This meeting took place on Thursday 26th September 2024.
Dr Hussain presented “B12 deficiency diagnosis and management: A review of updated guidelines” to the group. Dr Hussain reviewed recent NICE guidelines published in March 2024 and the evidence behind the recommendations. Dr Hussain relayed that most of the evidence available was of low quality or very low quality and thus the Committee used their expertise and clinical experience to develop recommendations for clinicians.
Dr Hussain also included information from other resources including the BMJ to compensate for the gaps in the NICE guidance.
Key learning points:
- Be aware of the wide variety of symptoms and signs that could indicate B12 deficiency.
- The clinical picture is the most important factor in assessing the significance of results of blood tests assessing cobalamin (B12) status because there is no “gold standard” test to define deficiency.
- If there is discordance between test results and clinical features, consider a trial of treatment with B12 before dismissing the diagnosis.
- Be aware that people of Black ethnicity may have a higher reference range for serum vitamin B12 concentrations than people of White or Asian ethnicity.
- Neurological symptoms resulting from B12 deficiency may take several months or even years to resolve completely.
- Do not rule out a diagnosis of vitamin B12 deficiency based solely on the absence of either anaemia or macrocytosis.
- Consider risk factors for B12 deficiency alongside signs and symptoms when deciding about treatment.
- Studies stating equivalence of oral and IM B12 supplementation are seriously flawed. Most of the evidence base is of very low quality and thus mode of treatment should be decided depending on the cause of deficiency and patient preference.
- Patients with Pernicious Anaemia and autoimmune gastritis may also develop coexisting iron, vitamin D, calcium and vitamin C deficiencies due to achlorhydia/ hypochlorydia impairing absorption of these nutrients.
- Consider repeating initial test in patients in whom it was deemed that B12 deficiency was unlikely if patients are still symptomatic after 3-6 months.
- Consider increasing frequency of B12 injections and individualise maintenance treatment based on patient’s preference and symptoms.
- Be aware that patients with Pernicious Anaemia / autoimmune gastritis are at higher risk of gastric cancer and should be referred for further investigations should they develop new or worsening GI symptoms.
- Be aware of the signs and symptoms of Subacute Degeneration of Spinal Cord and that this can present in patients who are using nitrous oxide recreationally. Serum B12 levels could be normal or raised. Blood tests including MMA and homocysteine levels should be undertaken and treatment with IM B12 injections initiated immediately and not waiting for the results. Delays in treatment can cause irreversible neurological damage.
Attached below are the meeting presentation and question and answers:
Please be aware that information in the field of medicine changes all the time, so we cannot guarantee the accuracy of this data when you read it, it is here for General Practitioners to learn.
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