subcutaneous administration in whole blood in vivo. These data suggest that LDOA of IFN-beta would have some clinical benefit for patients with asthma.

Gas chromatographic–tandem mass spectrometric determination of acetylsalicylic acid in human plasma after oral administration of low-dose aspirin and guaimesal

A fully validated gas chromatographic–tandem mass spectrometric (GC–MS–MS) method is described for the accurate determination of acetylsalicylic acid (ASA) in human plasma after a single low-dose oral administration of aspirin or guaimesal, an ASA releasing prodrug. ASA and the newly prepared O-[ 2H 3]-acetylsalicylic acid (d3-ASA) used as internal standard were determined in 100-μl aliquots of plasma by extractive pentafluorobenzyl (PFB) esterification using PFB bromide and tetrabutylammoniumhydrogen sulphate as the esterifying and ion-pairing agent, respectively, and by GC–MS–MS analysis in the negative-ion chemical ionization mode. The overall relative standard deviations were below 8% for ASA levels in the range 0–1 μg/ml plasma. Mean accuracy was 3.8% for ASA levels within the range 0–100 ng/ml. The limit of quantitation of the method was determined as 200 pg/ml ASA at an accuracy of 5.5% and a precision of 15.2%. The limit of detection was determined as 546 amol of ASA at a signal-to-noise ratio of 10:1.

Long-term treatment with some methylxanthines decreases the susceptibility to bicuculline- and pentylenetetrazol-induced seizures in mice. Relationship to c-fos expression and receptor binding.

The effects of long-term oral administration of low doses of caffeine (0.3 g/l) and its metabolites theophylline, theobromine and paraxanthine (each at 0.5 g/l in drinking water) on bicuculline- and pentylenetetrazol (PTZ)-induced seizures and c-fos expression were studied in mice. In addition, adenosine and benzodiazepine receptor density was examined. The plasma levels of the methylxanthines were much higher during the active period at night than during the day. The maximal level of caffeine was 14 microM. Brain theophylline levels (8-13 nmol/g) tended to be higher and more constant than brain caffeine levels in caffeine-consuming mice. Clonic seizures induced by bicuculline (4 mg/kg i.p.) were significantly reduced in severity by 14 day caffeine treatment and mortality was also reduced. Long-term treatment with caffeine metabolites was less effective. The seizures induced by PTZ (60 mg/kg i.p.) were also significantly reduced by long-term caffeine treatment. After bicuculline or PTZ treatment, c-fos mRNA expression was weaker in the cerebral cortex in animals receiving caffeine, irrespective of whether the animals had seizures or not. No significant changes in the binding of adenosine receptor ligands or benzodiazepines were seen after long-term caffeine treatment. These results show that long-term treatment with caffeine in a dose that is commonly seen in humans decreases the seizures induced by bicuculline, and to a lesser extent, those induced by PTZ. This may be related to a decreased neuronal excitability. The effect is due to the combined effects of theophylline, to which caffeine is metabolized in brain, and caffeine itself, but could not be ascribed to changes in A1 and A2A adenosine or benzodiazepine receptors.

Phase II Trial of Piritrexim and DTIC Using an Alternating Dose Schedule in Metastatic Melanoma

A Phase II trial was conducted in patients with metastatic malignant melanoma with DTIC 250 mg/m2 intravenously for 5 days alternating monthly with Piritrexim (PTX) using an intermittent, low-dose oral administration schedule. PTX was administered at a starting dose of 25 mg orally three times per day for 5 days weekly for 3 weeks followed by 1 week of rest. Twenty-one patients were entered into the study. Among the 17 patients assessable for response, 1 patient had a minor response, and 3 patients had stable disease. No partial or complete response were observed. Toxicity was tolerable and consistent mainly of myelosuppression. Using this alternating dose schedule, PTX and DTIC produced little response in metastatic melanoma.

Sodium fluoride dissolution of human calcium oxalate/phosphate stone particles.

The dissolutive effects of sodium fluoride on human calcium stone particles were investigated in an in vitro model. Stone particles composed of 65% calcium oxalate and 35% calcium phosphate dissolved in a dose-dependent fashion with NaF exposure. Stone particles exposed to 60 mM NaF had a 17% reduction in particle mass after 24 hours and a 62% reduction after 7 days in comparison with experimental controls bathed in physiologic normal saline. The systemic toxicity of the dose of oral fluoride necessary to achieve the optimal tested urinary concentrations would likely preclude oral administration, but NaF may have an adjunctive role in upper urinary tract irrigation for residual stone fragments after lithotripsy or in chronic low-dose oral administration for prophylaxis against recurrent calcium nephrolithiasis.

Vitamin D supplementation in the elderly: review of safety and effectiveness of different regimes.

Vitamin D deficiency is common in the elderly, especially in countries where effective sunlight or exposure to sunlight is limited. Two regimes for vitamin D supplementation--low-dose daily oral administration and intermittent high-dose administration--were examined with regard to safety and effectiveness. Eleven papers reporting studies in 449 elderly subjects were reviewed. On low-dose continuous supplementation mean concentration of 25 hydroxyvitamin D (25(OH)D) ranged from 57 to 105 nmol/L compared to 55 to 87 nmol/L following high-dose supplementation. These mean values fall within the physiological range for young adults. Hypercalcemia occurred in only 3 subjects and was associated with a predisposing cause in 2 of 3 subjects. We suggest that low dose continuous supplementation (10 to 20 micrograms daily) is the regime of choice but high-dose intermittent supplementation (2.5 mg six monthly) may be suitable where compliance is poor.