B12 question

[GetMeOuttaThisMess]

First of all, for those who have not been in a chronic, primary care position in their lifetime or at least in quite a while, as a courtesy reminder, B12 is a vitamin and it has multiple brothers and sisters.  I have a pt. seen for the first time this week who has a hx. of anemia ("think it was iron deficiency", though iron factors were normal) who also coincidentally is on B12 injections through a private PCP for who knows why.  No gastric surgeries to imply a deficiency in intrinsic factor (can't believe I remembered that) or any other conditions that I can point to which would affect absorption.  Her actual B12 value was within about 100 of the lower end of normal (range varies by 100's).

 

My question is would an attempt at oral supplementation be a viable option in lieu of monthly injections, especially since it isn't known why she would be deficient to begin with?  The oral forms address other known conditions, or so says Epocrates as I recall, but nothing specific to just maintenance dosing for deficiency that I can find.  Ah, the days of UC/EM where you didn't even care about the B family....

[Guest Paula]

Metformin can cause a B12 deficiency.  Is your patient on it? 

[GetMeOuttaThisMess]

Nope.  She is surprisingly one of the few relatively healthy vets I've run across, but part of that may be because she's young.  The primary question I have is can I reasonably switch her to p.o. versus IM, and if so, at what dose?  A lot of our folks seem to be on it but not for a primary B12 deficiency (which begs the question why then be on it?).  If it's a primary GI malabsorption issue then of course the answer would be no.  Since she's transferring in from the outside I don't have the necessary information (assuming that there is a legitimate reason).

[OpSite]

If I'm not mistaken, gastric bypass pts are given 1000mg sublingual and this works well for most (I assume your patient isn't post-RNY but similar principal with absorption issues). Sorry, no resources to list, just from memory. Anyone else?

[GetMeOuttaThisMess]

Awe heck, why ask questions if you have access to Dr. Google:  "Contrary to prevailing medical practice, studies show that supplementation with oral vitamin B₁₂ is a safe and effective treatment for the B₁₂ deficiency state. Even when intrinsic factor is not present to aid in the absorption of vitamin B₁₂ (pernicious anemia) or in other diseases that affect the usual absorption sites in the terminal ileum, oral therapy remains effective."  "Vitamin B₁₂ deficiency also has been linked to psychiatric disorders, including impaired memory, irritability, depression, dementia and, rarely, psychosis" (sounds like a lot of VA clientele and I'm now wondering if this is why so many are on it, unfortunately).  I frankly don't know that I knew about the potential for psychiatric issues from a deficient state.  "In addition to this method of absorption (stated in article at AAFP website), evidence supports the existence of an alternate system that is independent of intrinsic factor or even an intact terminal ileum."

 

"Other etiologies of vitamin B₁₂ deficiency, although less common, deserve mention. Patients with evidence of vitamin B₁₂ deficiency and chronic gastrointestinal symptoms such as dyspepsia, recurrent peptic ulcer disease, or diarrhea may warrant evaluation for such entities as Whipple's disease (a rare bacterial infection that impairs absorption), Zollinger-Ellison syndrome (gastrinoma causing peptic ulcer and diarrhea), or Crohn's disease. Patients with a history of intestinal surgery, strictures, or blind loops may have bacterial overgrowth that can compete for dietary vitamin B₁₂ in the small bowel, as can infestation with tapeworms or other intestinal parasites. Congenital transport-protein deficiencies, including transcobalamin II deficiency, are another rare cause of vitamin B₁₂ deficiency."  This pt. has none of these that I/they are apparently aware of.

 

"Because most clinicians are generally unaware that oral vitamin B₁₂ therapy is effective, the traditional treatment for B₁₂ deficiency has been intramuscular injections. However, since as early as 1968, oral vitamin B₁₂ has been shown to have an efficacy equal to that of injections in the treatment of pernicious anemia and other B₁₂ deficiency states.  Although the majority of dietary vitamin B₁₂ is absorbed in the terminal ileum through a complex with intrinsic factor, evidence for the previously mentioned alternate transport system is mounting."

 

And finally, here's the apparent answer:  "Although the daily requirement of vitamin B₁₂ is approximately 2 mcg, the initial oral replacement dosage consists of a single daily dose of 1,000 to 2,000 mcg. This high dose is required because of the variable absorption of oral vitamin B₁₂ in doses of 500 mcg or less. This regimen has been shown to be safe, cost-effective, and well tolerated by patients.  In mild vitamin B₁₂ deficiency, we recommend repeat measurements of serum vitamin B₁₂, homocysteine, and methylmalonic acid levels two to three months after initiating treatment."  Hmm, who says you can't teach an old dog new tricks, or even teach them.

 

For any who may be interested, I'm starting a new PA program, online, and all training will be conducted online through Google Search reference sites.  I do accept PayPal as tuition payment.  Clinical rotations?  Uh, you're on your own there.  This concludes our CME for today.

 

All kidding aside, I really would like to know why so darn many of these folks are on B12?  I can only recall one or two over thirty years in private practice.

[UGoLong]

We've got quite a few on oral B-12. Our patients tend to be older and the absorption goes down with age.  Helps a bit with anemia.

[GetMeOuttaThisMess]

^^^ I could buy this if these folks were anemic, but this one in particular isn't and according to the patient problem lists I don't recall seeing it listed as a problem (which assumes of course that the resident bothers to add the condition to the problem list).  How often are you checking follow up values if I may ask?

[myironlung]

on my preceptorship for outpatient fp, we had a lot of old timers come in requesting it and the doc had these patients for years.  Apparently they were hearing through the grapevine that B12 shots gave a boost of energy and obviously had no idea how out of context that was presumably taken.... just like "energy drinks" and those mysterious words like electrolytes and b vitamins. But the old time doc didn't really seem to mind "shooting them up" because one way or another it wouldn't really do any harm once every 6 months or so.

[GetMeOuttaThisMess]

These folks aren't on it for the "boost" effect because they're on prolonged oral dosings (for no obvious reasons which I can see, though I wouldn't be surprised if some were prescribed it with the thought that it would help their "peripheral neuropathy" from DM, spine issues, or some such without the prescriber understanding fully the concept of B12 and neuropathies (remember, most care is coming through residents).  I could see the placebo effect from an injection but not so much from the oral form when taken chronically.

[ventana]

anything that effects absorption can lower B vit - and hence cause anemia

 

used to be if you anemic even once with macrocytosis you would gt B12 shots monthly for the rest of your life..... ahhh no needed

 

good data to support high dose oral Vit B does just fine for most people

 

 

Have a patient who has celiac (not the fad type but actually Bx proven) and has done just fine on oral dosing

 

 

 

try oral first.......

[GetMeOuttaThisMess]

And therein lies the problem. The only anemia that she's aware of was IDA. As far as an absorption issue, who knows? She didn't have any idea about other potential sources. I don't doubt her validity due to the fact that with her being compliant with injections she's still on the lower end of normal. Normal indices on CBC and no anemia.

[bradtPA]

Lots of patients believe in B-12 shots for "energy" and lots of providers are willing to provide them this service for the money....

[winterallsummer]

Hey GetMe. Hope you are enjoying the FM gig my friend!

 

When I rotated through hem onc they had a lot of PTs on B12 injections. My docs opinion was that it was "voodoo medicine" and they switched almost all of them to B12 supplements excluding a couple who had legitimize malabsorption. There are a lot of PTs in FM getting B12 for "energy" or whatnot and I agree switch them all to PO or take them off unless there is an explainable pathology or lab value justifying deficiency. I've seen a decent number of PTs on these injections who don't need it and personally if lab values were normal and there's no pathology to justify it I'd switch to PO and/or take them off and can always recheck a b12 to reassure them. Just my humble opinion! If another one of their PAs/MDs wants to give it fine but I could see no reason to justify it personally.

[GetMeOuttaThisMess]

And therein lies the problem that I'm facing.  The patient(s) are not certain as to why they are on them and I can't make the assumption that it was for the purpose of $$$ to the provider who was administering the injection.  The obvious answer will be to first try this patient in particular on an oral dose and recheck in three months and see where they are at.  At time of follow up, check lab value and readdress this isolated treatment (versus the multiple conditions which I saw this individual for initially).  I'll start at a gram a day and titrate up as needed.  Thanks to all.

[JohnnyM2]

 

My question is would an attempt at oral supplementation be a viable option in lieu of monthly injections, especially since it isn't known why she would be deficient to begin with? The oral forms address other known conditions, or so says Epocrates as I recall, but nothing specific to just maintenance dosing for deficiency that I can find. Ah, the days of UC/EM where you didn't even care about the B family....

What about the nasal spray? Or the sub-lingual dissolving tablets?

 

Sent from my Kindle Fire HDX using Tapatalk 2

 

 

[GetMeOuttaThisMess]

Any non-injectable form would be appropriate however the employer formulary only covers cheapest options (your uncle, Sam).

[SoFarAway]

Late reply here, but have you checked her folate level? 

[GetMeOuttaThisMess]

Yep. Peachy. Sent orals.

[quarternote]

If it isn't malabsorption could it be dietary? Are you at a VA? You mentioned she is a vet. I think we will see more of this as a strictly Vegan diet is becoming the "in" thing. Many people are avoiding soy also (so tofu is out) due to it being a high GMO product. Also the price of meat and dairy is going up so many people can't afford meats.

What about age >50, long term PPI, hypothyroidism, alcohol?

With our bariatric patients we gave oral.

Just some thoughts...

[GetMeOuttaThisMess]

None apply in this case but good considerations.

[True Anomaly]

Lots of patients believe in B-12 shots for "energy" and lots of providers are willing to provide them this service for the money....

 

This is the correct answer- you need dig no further into the reasons

[GetMeOuttaThisMess]

I wasn't going to once confirming the level was in fact in the normal range. Strong believer in "not broke, don't fix it".

[GetMeOuttaThisMess]

Along a similar thread, why do folks keep looking for/treating conditions in folks that are in their 80's plus (no offense intended to those in their 80's plus)?  Statins (finally got my mom off the stuff for primary prevention)?  Colonoscopies (wonder what the perf NNH, or number needed to harm, rate is in this specific demographic group)?  Mammograms, or better yet, cervical cancer screening?  Thank goodness we finally put two and two together and realized that these folks don't necessarily need to be <140/90 mmHg on their BPs (kind of like ezetimibe as your numbers look great while you're lying in the casket) and someone put the lid on screening for prostate cancer past 75 y/o, assuming of course that anyone even knows of the recommendation.  I realize that there are exceptions and that some octogenarians are gung-ho at 80 but reality says most aren't.  This has become my most frequent reason for approaching attendings at my workplace in that I'm asking them why do we have these folks on all this crap?  Not surprisingly, they don't have an answer.

[Guest Paula]

I'm with you on that.  My last trip home to see my parents brought all of this to light.  My 87 y/o mother was fretting about scheduling her mammogram because she got a letter from her "doctor" (it was really just a reminder letter) that she needed it.  I discussed with her it is not needed and she has never had a positive mammo.  She was so worried they would be mad at her if she didn't get it scheduled.  I explained there is no reason to do it and even if they found cancer she may not be a candidate for any kind of treatment.  Then I told her it was just about billing for  a service and was financially driven. 

 

Not sure she got it because she is having memory issues, so I just threw the notice away for her and she has probably forgotten about it now.  Plus she is so worried my Dad will have a heart attack if he keeps eating donuts every day.  My talk with her is Let him eat whatever he wants, he is very frail and mostly housebound.  Donuts are a pleasure he can enjoy.  He's 87 too. 

 

I've taken a few of my 90 y/o off of their diabetes and lipid meds and they do just fine with diet controlled DM.  Most of the time they had quit the meds anyway and nothing happened.  I monitor BS's and so far the few are stable with fairly normal or A1Cs at 7%.  Pretty good for  90 y/o's.

 

I've stopped PSA testing too, even in some of the younger men who have had yearly normal PSAs with no Fam Hx.   

[GetMeOuttaThisMess]

We think too much medicine and don't use enough common sense, IMO.