NICE Clinical Knowledge Summary - B12 and Folate deficiency

[Sleepybunny]

Hi,

Apologies if this has been posted recently. It was updated in July 2020.

Worth sifting through if you have time.

cks.nice.org.uk/topics/anae...

Click on underlined headings for more information.

Interested as usual in what people think, both positive and negative points.

[Cherylclaire Forum Support]

Thanks for that, Sleepybunny - very useful information for anyone with a GP who is not sure of procedures, especially during lockdown.

Good bits:

- clarity of treatment guidelines, including during covid pandemic

- clarity re reasons for monitoring after treatment has started, and crucially when "unhelpful" and "unnecessary"!

- states clearly that "neurological impairment occurs with normal MCV in 25% of cases".

- associated disorders listed (although not all autoimmune conditions made the list)

- notes that B12 deficiency can occur without anaemia or low serum levels

- notes that clinical "normal" for serum B12 is unclear

- reminder to check B12 levels in all people with folate deficiency before folate treatment

- in monitoring after treatment for B12 deficiency and noting no improvement: check folate and iron

- listing symptoms that are considered to be neurological- including behavioural changes

- reminder that neurological symptoms will take longer to repair (although suggested 6 weeks - 3 months seems a little previous !)

Bad bits:

- despite statement above, an emphasis/ reliance on MCV testing remains (!)

- "Signs and Symptoms" still begins with megaloblastic anaemia, although note at the end of the paragraph states B12 def can occur without anaemia or low serum levels

- despite all the reservations expressed re blood tests, people with neurological involvement are to be sent straight to ........ a haematologist (?)

- "it is thought that" a serum B12 level of less than 200 ng/L (148pmol/L) will pick up" 97% of those with B12 deficiency" - despite saying that the clinical normal is unclear and that B12 can occur without low serum levels. Unsure of source or reliability but aware GPs might use this as the bar !

- some confusion: adverse effects of cyanocobalamin (acne) in comparison with the long list for hydroxocobalamin - some of which I think belong more appropriately to the "symptoms for B12 deficiency" list !

- "doarrhoea" - really !

- In spite of the many adverse effects listed for hydroxocobalamin (including "arrhythmias"), excretion in breastmilk is "unlikely to be harmful" to the feeding baby (?)

Wish list:

"Vitamin B12 has no known toxicity level" : this simple statement always gets omitted, but is likely to make the most difference to the way in which initial treatment decisions at primary care level are made.

I agree: well worth the time it takes- keep scrolling !