Help please! B12 and Anaemia.

Please could anyone help? My aunt is 95 years of age and she's had her B12 tested and it's 200 which is quite low in the range. The doctor won't give her injections because she isn't anaemic. She has a thyroid problem too but at the moment I just want someone's advice on B12/Anaemia please. As far as I'm concerned it doesn't always follow that one has to be anaemic to have PA. Thanks guys.

[Gambit62 Administrator]

suggest you

a) make a full list of all symptoms your aunt had that could be B12 - regardless of whether they could also be thyroid

pernicious-anaemia-society....

using this (and assuming you are UK based - guidelines for treatment do vary from country to country)

write to your GP with a copy to the practice manager pointing out the following

a) serum B12 is not a gold standard test and will miss 25% of those who are B12 deficient whilst also picking up 5% who aren't if taken as a single measure so evaluation of symptoms is important.

b) guidelines are to treat on the basis of symptoms if there is a discordance between symptoms and test results - particularly if there are neurological symptoms - and the giddiness would appear to be a neurological symptom.

c) at 95 your aunt is in a high risk category for B12 deficiency - incidence increases with age because of the tendency for stomach acidity to fall with age.

d) 25% of patients who are B12 deficient don't present with macrocytosis amongst first symptoms so lack of any signs of macrocytosis should not be considered evidence that there is no B12 deficiency.

source of info to quote is the BCSH (British Council for Standards in Haematology) guidelines for diagnosis and treatment of cobalamin and folate deficiency. These can be accessed via the BNF which points to this link

onlinelibrary.wiley.com/doi...

[GGourmet]

This does not look good.

Anaemia cannot necessarily be determined from blood tests alone. This is because low normal ferritin can mean that anaemia is negative on the test even though B12 is low. I understand that low Ferratin can mean megolablastic anaemia is negative if B12 is also low. If Ferratin in well within the normal range and B12 is low you may experience results that show 'normal' blood test results.

[fbirder in reply to GGourmet]

Anaemia can be determined from blood tests alone. A combination of tests (haemaglobin, ferritin, B12, folate, MCV, MCH, MCHC, RDW plus others) can detect and differentiate between iron-deficiency anaemia and different macrocytic anaemias.

The problem in this case is that a B12 deficiency doesn't necessarily require macrocytic anaemia as one of the symptoms.

[GGourmet in reply to fbirder]

Well that's really added to the knowledge pool, thank you fbirder.

[Galixie in reply to fbirder]

I suspect that what GGourmet was trying to express was this,

"...it is important to remember also that peripheral blood macrocytosis may be masked by concomitant iron deficiency or thalassaemia trait."

(Excerpted from Dacie and Lewis Practical Hematology, Ninth Edition)

Anemia can be determined from blood tests alone when there is only one type of anemia going on, but it is also easy to miss if the patient has multiple anemias. If the patient has both microcytic and macrocytic anemias, the MCV and hemoglobin levels will appear to be normal.

We could dismiss this as a rare occurrence, but it does happen. It happened to me.

[fbirder in reply to Galixie]

That is so. Which is why I included RDW as one of the necessary test parameters.

If both macrocytic and macrocytic anaemias are present then the Red cell Distribution Width will be greater than normal.

[Polaris]

This research posted by 'Diogenes', scientist and advisor on TUK forum, shows the progression from Hashimoto's to gastric atrophy, followed by damage to parietal cells, leading to reduced or absent acid production, followed by PA.

journal.frontiersin.org/art...

.............

Re. your aunt's serum B12 level, many experts believe the serum B12 levels are set too low, especially for older people, who are even more likely to be deficient in hydrochloric acid - essential for absorption of B12, as well as other essential nutrients,

'The traditional cut-off values for deficiency are too low and deficiency is more common than generally thought,’ explains Professor David Smith. ‘We have evidence that people suffer harm from levels up to 300pmol/L, yet they receive lab reports saying their levels are normal. That’s why it’s important to ask for your exact level if you’ve been tested.’

The signs of deficiency — which typically include tiredness, muscle weakness, disturbed vision and numbness or tingling — are insidious and slow to develop, he says, so ‘people often think they are just getting old’.

‘Or they may go to the GP and they sometimes are misdiagnosed with depression. This condition isn’t obvious like a heart attack or a stroke, it builds up slowly.’ But early treatment can make a big difference, says Professor Smith. ‘Memory loss is one of the key signs of advanced deficiency. If they are caught early enough, the neurological signs can improve after treatment.'