To the editor: - The increasing interest in vitamin E (tocopherol) in California has led to tremendous public self-experimentation. Health food stores sell massive amounts of concentrated vitamin E.
Ayres and Mihan ("Leg Cramps [Systremma] and 'Restless Legs' Syndrome") observed a reference to vitamin E (Calif. Med. 111:87, 1969). In the practice of orthopedics, idiopathic leg cramp and other types of muscle cramps are common complaints. Because of this article, I casually began to prescribe the vitamin in the doses recommended - 300 international units (I.U.) a day - first to patients complaining of leg cramps and other types of idiopathic cramps, and then sometimes to patients with pain in the neck and lower part of the back. I have now prescribed the medication to almost 100 patients.
I would agree with Ayres and Mihan that the medication is almost universally effective on idiopathic nocturnal leg cramps. In my opinion, it is more effective and safer to use than quinine or quinine-aminophylline combinations. Certainly, the dosages we have been prescribing and the dosages taken by the health food advocates are in excess of anything conceived of being a minimum daily requirement for the vitamin. The amount is also far in excess of what could possibly be obtained through any reasonable normal diet.
The body may make some compensatory adjustments to these massive doses. In support of this idea has been the observation that some patients who take the medication irregularly or who stop the medication are bothered by leg cramps in excess of those first complained of for a few days. After several days, however, this problem seems to cease. As we all know, patients who suffer from leg cramps may either have them quite regularly or have them come and go. Therefore, some patients find that they want to keep taking the medication on a permanent basis. Others find that it helps them over a crisis.
Ayres and Mihan warn against using the medication in patients with hypertension or diabetes, about which I have no experience. Eventually, all patients seem to be able to tolerate the medication without difficulty. Patients who have tried to reduce the medication down to 100 I.U. per day have often found that this amount of the medication no longer is effective. Others who have settled at a dosage of about 200 I.U. may find, after several months, that they also must increase the dosage to obtain the benefits they wish. It has not been my experience that the medication needs to be taken in doses of excess of 300 I.U. There does seem to be a mild amount of tachyphylaxis exhibited by the medication.
This problem of defining all of the multiple interdependent variables may thwart efforts at double-blind studies. Most frustrating may be a real or imagined effect of the central nervous system.
Some of my own observations but point up factors which may have caused difficulties. I would second Ayres and Mihan's observations that massive doses of tocopherol are extremely effective in the control of idiopathic night leg cramps.
Robert F. Cathcart, III, M.D., San Mateo, California
This letter to the editor of JAMA may be of minor importance in the history of vitamin E. I believe it was the first favorable report on vitamin E in JAMA.
In retrospect, I believe that the mechanism of action is to reduce free radicals and increase circulation to the legs. There may be a mild anti-coagulant effect where there is a tendency toward hyper-coagulation. In severe cases, magnesium, calcium, potassium, vitamin C, and the elimination of food and chemical sensitivities may be necessary. Additionally, chelation therapy may be necessary and of benefit in the elderly or diabetic patients with poor circulation to their extremities.
We must never forget as vitamin E becomes accepted medical practice, especially in the prevention and treatment of heart disease, that the honor for most of the major discoveries about the clinical usefulness of large doses of vitamin E must be given to Wilfrid E. Shute, M.D.
Robert F. Cathcart, III, M.D.
127 Second Street, #4
Los Altos. CA 94022