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Pernicious Anaemia Society

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Am I being fobbed off?

Ordinary39 profile image
11 Replies

I have Hashimotos and after a recent spell of feeling exhausted beyond belief but also tense at the same time, I was diagnosed with B12 deficiency and also had to have my thyroxine reduced as my TSH was toolow. I raised the question the casual factor being PA, but was ignored. I'm having 3 injections 2-3 months apart and then a blood test 4 months after the last injection. Surely if it's PA I should be having a loading dose? Should I fight my corner and ask for an IF test? What are the benefits of a diagnosis?

Thank you in advance!

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Ordinary39
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fbirder profile image
fbirder

You need to insist on being treated according to the British National Formulary. medicinescomplete.com/#/con...

If the doctor says it's not PA ask them to tell you what it is, and how they know it's not PA.

Sleepybunny profile image
Sleepybunny

Hi,

Some B12 info that might be helpful.

Unhappy with Treatment (UK info)?

Letters to GPs about B12 deficiency

b12deficiency.info/b12-writ...

Point 1 in above link is about under treatment of b12 deficiency with neuro symptoms.

Point 5 is about being symptomatic for B12 deficiency with an in range serum b12 result.

Letters avoid face to face confrontation with GP and allow patient time to express their concerns effectively.

Best to keep letters as brief, to the point and polite as possible. It's harder to ignore a letter in my opinion.

Keep copies of any letters sent or received.

CAB NHS Complaints

citizensadvice.org.uk/healt...

Local MPs may be worth talking to if struggling to get adequate treatment.

Retention of UK medical records

bma.org.uk/advice-and-suppo...

Don't rely on there being evidence of a past diagnosis of PA (Pernicious Anaemia) or other cause of B12 deficiency in current medical records.

If you get proof of diagnosis eg positive test result/letter from specialist confirming diagnosis etc keep a copy in a safe place.

Accessing Health Records (England)

nhs.uk/using-the-nhs/about-...

england.nhs.uk/contact-us/h...

patients-association.org.uk...

UK B12 documents

BSH Cobalamin and Folate Guidelines

b-s-h.org.uk/guidelines/gui...

Summary of above document

pernicious-anaemia-society....

BMJ B12 article

bmj.com/content/349/bmj.g5226

Emphasises need to treat patients who are symptomatic even if their B12 level is within range.

BNF Hydroxycobalamin

bnf.nice.org.uk/drug/hydrox...

NICE CKS

cks.nice.org.uk/anaemia-b12...

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

Two useful B12 books

"What You Need to Know About Pernicious Anaemia and B12 Deficiency" by Martyn Hooper

Martyn Hooper is the chair of PAS (Pernicious Anaemia Society). BNF treatment info in book is out of date. See BNF Hydroxycobalamin link in this reply.

"Could it Be B12?: An Epidemic of Misdiagnoses" by Sally Pacholok and JJ. Stuart (USA authors)

Very comprehensive with lots of case studies.

B12 article from Mayo Clinic in US

ncbi.nlm.nih.gov/pmc/articl...

Table 1 in above article is about frequent misconceptions about B12 deficiency.

If you suspect PA, worth joining and talking to PAS.

PAS (Pernicious Anaemia Society)

Based in Wales, UK.

pernicious-anaemia-society....

There is a helpline number that PAS members can ring.

PAS website has useful lealflets/articles that PAS members can print out.

pernicious-anaemia-society....

Link about "What to do next" if B12 deficiency suspected

b12deficiency.info/what-to-...

Consequences

Vital to get adequate treatment. Untreated or under treated B12 deficiency increases the chance of permanent neurological damage including damage to spinal cord.

Neurological Consequences of B12 Deficiency

PAS news item

pernicious-anaemia-society....

PAS article about SACD, sub acute combined degeneration of the spinal cord

pernicious-anaemia-society....

I am not medically trained.

Ordinary39 profile image
Ordinary39 in reply toSleepybunny

Wow, thank you! I'm very grateful for all this info 😊

Sleepybunny profile image
Sleepybunny in reply toOrdinary39

I sometimes add more to a reply so check back later....

I've written some very detailed replies with more B12 info eg more B12 articles, more B12 websites, B12 books etc in threads below which might be of interest.

healthunlocked.com/pasoc/po...

healthunlocked.com/pasoc/po...

HowNowWhatNow profile image
HowNowWhatNow

Are you a member of the thyroid group here? It’s given me excellent advice before. I would ask them the same question.

Vitbpa profile image
Vitbpa in reply toHowNowWhatNow

Can you tell me how I join the thyroid group please? Thank you

Ordinary39 profile image
Ordinary39 in reply toVitbpa

Search thyroid, click on communities, then choose thyroid UK and click join!

Cherylclaire profile image
CherylclaireForum Support

Yes.

If B12 deficiency has been detected, you should first have a loading dose to raise level, whether pernicious anaemia or not. Even if the sole cause turns out to be dietary, and tablets can be absorbed for maintenance thereafter. A PA diagnosis is difficult. An anti-Intrinsic Factor antibody test (IFAB) could give you a positive result, but only 40-60% of those with PA will get this. PA is in your case is more likely because you have diagnosed Hashimoto's. Have you any close relatives with either a PA diagnosis or B12 deficiency ?

If you have neurological symptoms, you should then be treated with a frequency of every other day injections until there is no further improvement to be gained by continuing. Then an injection every 2 months. Nerve repair can take quite a while. You might encounter reluctance to treat at this frequency- a neurologist can help with a recommendation if evidence of nerve damage found on MRI scan of brain/spine.

Without neurological symptoms, the maintenance dose would follow the loading dose (6 injections over the course of a month generally) at once every 2-3 months.

Since the injections after the loading dose are intended to be maintenance injections, ensure you are as symptom-free as you are able to get first. In other words: is this a state of health that you are happy to maintain ?

Serum B12 testing after treatment has begun is pointless. It will only show that the treatment is in the bloodstream. This test being used to stop further injections is also pointless - and can lead to further deterioration or even permanent damage. Testing B12 levels after treatment has begun is only useful if non-compliance with oral treatment is suspected, or if the patient is getting worse and functional B12 deficiency is suspected (fortunately, this is rare).

Stopping appropriate treatment for 4 months in order to check if you have deteriorated seems barking mad to me. Especially if the treatment proves effective.

So, used for detecting why B12 might be failing to take effect, along with methylmalonic acid (MMA) test and renal problems ruled out; yes, it makes sense. In order to say "Hooray. You're now cured. We'll stop the injections" - without an inkling about the cause of B12 deficiency ? Possibly a dangerous error.

For some people, there is an immediate improvement. For some, there is a period of getting worse before better. For some, the maintenance dose is inadequate - and so, if GP or practice stick rigidly to the guidelines above, these people have no remaining option but to self inject. Some GPs do understand that we are all different, from presenting symptoms to response to treatment - I hope you have a GP who looks and listens.

Ordinary39 profile image
Ordinary39 in reply toCherylclaire

Thank you so much for all this. I have since had a chat with the pharmacist and he was very helpful. I am now going to get a loading dose and then a maintenance dose with a blood test down the line. I am utterly convinced that diet has not played a part in my deficiency, and I'm really worried that they'll stop my treatment, take a blood test and say I'm fine. I don't really know what to say if this situation arises! I definitely felt a positive effect from the one injection I've had so far although it's wearing off. 2 weeks on my headaches have returned and my motivation has disappeared. It's such a shame when you have to fight so hard just to feel normal. I had that with my thyroid for years and really struggled to make myself heard.

Cherylclaire profile image
CherylclaireForum Support in reply toOrdinary39

I would say just that.(You may well have to add some medical guidance backup : see Sleepybunny 's links above !)

Sleepybunny profile image
Sleepybunny

Hi,

I've assumed you're in UK.

"I am utterly convinced that diet has not played a part in my deficiency, and I'm really worried that they'll stop my treatment, take a blood test and say I'm fine. I don't really know what to say if this situation arises!"

Risk Factors for PA and B12 Deficiency

pernicious-anaemia-society....

b12deficiency.info/what-are...

b12deficiency.info/who-is-a...

Have you been tested for PA?

The benefit of a diagnosis is that you then have some evidence to back you up if GPs in future stop treatment.

PAS have a leaflet "Treatment is for Life".

pernicious-anaemia-society....

PA tests

Intrinsic Factor Antibody (IFA) test

labtestsonline.org/tests/in...

Parietal Cell Antibody (PCA) test

labtestsonline.org/tests/pa...

PCA is not recommended as a diagnostic test for PA in UK.

It is still possible to have PA with a negative result in IFA or PCA test.

About 50% of people with PA test negative on IFA test.

About 10% of people with PA test negative on PCA test.

I'm not medically trained but I'm guessing that there might be few with PA who test negative on both IFA and PCA tests.

If you suspect PA, I recommend joining and talking to PAS who can offer support and pass on useful info.

pernicious-anaemia-society....

Have you been tested for coeliac disease, another auto immune condition that can lead to B12 deficiency?

NICE guidelines Coeliac Disease

nice.org.uk/guidance/ng20/c...

Coeliac Blood Tests

coeliac.org.uk/coeliac-dise...

H Pylori infection?

patient.info/digestive-heal...

NICE guidelines H pylori

pathways.nice.org.uk/pathwa...

Click on blue boxes in flowchart for more info.

Exposure to Nitrous Oxide?

gov.uk/drug-safety-update/n...

NICE guidelines Nitrous Oxide ( see side effects section)

bnf.nice.org.uk/drug/nitrou...

Internal parasites?

Fish tapeworm infection can lead to severe B12 deficiency. Giardia Lamblia is another parasites associated with B12 deficiency.

Search online for "parasites B12 deficiency" for more info...some stories may have some gruesome details.

Have you ever eaten raw or uncooked fish eg sushi/smoked salmon?

Lived or stayed somewhere where internal parasites are common?

One potential sign of fish tapeworm infection is an increase in eosinophils, a type of white blood cell. Eosinophil result can be found on Full blood Count results.

More B12 info in threads I listed at end of my second reply.

I wrote some detailed replies in thread listed below.

healthunlocked.com/pasoc/po...

TESTING B12 DURING TREATMENT (PAS article)

pernicious-anaemia-society....

Article has some useful quotes from UK documents.

Testing B12 during treatment

(from Dutch B12 website - units, ref ranges, treatment patterns may vary from UK)

stichtingb12tekort.nl/engli...

Misconceptions about a B12 deficiency

(from Dutch B12 website - units, ref ranges, treatment patterns may vary from UK)

stichtingb12tekort.nl/engli...

B12 article from Mayo Clinic in US

ncbi.nlm.nih.gov/pmc/articl...

Table 1 in above article is about frequent misconceptions about B12 deficiency.

More about Letters ( also see letter writing link in my first reply).

I think queries about treatment/diagnosis are likely to be more effective if put in writing to GP as harder to ignore. May be worth copying them to Practice Manager.

It's possible that writing letters will irritate GPs but weigh the risk of irritating GPs against risks of not getting effective treatment.

Letters avoid face to face confrontation with GP and allow patient time to express their concerns effectively.

Best to keep letters as brief, to the point and polite as possible. It's harder to ignore a letter in my opinion.

When a letter is sent to GP, worth including a request that GP practice sends written confirmation to letter writer that they have received letter. Proof a letter was received may be useful in the event it's necessary to make a formal complaint.

I included a request in letters that a copy of letter was filed with medical notes.

My understanding is that in UK, letters to GPs are supposed to be filed with medical notes so are therefore a record that an issue has been raised.

Useful to have a paper trail in case there is a need for a formal complaint over treatment in future.

Letters could contain relevant test results, date of diagnosis, brief family and personal medical history, extracts from UK B12 documents, requests for referrals to relevant specialists eg neurologists, haematologists, gastro enterologists.

Keep copies of any letters sent or received.

Retention of UK medical records

bma.org.uk/advice-and-suppo...

Don't rely on there being evidence of a past diagnosis of PA (Pernicious Anaemia) or other cause of B12 deficiency in current medical records.

If you get proof of diagnosis eg positive test result/letter from specialist confirming diagnosis etc keep a copy in a safe place in case needed in future.

Accessing Health Records (England)

nhs.uk/using-the-nhs/about-...

england.nhs.uk/contact-us/h...

patients-association.org.uk...

Local Guidelines

Each CCG/Health Board /NHS hospital trust will have its own local guidelines on treatment/diagnosis of B12 deficiency.

I recommend you track down the local guidelines for your area and compare what they say with BSH/BNF and NICE CKS links in my first reply.

Some of these local guidelines are unhelpful so it's useful to know what you're up against.

Hope you are not in area below.

b12deficiency.info/blog/202...

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