Is Equate All Day Back & Muscle Pain Relief [naproxen Sodium 200 mg] gluten free?

[Bob Land]

I have some pain medications that I take, at times. Just checking before I start making phone calls. Thank you!

[trents]

Even if there is no gluten in it, it is well-known that regular NSAID use can blunt small bowel villi just like gluten does.

[Scott Adams]

You can search this site for prescriptions medications, but will need to know the manufacturer/maker if there is more than one, especially if you use a generic version of the medication:

To see the ingredients you will need to click on the correct version of the medication and maker in the results, then scroll down to "Ingredients and Appearance" and click it, and then look at "Inactive Ingredients," as any gluten ingredients would likely appear there, rather than in the Active Ingredients area.

• https://dailymed.nlm.nih.gov/dailymed/ 

 

[knitty kitty]

@Bob Land,

Welcome to the forum!

 I take Thiamine Vitamin B 1, Pyridoxine Vitamin B 6, and Cobalamine Vitamin B12 for back pain.  The combination really works.

Analgesic and analgesia-potentiating action of B vitamins

https://pubmed.ncbi.nlm.nih.gov/12799982/

 

I take 500 mg Thiamine, 50 mg Pyridoxine, and 1000 mcg B12.

Hope this helps!

[Nick Cheruka]

On 8/24/2023 at 3:53 PM, trents said:

Even if there is no gluten in it, it is well-known that regular NSAID use can blunt small bowel villi just like gluten does.

Where has it been shown that NSAID’s flatten Villi? I’m a Celiac of over 20yrs and this is a new one to me! I take a 81mg aspirin a day per my Cardiologist and Advil occasionally for a head ache or back pain! Can you produce your proof here Trents? It would be appreciated!

[Nick Cheruka]

20 minutes ago, Nick Cheruka said:

Where has it been shown that NSAID’s flatten Villi? I’m a Celiac of over 20yrs and this is a new one to me! I take a 81mg aspirin a day per my Cardiologist and Advil occasionally for a head ache or back pain! Can you produce your proof here Trents? It would be appreciated!

Never mind Trents, I researched it myself and you are correct not saying you weren’t I have Gastro Dr’s and Celiac Specialist that know of my use of Aspirin for my heart and never said a word about the NSAD use flattening villi and I also have had multiple Cardiologist that know I’m Celiac that recommended the aspirin for my heart! We as Celiacs can’t get ahead no matter how hard we try or how strict we are being gluten-free! I do appreciate the info as I will discuss this with both Dr’s! Thank you! I’m happy you and people like yourself are on here! I’ve learned so much more than I ever have!

[trents]

The danger of NSAIDs damaging villi, like many other medical risks, is more of an issue for some people than others. It may not be that common in the general population and modern medicine is all about metrics. If the risk is low, if something is uncommon and rare, docs don't think about it. However, it is especially relevant for those of us who have celiac disease and already struggling to protect villi against damage.

[knitty kitty]

@Nick Cheruka,

Have you researched your heart problem and thiamine?

[Nick Cheruka]

Hi Knitty Kitty, yes I have researched my heart condition Coronary Artery Disease but not Thiamin? I’m looking that up now! Why do you ask?

[knitty kitty]

@Nick Cheruka

Thiamine insufficiency has been linked to cardiovascular problems...

Association of vitamin B1 with cardiovascular diseases, all-cause and cardiovascular mortality in US adults

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10502219/

"In this large cohort study, it was observed that higher vitamin B1 intake was associated with a trend toward lower risk of hypertension, heart failure and cardiovascular mortality. In addition, vitamin B1 intake was found to be more protective and pronounced in elderly-aged men, overweight individuals, smokers, drinkers and patients with dyslipidemia. Although the observed correlations require further validation in other populations and intervention studies targeting CVD risk factors, this study highlights the role of vitamin B1 in mitigating cardiovascular diseases."

 

My dad had a Triple A.  He had surgery.  He survived.  It was caught in the nick of time.  I should add that he was an undiagnosed Celiac.  

Edited September 24, 2023 by knitty kitty
Typo correction

[Nick Cheruka]

1 hour ago, knitty kitty said:

@Nick Cheruka

Thiamine insufficiency has been linked to cardiovascular problems...

Association of vitamin B1 with cardiovascular diseases, all-cause and cardiovascular mortality in US adults

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10502219/

"In this large cohort study, it was observed that higher vitamin B1 intake was associated with a trend toward lower risk of hypertension, heart failure and cardiovascular mortality. In addition, vitamin B1 intake was found to be more protective and pronounced in elderly-aged men, overweight individuals, smokers, drinkers and patients with dyslipidemia. Although the observed correlations require further validation in other populations and intervention studies targeting CVD risk factors, this study highlights the role of vitamin B1 in mitigating cardiovascular diseases."

 

My dad had a Triple A.  He had surgery.  He survived.  It was caught in the nick of time.  I should add that he was an undiagnosed Celiac.  

Hi Knitty kitty, thank you like I mentioned I did the research on it immediately upon reading your comment and found the B1 issue related to CAD and read up on it! I will pull up my latest labs to see what my B1 levels are! I am however taking not only 1000mg of B12 daily but also a B-Complex and a Multi-Vitamin as well! I do appreciate you and everyone on here doing everything you can to help us in this Struggle called life to try to inform all of us on how to live a better healthier and happy life with Celiacs! May God Bless🙏and keep all of you on here close!🙂

[newtonfree]

Trents is actually correct that chronic NSAID use can damage villi, and it's not a "one in a million" chance or anything like that. We call it NSAID-induced enteropathy, and it has only recently come to our collective attention just how common and serious it may be. There have been some preliminary studies, like one that found signs of small bowel injury in 68% of healthy volunteers who took a 2-week course of diclofenac, and another small one that found small bowel damage in 81% of rheumatoid arthritis patients who took NSAIDs chronically vs 33% of RA patients who did not.

It has been chronically underdiagnosed because the symptoms are nonspecific and our ability to investigate it has historically been limited. Capsule endoscopy (where you swallow a pill-sized camera that takes pictures the whole way through you) has been instrumental in uncovering it.

We currently have very little understanding of the underlying mechanisms, and absolutely no way of treating it other than discontinuing NSAIDs.

But conversely, the impact on celiac patients has not yet been demonstrated to be significant. There was a study that looked at celiacs on longterm GFDs, and tried to find an explanation for why some had persistent villous blunting while others were completely healed. They looked at NSAID use, but only found a weak correlation, meaning that it certainly wasn't the main differentiator between the healers and non-healers. Because the damage caused by gluten in celiac disease is pathophysiologically distinct from NSAID-induced enteropathy, there's not yet any reason to believe that celiacs are especially susceptible to it given what limited data we have.

However, it's looking like NSAIDs are a lot worse for everyone's gut health than we previously believed, and we already knew they carried a high risk of causing both gastric and duodenal ulcers.

Because we don't fully understand the underlying mechanism and don't have anything we can do about it, all we've really done in medicine is add it to the list of possible side effects. As someone who both suffers from chronic pain and has treated it, it's been my experience that most people on both sides of the doctor-patient interaction are more concerned with relieving pain than dwelling on side effects. Usually people want pain relief and basically say, "if I develop side effects, we'll deal with it then."

And, frankly, that's not an unreasonable approach. If someone's arthritic knee pain is preventing them from getting exercise, leaving the house to visit family and friends, or sleeping, that's of much more immediate concern to most than the possibility of developing intestinal issues of uncertain severity.

That's not saying that I'm dismissing it. It's very worrisome to me, frankly, but if an NSAID made the difference between my being able to live my life or losing my mobility to pain, I'm not certain it would stop me from taking one. I'll be keeping an eye on data as we gather it, though. We're only in the very early days of understanding it.

As always, starting or discontinuing any medication should only ever be a discussion between someone and their doctor, and anything I'd said here is just meant for the purposes of general information and discussion.

[knitty kitty]

@newtonfree, 

But what about this article?

Factors associated with villus atrophy in symptomatic coeliac disease patients on a gluten-free diet

https://pubmed.ncbi.nlm.nih.gov/28220520/

"Villus atrophy was associated with use of proton-pump inhibitors (PPI'S), non-steroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs)"

"In this study, we identified several novel risk factors for persistent villus atrophy. In particular, use of NSAIDs, PPIs and SSRIs appears to be associated with impaired mucosal healing. We also found that the DGP IgG serology appears to be the most reliable marker for persistent villus atrophy."

Edited September 25, 2023 by knitty kitty
Add more information

[newtonfree]

1 hour ago, knitty kitty said:

@newtonfree, 

But what about this article?

Factors associated with villus atrophy in symptomatic coeliac disease patients on a gluten-free diet

https://pubmed.ncbi.nlm.nih.gov/28220520/

"Villus atrophy was associated with use of proton-pump inhibitors (PPI'S), non-steroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs)"

"In this study, we identified several novel risk factors for persistent villus atrophy. In particular, use of NSAIDs, PPIs and SSRIs appears to be associated with impaired mucosal healing. We also found that the DGP IgG serology appears to be the most reliable marker for persistent villus atrophy."

A few quick notes on why that study makes me think, "I'd like to learn more," but not, "this is worth hanging my hat on."

1) Multivariate analysis is tremendously opaque and therefore difficult to audit for errors and biases. It's good for pointing us in a direction that may be worth examining, but is several steps of abstraction away from the kind of gold standard study that changes clinical practice.

2) The 95% confidence interval of the NSAID subgroup comes perilously close to including 1 (which would mean no effect at all).

3) As the study is correlative, absolutely no causality can be inferred. The NSAIDs might not even be implicated. That study already showed that advanced age was the biggest risk factor outside of a positive DGP IgG. I can tell you right now that advanced age and NSAID use go hand in hand, because of osteoarthritis alone. The mild positive result for NSAID use might simply be because it's a loose correlate for advanced age.

Alternatively, we know that everyone who takes NSAIDs has either pain, inflammation, or both. NSAID use may therefore be a surrogate for an actual causative factor - for example, the presence of an active comorbid autoimmune or inflammatory disease. Perhaps the majority of NSAID users with persistent atrophy have active psoriasis, rheumatoid arthritis, lupus, multiple sclerosis, etc.

Even being in a state of chronic pain is well-established to be pro-inflammatory on the systemic level, as is any state of persistent stress. So even if they're taking NSAIDs for migraines or hip osteoarthritis, if they're in constant severe pain, they're in a pro-inflammatory state.

These are, after all, anti-inflammatory drugs. Having witnessed the gamut of patients who regularly take NSAIDs, I can confidently say that the majority have pro-inflammatory issues. And from physiological first principles, I wouldn't be the least surprised if being in a pro-inflammatory state from disease processes other than Celiac turned out to be a primary factor in the persistence of villous atrophy on a GFD. You yourself pointed me toward Dr. Ballantyne and the AIP. What's one of her first rules? Eat well, sleep well, relax, exercise, and reduce stress, because it's an anti-inflammatory lifestyle, not just an anti-inflammatory diet.

4) Lastly, but crucially, this study prefaces the entire analysis by pointing out that persistent villous atrophy correlated poorly with symptoms. In medicine, we must take great care to treat people rather than lab values. Its the same reason we don't recommend "checkups" for young healthy people anymore, or "total body scans" in the absence of symptoms. If you look hard enough, you'll find abnormalities in any healthy person. Why? It's simple. Ever wonder how we come up with "normal" lab values? It's typically defined as the range lying within two standard deviations of the mean in healthy people - which captures 95% of the data points. Conversely, that means that 5% of healthy people will, by definition, have an abnormal result on any given blood test!

Indulge me for a moment as I tell a story about how I came to understand the difference between treating people and treating statistics.

One of the most fun procedures you get to do in my specialty is the epidural. You have to examine someone's back, visualize the 3D structure of the spine, including the normal and abnormal twists and turns of the vertebrae, and then advance a needle in a straight line for several centimeters while using the tactile feedback of the resistance of the plunger of the connected syringe to tell you when you've hit the epidural space. It's challenging, it's hands-on, and it's very rewarding when you put it all together and succeed in finding a tiny window hidden deep within the body. It also happens to pay very well, as all interventional pain procedures do.

It's common practice to offer epidural steroid injections to patients with sciatica from spinal stenosis - the idea being that the steroids calm down the inflammation of the impinged nerve root, thus decreasing the degree of impingement and the degree of pain. There have been many studies concluding that it's helpful, both in reducing pain and in perhaps delaying how soon the patient needs spinal surgery (laminectomy) to decompress the nerve root definitively.

But one day, as an enterprising resident, I was reading the references in a new study on epidural steroid injections. And then I read the references in those studies. And I kept going deeper, noticing that everyone seemed to reference this one study in particular.

And then I found that study, done years ago. And what they had done was measure people's pain using a "visual analog scale", meaning a line starting at "0" and ending at "10," and getting the patient to mark an X at the point they felt represented their pain. The line was 10cm long (about 4"), so the 1cm mark was "1/10", halfway was "5/10," etc.

And this study used a huge number of patients, so they had high power as we say, and the improvement was statistically significant, meaning it was unlikely to be due to sheer chance.

But do you know what the actual clinical significance was? The post-epidural group had a lower average pain score by roughly 0.2 cm. So that's the difference between a "6.2/10 pain" and a "6/10 pain."

That was the day I resolved never to perform an epidural steroid injection. They're uncomfortable at best, painful at worst, and carry a non-zero risk of nerve damage, bleeding or infection severe enough to require emergency neurosurgery. And they help...by 0.2/10. Performing them would be fun and interesting for me, and I'd make better money. Most in my specialty jump at the chance. But my rule is to only do things I either truly believe will help, or at least truly believe won't harm. I can no longer include epidural steroid injections among the former.

So that's why we have to remember to treat people, and not statistics or lab values. Not only is the result of that NSAID subgroup analysis unconvincing for the reasons #1-3 I outlined above, it all follows the statement that the presence of symptoms and the presence of persistent villous atrophy were poorly correlated to begin with.

The last thing in the world I'd want is for someone to stop prescribing or taking a medication that allowed them to pick up their grandkids for a piggyback ride, or go for a walk with their wife, or exercise to keep their weight down and diabetes in check, because of a chance that it might cause an abnormal looking result on a test they didn't need because they felt fine.

And that's where the art and the science of medicine meet. Looking at the whole picture, weighing the risks, and helping people find the best solutions that keep them active, happy and healthy, because sitting at home dwelling on their pain might be a whole lot worse for their health, Celiac disease included, than taking an imperfect drug that allows them to maintain a happier and healthier lifestyle.

Sorry that this post was so long. It's extremely difficult for me to be brief on a subject such as this.

[knitty kitty]

@newtonfree,

When I read this article, I understood that the scientists sifted through Celiacs that had been on a gluten free diet, separating the ones that had healed intestines from the ones that didn't. 

The scientists then looked at what the Celiacs that hadn't healed had in common.  The use of Nsaids, PPIs, and SSRIs was what the unhealed Celiacs had in common.  

I find this important even if the scientists don't know the mechanics.  

I still prefer to take Thiamine B 1, Cobalamine B12, and Pyridoxine B 6.   These vitamins together alleviate my pain quickly and much more safely.  

 

[newtonfree]

51 minutes ago, knitty kitty said:

@newtonfree,

When I read this article, I understood that the scientists sifted through Celiacs that had been on a gluten free diet, separating the ones that had healed intestines from the ones that didn't. 

The scientists then looked at what the Celiacs that hadn't healed had in common.  The use of Nsaids, PPIs, and SSRIs was what the unhealed Celiacs had in common.  

I find this important even if the scientists don't know the mechanics.  

I still prefer to take Thiamine B 1, Cobalamine B12, and Pyridoxine B 6.   These vitamins together alleviate my pain quickly and much more safely.  

 

No, that is not at all the conclusion supported by the data. This is why I laid out my analysis above.

The odds ratio for PPI, NSAID and SSRI use were each on the order of 1.5-1.7, meaning those groups were about 50%-70% more likely to have unhealed villi (though saying even that much is a stretch, since the 95% confidence interval dipped as low as 1.2).

Compare those magnitudes to the odds ratio for being age 40-49 (vs under 30 years old) at 1.85, age 50-59 at 2.51, 60-69 at 2.4, and 70-79 at 5.08.

That means that being 50 or 60 years old conferred more than twice as great an increased risk of having unhealed villi as being on an NSAID. Being 70 conferred 10x as much increased risk as any of those drugs. Like I said above, with the rate of NSAID prescription correlating somewhat with age, and tightly correlating with the presence of a pro-inflammatory state, there's nothing in that particular study that makes me worried about NSAIDs in celiacs. Simply celebrating your 40th birthday (or beyond) was a greater risk factor as per the data.

But like I said earlier, I'm somewhat worried about NSAID-induced enteropathy in anybody, given how prevalent it's beginning to look and how little we understand about it, but there isn't much to do there but wait for clearer data to emerge.

[knitty kitty]

But there is evidence that Nsaids by themselves cause intestinal damage.  

"NSAID use has been shown to cause duodenal histopathology nearly identical to what is found in early celiac disease."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587842/

Many of our members are not diagnosed with Celiac Disease until later ages.  Many may have been self medicating with OTC Nsaids.  

Isn't Nsaids use on top of CeD like putting out a fire with gasoline?

 

[trents]

Would villi blunting from NSAID use throw positive antibody tests as would celiac disease? We have reports sometimes of people who have positive biopsies but were negative for antibody testing.

[newtonfree]

8 hours ago, knitty kitty said:

But there is evidence that Nsaids by themselves cause intestinal damage.  

"NSAID use has been shown to cause duodenal histopathology nearly identical to what is found in early celiac disease."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587842/

Many of our members are not diagnosed with Celiac Disease until later ages.  Many may have been self medicating with OTC Nsaids.  

Isn't Nsaids use on top of CeD like putting out a fire with gasoline?

 

Correct, NSAIDs independently can cause NSAID-induced enteropathy like I mentioned above. But it's early days in terms of understanding it. And we will preferably use clinical data when we can get it, rather than making assumptions based on first principles. In the case of the first study we talked about, it was very interesting to me that NSAID use was such an apparent non-factor in the healing of villous blunting among celiacs. But just like I said about it before, I wouldn't hang my hat on a multivariate analysis when making clinical decisions.

All we can do is make decisions based on the best data we have, and despite their risks, NSAIDs can still very much be an appropriate medication for someone whether they have celiac or not, which is why I will always reiterate that these decisions have to be made on an individual basis together with one's doctor(s). There is rarely any "one size fits all" answer in medicine.

Even therapeutic doses of B vitamins, which I know you are fond of, are not devoid of risk. B1 (thiamin) hypervitaminosis can cause paralysis, convulsions, respiratory and cardiac failure. B3 (niacin) hypervitaminosis can cause liver failure, hypotension, peptic ulcers, rashes, asthma attacks, gout, and hyperglycemia.

Does it typically take very high and prolonged dosage of those vitamins to cause those issues? Yes. Is it impossible to cause the symptoms listed above? No.

Which is why we have a saying in medicine that the only difference between a medication and a poison is the dosage, and why I will never dispense "dos" and "don'ts" to people I don't know on the internet. Medicine is all about the grey areas. There's rarely a black and white. So it's important to keep the emerging evidence on NSAID-induced enteropathy in mind, but it does not mean that NSAIDs are contraindicated in all celiacs.

6 hours ago, trents said:

Would villi blunting from NSAID use throw positive antibody tests as would celiac disease? We have reports sometimes of people who have positive biopsies but were negative for antibody testing.

No, there's no evidence that NSAID-induced enteropathy is antibody-mediated, and even if it was, the antibodies we use test for celiac disease are very specific in nature.

The phenomenon of biopsy-positive but antibody-negative celiac disease appears to be an unrelated issue, likely related to the nature of the sensitivity and specificity of the antibody tests themselves (no current antibody assay is 100% sensitive and specific, which is the only situation where you'd get neither false-positives nor false-negatives).

Whether NSAID-induced enteropathy could ever be mistaken for celiac disease on biopsy is a separate question better posed to a pathologist. From my current understanding, there are a significant number of ways in which they can be differentiated.

[knitty kitty]

Nsaids cause villi blunting and damage to the intestine, but it does not affect the antibodies from what I can find.  However....

PPI's can cause serionegative results for Celiac Disease.  PPI's can cause false negatives.  People who take PPI's are more prone to develop Celiac Disease later.

References...

The Impact of Acid Suppression Medications and Non-steroidal Anti-Inflammatory Drugs on Clinical and Histologic Features in Celiac Disease

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5511753/

And...

https://celiac.org/about-the-foundation/featured-news/2017/05/medication-use-associated-persistent-villous-atrophy/

And...

Clinical and Histologic Mimickers of Celiac Disease

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587842/

 

[knitty kitty]

18 minutes ago, newtonfree said:

 

Even therapeutic doses of B vitamins, which I know you are fond of, are not devoid of risk. B1 (thiamin) hypervitaminosis can cause paralysis, convulsions, respiratory and cardiac failure. B3 (niacin) hypervitaminosis can cause liver failure, hypotension, peptic ulcers, rashes, asthma attacks, gout, and hyperglycemia.

 

Please provide references for these statements.

 

https://ods.od.nih.gov/factsheets/Thiamin-HealthProfessional/#h19

https://ods.od.nih.gov/factsheets/Niacin-HealthProfessional/

[newtonfree]

1 hour ago, knitty kitty said:

Please provide references for these statements.

 

https://ods.od.nih.gov/factsheets/Thiamin-HealthProfessional/#h19

https://ods.od.nih.gov/factsheets/Niacin-HealthProfessional/

The most serious adverse effects of thiamine are usually seen with parenteral (IV) forms that we commonly administer to patients such as alcoholics. There's debate as to whether it was a direct effect or a result of older vehicles or contaminants (we used to use premixed solutions of the various things we needed to give alcoholics, called "banana bags" after their yellow colour), but that's beyond the scope of this discussion. We've seen it less with newer preparations, but it's not disappeared entirely. Pulmonary edema causing respiratory failure is generally limited to patients being treated for severe deficiency (beriberi). Paralysis and resulting respiratory failure have been observed in hospitalized patients and is hypothesized to at least partly be related to potentiation and thus "reactivation" of neuromuscular blockers used for a prior intubation in the ER or ICU (what we call "residual block" in Anesthesia and ICU).  Reference.

Oral thiamine is much more rarely associated with major complications but there are still plenty of case reports of patients with major adverse reactions to a therapeutic oral dose. This one, for example.

Niacin-induced hepatitis is a known clinical entity, and its hepatotoxicity in sustained excess levels is well-documented. It causes what we refer to as a hepatocellular pattern of liver failure, which comes with a host of consequences, some of which I listed above. Reference.

High levels of niacin are also well-documented triggers for peptic ulcer disease, certain thyroid conditions, and can aggravate allergic processes including rashes and asthma. It can both raise blood sugar in diabetics, and appears to be a risk factor for the development of type II diabetes as well. It raises blood uric acid levels which can precipitate gout. Reference. That reference is obviously not granular (it's a Mayo Clinic site meant for patients), but those effects are common enough to be mentioned in textbooks, so you don't see a lot of cutting edge research being directed at it.

Please note that I did not at any point tell you not to take B vitamins in the doses you mentioned, nor would I warn any celiac not to take B vitamins in general. We, as a group, are far more likely to struggle with B vitamin deficiency than with overdose and toxicity. And, as I've mentioned before, I will never tell someone what to do without knowing their full medical history and having access to them for a physical exam (i.e. being my own patient). So please don't take my statements as an insinuation of danger regarding your personal regimen.

I was merely trying to illustrate my point that the difference between medicine and poison lies in the dosage. To read the list of adverse effects of therapeutic doses of B vitamins and conclude that nobody should ever take them would be as misguided as reading the list of adverse effects of NSAIDs and concluding that nobody should ever take them.

This all comes back to my point that medicine and health are by nature individualized, and decisions to start or discontinue any medication, including NSAIDs, should be made by the individual and their doctor(s). I can tell you that I have personally seen patients for whom NSAIDs were life-changingly beneficial, and ones for whom they were ineffective, counterproductive, or harmful. I have no great love for them, as I'm very wary of their side effects, but the risk:benefit ratio truly does vary on an individual basis.

A fun and mildly relevant fact is that NSAIDs can actually be quite effective in treating the flushing associated with niacin administration.

[knitty kitty]

@newtonfree,

No offense taken.  I want our readers to know oral Thiamine is rarely associated with major complications.  

It's interesting to note that while Niacin may raise blood sugar levels and may figure in developing diabetes, Thiamine is known to improve fasting blood sugar levels and may prevent diabetes.  Most diabetics are deficient in Thiamine.  

https://pubmed.ncbi.nlm.nih.gov/23715873/

And...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282352/

While Niacin raises blood uric acid levels which can precipitate gout, Thiamine lowers uric acid levels.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8436171/

And Thiamine helps improve certain thyroid conditions.

https://thyroidpharmacist.com/articles/thiamine-and-thyroid-fatigue/

And Thiamine can help asthma.

https://www.hormonesmatter.com/asthma-a1at-deficiency-thiamine/

 

Niacin in the form Niacinamide doesn't cause flushing and also improves Dermatitis Herpetiformis.  The niacin flush doesn't occur the longer you take it.

The eight B vitamins work together.   Thiamine and Niacin work together like a seesaw.

Thanks for the clarification.