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Prescriber's Guide - Naltrexone/Cyanocobalamin 1/0.07% Topical Cream
Prescriber's Guide

Naltrexone

Cyanocobalamin
Topical Cream

Cyanocobalamin Topical Cream
WHAT IS THIS MEDICATION?

Naltrexone and cyanocobalamin have been clinically studied in the treatment of patients with Psoriasis.

HOW ARE THE INGREDIENTS COMPOUNDED?

Naltrexone and cyanocobalamin may be compounded individually or combined. The combination is commonly compounded in a hydrating cream base in the following strength, Cyanocobalamin /Naltrexone 0.07/1/%.

Naltrexone is also commonly compounded as a capsule in strengths ranging from 0.1-4.5mg with microcrystalline cellulose as the only filler.

WHAT IS HAPPENING IN THE PSORIATIC SKIN?

1 in 5 sufferers don’t respond well to traditional therapies. Research shows that when one cytokine or inflammatory pathway is blocked, the immune system finds a work around that upregulates other inflammatory cytokines and pathways.

Psoriasis is a chronic T-cell mediated disorder. Psoriatic patients express large amounts of CD4+ Th1, CD8+ cytotoxic T type 1 cells as well as elevated levels of the cytokines IFN-γ, tumor-necrosis factor (TNF)-α and IL-12 and has been distinguished to be a Th1 cell mediated disease.

One of the other major triggering processes for psoriasis is the release of IL-23 from antigen-presenting dendritic cells. IL-23 promotes Treg cells to differentiate into T17 cells. T17 cells promote the inflammatory cytokine cascade which includes IL-17A, IL-17F, IL-22, IL-21 and TNF-α, which are found at increased levels in psoriatic skin and circulation.

The activated T cells and resulting cytokines result in keratinocyte hyper-proliferation and abnormal differentiation. These cytokines result in chemotaxis of neutrophils and lymphocytes in skin.

The proinflammatory cytokines involved in psoriasis also stimulate the expression of inducible nitric oxide synthase (iNOS) in keratinocytes and other cell types.

High levels of iNOS have been detected in psoriatic lesions and in skin affected by atopic dermatitis and are shown to be associated with a greatly increased release of nitric oxide (NO). NO has been found to be implicated in the pathogenesis of psoriasis (and atopic dermatitis). Application of a NO synthase inhibitor leads to a clear decrease in pruritus and erythema in atopic dermatitis.

HOW DO THE INGREDIENTS WORK IN THE HUMAN BODY?

Naltrexone
Naltrexone is involved in transient opioid receptor blockade ensuing from low-dose use and produces an opioid rebound effect. Naltrexone’s chemical structure is almost identical to the endogenous endorphins, Met- Enkephalin, also known as Opioid Growth Factor (OGF). L-Naltrexone is an antagonist at the OGF Receptor found on a wide range of places including the CNS, PNS, GI Tract, and lymphocytes. By blocking the OGF receptors, L-Naltrexone interferes with the endorphin feedback loop. Blockade lasts roughly 4 hours, and subsequently results in an increase of endogenous opioids (endorphins and enkephalins) as well as receptor density in subsequent 24h period - which is favorable to the immune system since endorphins regulate cell growth including immune cells and increases in OGF receptors is associated with tissue repair and healing.

The subsequent immunomodulatory effects occur by affecting B cell production and shifting T cell production from TH1 to TH2. The significance of this shift is apparent since psoriasis has been deemed a Th1 and cytokine mediated disease.

While there is no specific research on LDN and IL23, it is known to respond to opioids through OGF, which is upregulated with LDN. This may be a potential mechanism through which LDN may decrease the triggering process for psoriasis.

Vitamin B12
Cobinamide, a cobalamin (vitamin B12) precursor binds to NO (Nitric Oxide) with high affinity and has been shown to be a potent NO-scavenger in biologic systems.

Systemic and topical administration of vitamin B12 has been reported to decrease the immunological factors responsible for skin inflammation and cell proliferation, producing a significant improvement of symptoms and positive impact on psoriatic patients. Since Vitamin B12 is cleared through renal excretion (nearly 90%) after parenteral administration, it requires high blood concentrations to reach peripheral targets which can be associated with toxicity. To avoid the possible concentration-related adverse events, transdermal application was recently considered the most appropriate way of administration.

WHICH CONDITIONS HAVE THESE INGREDIENTS BEEN STUDIED FOR?

Vitamin B12 has been studied in patients with:

  • Mild to Moderate Plaque Psoriasis1
  • Manifest & Treatment Resistant (Moderate to Severe) Psoriasis 2
  • Chronic Plaque Psoriasis7

Naltrexone has been studied in patients with:

  • Pruritis3
  • Psoriasis Vulgaris4
  • Erythrodermic Psoriasis5
WHAT ARE THE RESULTS OF THE CLINICAL STUDIES?

NALTREXONE
Naltrexone has been observed to help with itching in different dermatologic diseases (eczema, psoriasis, and atopic dermatitis).

Pruritis
In one small placebo-controlled pruritus study, more than 70% of the patients using the naltrexone 1% cream experienced a significant reduction of pruritus. This study showed a significant advantage of topically applied naltrexone over the placebo formulation and the findings were supported by the biopsy data from the open studies.3

Psoriasis Vulgaris, Erythrodermic Psoriasis
Published case studies of low doses of naltrexone (4.5mg nightly) have shown substantial relief from psoriasis vulgaris4 and erythrodermic psoriasis5.

VITAMIN B12
Mild to Moderate Plaque Psoriasis
24 patients with mild to moderate plaque psoriasis were enrolled in a 12-week randomized, controlled, single-blind study, followed by a 4-week observational washout period.

Patients were administered either Vitamin B12 ointment containing 0.07% cyanocobalamin with 20% avocado oil (M-treatment) and a glycerol-petrolatum emollient cream (C-treatment) twice daily to the affected skin areas on contralateral sides of their bodies.

After 14 days, there was a statistically highly significant decrease in PASI scores in all M-treated body sides, whereas only small decrease in C-treated sides. The M-treated PASI scores remained lower than the C-treated body scores throughout the study, as well as the washout period.1

Manifest & Treatment Resistant Psoriasis
A total of 12 patients (8 males and 4 females, 21–86 years old) with manifest and treatment-resistant psoriasis (moderate to severe) were included and treated for 12 weeks.

All patients were assigned to twice-daily treatment with a newly developed topical combination containing plant-based extracts traditionally used in skin disease as black cumin, olive oil, tea tree oil, cocoa butter completed by vitamin A and vitamin B12.

Treatment success was determined by the Psoriasis Area and Severity Index (PASI) score, the body surface area, and the dermatology life index. PASI reduction of >75% in 10 of the 12 treated patients (83%). The remaining two patients showed a PASI reduction of ≤50%. In 5 of the patients PASI reduction was achieved <12 weeks (between week 3–11). 2

Chronic Plaque Psoriasis
In this randomized, prospective clinical trial, the effects of the vitamin D3 analog calcipotriol were evaluated in a trial population of 13 patients (10 men, 3 women) with chronic plaque psoriasis against those of a recently developed vitamin B12 cream containing avocado oil in an intraindividual right/left-side comparison for an observation period of 12 weeks.

There was a more rapid development of beneficial effects with the use of calcipotriol in the initial 8 weeks, although differences in effects were significant only at the time point of therapy week 8 (p < 0.05). After 12 weeks, neither the PASI score nor 20-MHz sonography showed significant differences between the two treatments. While the efficacy of the calcipotriol preparation reached a maximum in the first 4 weeks and then began to subside, the effects of the vitamin B12 cream containing avocado oil remained at a constant level over the whole observation period.7

HOW CAN THE INGREDIENTS BE USED?

Topical Application

  • Topical cyanocobalamin has been clinically studied at a dosing strength of 0.07%.1,2,7
  • Topical naltrexone has been clinically studied at a dosing strength of 1%.3
  • Naltrexone and cyanocobalamin may be used in combination or separately and is mostly used as a once daily application to affected areas.

Naltrexone (Oral)

  • Naltrexone is most commonly prescribed at doses ranging from 0.5-4.5mg to be taken daily by mouth at bedtime.3,4
  • Each patient will react to LDN at their own individual dosage.
  • Pediatric doses are most commonly prescribed at 0.1mg/kg/day.
  • Patients should be encouraged to assess the efficacy of LDN for at least 6 months before dismissing it as a clinical utility.
  • If clinical efficacy has not been achieved at the typical studied dosage of 4.5mg, some physicians have found benefits for their patients from doses up to 6-12mg.
  • If clinical efficacy has been achieved, and patients subsequently complain of a resurgence in symptoms, consider implementing drug holidays, or a complete stoppage of therapy for 2 weeks followed by a re-initiation and reassessment of an efficacious dosage.
  • Some patients may benefit from dosing LDN in the morning for several weeks if they experience insomnia and vivid dreams.
  • Many physicians report no safety concerns when dosed with short acting opioids (i.e morphine). In this population, patients should separate short acting opioid consumption to 4-6 hours before an LDN dose, or 3-4 hours after an LDN dose.
WHAT SIDE EFFECTS CAN BE CAUSED BY THE INGREDIENTS?

The most commonly reported adverse effects of naltrexone taken orally include insomnia, vivid dreams, diarrhea, and headaches.

Common adverse effects of parenteral administration of cyanocobalamin include asthenia, headache, paresthesia, congestive heart failure, pulmonary edema, thrombosis, anaphylaxis, and optic atrophy.

WILL THE INGREDIENTS INTERACT WITH OTHER DRUGS, AND IF SO HOW?

Naltrexone
Naltrexone antagonizes the effects of opioid-containing medicines, such as cough and cold remedies, antidiarrheal preparations and opioid analgesics. Therefore, patients taking naltrexone may not benefit from opioid-containing medicines.

No clinical drug interaction studies have been performed with naltrexone to evaluate drug interactions; therefore, prescribers should weigh the risks and benefits of concomitant drug use.

Naltrexone is not a substrate for CYP P450 drug metabolizing enzymes. Therefore, inducers or inhibitors of these enzymes are unlikely to change the clearance of naltrexone.

Vitamin B12
Chloramphenicol (moderate), colchicine/omeprazole/ ascorbic acid/aminosalicyclic acid (minor)

HOW DO THE INGREDIENTS MOVE THROUGH THE HUMAN BODY?

Absorption. Naltrexone is almost completely absorbed (96%), but its oral bioavailability ranges between 5% and 40% due to first-pass metabolism.

Distribution. In vitro data demonstrate that naltrexone plasma protein binding is low (21%).

Metabolism. Naltrexone’s half-life is 4 hours and it is extensively metabolized (>98%) in humans—the major metabolite being 6-β-naltrexol with a half-life of 13 hours and antagonist action on opioid receptors.

The cytochrome P450 system is not involved in naltrexone metabolism. Two other minor metabolites are 2-hydroxy-3-methoxy-6β-naltrexol and 2-hydroxy-3-methoxy-naltrexone. Naltrexone and its metabolites are also conjugated to form glucuronide products.

Significantly less 6β-naltrexol is generated following subcutaneous administration of naltrexone compared to administration of oral naltrexone due to a reduction in first-pass hepatic metabolism.

Elimination. Glomerular filtration is the predominant mode of renal elimination for a small fraction of unmetabolized naltrexone, while 6-β-naltrexol is additionally secreted.

ARE THE INGREDIENTS SAFE DURING BREASTFEEDING AND CAN I USE IT FOR KIDS?

Pregnancy
Safety and effectiveness have not been clinically studied in this population. Therefore, this compound should not be used in pregnant women.

Lactation
It is not known whether it is safe for breastfeeding mothers. Therefore, this compound should not be used in lactating women who are breastfeeding.

Children
Studies with children 8-17 years old were given low dose naltrexone at 0.1mg/kg for 8 weeks to treat Crohn’s disease. Oral LDN was well tolerated without serious adverse events in this patient population.

WHAT PRECAUTIONS SHOULD BE KEPT IN MIND WHEN PRESCRIBING THIS MEDICATION?

Interference with Laboratory Tests
Naltrexone may be cross-reactive with certain immunoassay methods for the detection of drugs of abuse (specifically opioids) in urine.

Unintended Opiate Withdrawal
To prevent occurrence of an acute abstinence syndrome (withdrawal) in patients dependent on opioids, or exacerbation of a pre-existing subclinical abstinence syndrome, opioid-dependent patients, including those being treated for alcohol dependence, patients should be opioid-free from longer acting opioids for a minimum of 7–10 days before starting naltrexone treatment. Since the absence of an opioid drug in the urine is often not sufficient proof that a patient is opioid-free, a naloxone challenge test may be employed if the prescribing physician feels there is a risk of precipitating a withdrawal reaction following administration of naltrexone. Patients treated for alcohol dependence with naltrexone should be assessed for underlying opioid dependence and for any recent use of opioids prior to initiation of treatment with naltrexone. Precipitated opioid withdrawal has been observed in alcohol-dependent patients in circumstances where the prescriber had been unaware of the additional use of opioids or dependence on opioids.

Surgery
When Reversal of Naltrexone is Required for SurgerY, patients taking naltrexone should be encouraged to stop their medication by at least 24 hours before a scheduled or elective surgery.

WHEN SHOULD THE INGREDIENTS NOT BE PRESCRIBED?
  • Patients receiving opioid analgesics
  • Patients with current physiologic opioid dependence
  • Patients in acute opiate withdrawal
  • Any individual suspected of opioid abuse, and who has failed the naloxone challenge test or has a positive urine screen for opioids.
  • Hypersensitivity to cobalt, vitamin B12, or any component of the product.
HOW IS THIS MEDICATION STORED?
  • Keep out of reach from children.
  • Store in a cool and dry place. Avoid exposure to direct sunlight.
REFERENCES
  1. Del Duca E, Farnetani F, De Carvalho N, Bottoni U, Pellacani G, Nisticò SP. Superiority of a vitamin B12-containing emollient compared to a standard emollient in the maintenance treatment of mild-to-moderate plaque psoriasis. Int J Immunopathol Pharmacol. 2017; 30(4):439‐444.
  2. Michalsen A, Eddin O, Salama A. A case series of the effects of a novel composition of a traditional natural preparation for the treatment of psoriasis. J Traditional and Complementary Medicine. 2016 Oct; 6(4) 395-398.
  3. Bigliardi Pl, Stammer H, Jost G, Rufli T, Buchner S, et al. Treatment of pruritus with topically applied opiate receptor antagonist. J Am Aca Dermatol. 2007; 56: 979-988.
  4. Bridgman AC, Kirchhof MG. Treatment of psoriasis vulgaris using low-dose naltrexone. JAAD Case Rep. 2018;4(8):827‐829. Published 2018 Sep 18.
  5. Beltran Monasterio EP. Low-dose Naltrexone: An Alternative Treatment for Erythrodermic Psoriasis. Cureus. 2019;11(1):e3943. Published 2019 Jan 23. doi:10.7759/cureus.3943
  6. Ip K, Song G, Banov D, Bassani AS, Valdez BC. In vitro evaluation of Naltrexone HCl 1% Topical Cream in XemaTop™ for psoriasis. Arch Dermatol Res. 2020;312(2):145‐154
  7. Stücker M, Memmel U, Hoffmann M, Hartung J, Altmeyer P. Vitamin B(12) cream containing avocado oil in the therapy of plaque psoriasis. Dermatology. 2001;203(2):141-7. doi: 10.1159/000051729. PMID: 11586013.
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