Successful treatment of patients with folate deficiency involves:
1. Correction of the folate deficiency
2. Treatment of the underlying causative disorder
3. Improvement of the diet to increase folate intake
4. Follow-up evaluations at intervals to monitor the patient's clinical status.
Optimal response occurs in most patients with 100-200 |g folic acid per day. Because the usual commercially available preparations include a tablet (0.3-1.0 mg) and an elixir (1.0 mg/mL), these available preparations are utilized. Before folic acid is given, it is necessary to exclude vitamin B12 deficiency.
The clinical and hematologic response to folic acid is prompt. Within 1-2 days, the appetite improves and a sense of well-being returns. There is a fall in serum iron (often to low levels) in 24-48 hours and a rise in reticulocytes in 2-4 days, reaching a peak at 4-7 days, followed by a return of hemoglobin levels to normal in 2-6 weeks. The leukocytes and platelets increase with reticulocytes and the megaloblastic changes in the marrow diminish within 24-48 hours, but large myelocytes, metamyelocytes, and band forms may be present for several days.
Folic acid is usually administered for several months until a new population of red cells has been formed. Folinic acid is reserved for treating the toxic effects of dihy-drofolate reductase inhibitors (e.g., methotrexate, pyrimethamine).
It is often possible to correct the cause of the deficiency and thus prevent its recurrence, for example, improved diet, a gluten-free diet in celiac disease, or treatment of an inflammatory disease such as tuberculosis or Crohn's disease. In these cases, there is no need to continue folic acid for life. In other situations, it is advisable to continue the folic acid to prevent recurrence of, for example, chronic hemolytic anemia such as thalassemia or in patients with malabsorption who do not respond to a gluten-free diet.
Cases of hereditary dihydrofolate reductase deficiency respond to N-5-formyl tetrahydrofolic acid and not to folic acid.
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