Bruce H. R. Wolffenbuttel, MD, PhD, and others have published a new article, the result of thorough review of the medical literature, with the purpose of the literature review stated in the article title:
A Brief Overview of the Diagnosis and Treatment of Cobalamin (B12) Deficiency
The entire article will probably be of interest to many on this forum, and will serve as a useful summary for us and for our physicians.
The following except is an example of the article's content:
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B12 Malabsorption
In most, if not all, cases of symptomatic B12 deficiency caused by malabsorption, B12 should be administered intramuscularly because of low absorption following oral administration due to the underlying disease.33,68 Importantly, once started, B12 administration should be maintained for life. Suggested treatment schemes differ considerably between countries and, unfortunately, there is very little clinical evidence supporting any one of the treatment regimens over others worldwide. The initial recommended dose is 1000 µg hydroxocobalamin by intramuscular injection twice weekly (Netherlands), or on alternate days (United Kingdom).62 This frequency should be continued when neurological complaints are present until the symptoms have entirely resolved or do not improve further. This may take several months or even years. Clinical experience suggests that the dose or injection frequency should not be suddenly reduced to a maintenance dose once every 2 months, as too rapid dose reduction may lead to symptom reoccurrence.5,62 Instead, it is recommended to gradually increase the interval between injections over the course of several months while monitoring symptoms. A recurrence of symptoms suggests halting any further reduction in injection frequency. In general, this personalization of treatment is rarely observed in practice.
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The article is freely available in its entirety at this link:
I will print the article and read with interest. It will be interesting to see the dates of the referenced research. There seems so little current quality research into B12 deficiency.
Here’s a detailed breakdown for quick read of the document, “A Brief Overview of the Diagnosis and Treatment of Cobalamin (B12) Deficiency” by Bruce H. R. Wolffenbuttel et al.:
Background
• Vitamin B12 Deficiency Risks: Increasing numbers of individuals are at risk due to reduced intake or impaired absorption of vitamin B12 (cobalamin).
• Consequences: Untreated deficiency can cause irreversible neurological damage and cognitive impairments.
Diagnosis Challenges
1. Symptoms: Highly variable, including neurological, cognitive, and sometimes megaloblastic anaemia.
2. Testing Limitations:
• Primary Biomarker: Serum B12 levels below 148 pmol/L are typically indicative of deficiency, but symptoms may exist above this threshold.
• Secondary Biomarkers: Holo-transcobalamin (active B12), methylmalonic acid (MMA), and homocysteine levels are often unreliable.
• Variability: Diagnostic assays differ significantly across laboratories, complicating the interpretation of results.
Causes
1. Reduced Dietary Intake:
• Common in vegetarians, vegans, and the elderly.
• Inadequate intake from animal-derived foods is a primary cause.
2. Malabsorption:
• Common in conditions like pernicious anaemia, Crohn’s disease, or after bariatric surgeries.
• Medications (e.g., metformin, proton-pump inhibitors) can also interfere with absorption.
3. Familial Deficiency:
• Potential genetic and epigenetic links between maternal B12 deficiency during pregnancy and offspring deficiency.
4. Nitrous Oxide Exposure: Inactivates B12 and may exacerbate neurological symptoms.
Treatment
1. Initial Therapy:
• Dietary Deficiency: Oral supplementation (e.g., 50 µg cyanocobalamin) is often effective.
• Malabsorption: Requires intramuscular injections of hydroxocobalamin. Typical regimen:
• Loading phase: 1000 µg twice weekly or alternate days for 5+ weeks.
• Maintenance: Every 2 months or as frequently as every 2–4 weeks for some individuals.
2. Ongoing Challenges:
• Individualised Care: Up to 50% of patients need personalised injection schedules for sustained relief.
• Neurological Symptom Recovery: Can take months or years; some may not fully recover.
• Monitoring: Clinical symptoms guide treatment, not biomarkers.
Efficacy of Treatment Methods
1. Oral vs Parenteral:
• Intramuscular injections are the gold standard, especially for malabsorption-related cases.
• Oral therapies may suffice in dietary insufficiency but are unreliable in symptomatic patients.
2. Alternative Methods:
• Nasal and sublingual B12 have limited evidence and inconsistent bioavailability.
Key Recommendations
• Prevention: Encourage adequate B12 intake in high-risk groups (e.g., vegans, the elderly).
• Diagnosis: Avoid relying solely on biomarkers; consider therapeutic trials in symptomatic patients.
• Treatment:
• Tailor injection frequency to patient needs, avoiding abrupt reductions.
• Maintain intramuscular therapy for malabsorption indefinitely.
Conclusions
• Long-term B12 supplementation is safe, but treatment should prioritise symptom relief rather than biomarker normalisation.
• Personalised regimens are critical for managing individual responses, particularly in patients with neurological involvement.
This document emphasises the complexity of diagnosing and managing B12 deficiency, advocating for a nuanced, patient-centred approach.
This ‘key takeaway’ is extrapolated from other applicable knowledge to enhance the veracity of the article. (Ed.)
The key takeaway for patients from this document is the importance of personalised and proactive management of vitamin B12 deficiency. Here’s why this is crucial:
1. Symptoms Can Be Misleading:
Many people with B12 deficiency may not show classic symptoms like anaemia. Neurological and cognitive issues often dominate, making it essential to recognise subtle signs like fatigue, memory issues, or numbness.
2. Timely Diagnosis Is Vital:
Early intervention prevents irreversible damage, but diagnosis can be tricky. Standard blood tests for B12 may not always reflect actual deficiency. If symptoms persist despite “normal” test results, patients should advocate for additional tests or therapeutic trials.
3. Treatment Is Highly Individualised:
• Those with dietary deficiencies often benefit from oral supplementation, but this is not effective for everyone.
• Patients with malabsorption issues need intramuscular injections, which may require a flexible schedule to maintain symptom relief—sometimes as frequently as every 2–4 weeks.
• Don’t settle for standard protocols if symptoms persist; seek adjustments to your treatment plan.
4. Symptoms, Not Just Numbers, Should Guide Care:
Success is measured by symptom relief, not solely by improving blood levels of B12. Patients should work closely with their healthcare providers to adjust treatment based on how they feel.
5. Advocate for Yourself:
If you suspect a deficiency or don’t feel well even with treatment, ask questions. Explore the possibility of more frequent injections or alternative approaches. B12 deficiency is manageable, but vigilance and communication are essential.
This patient-focused takeaway encourages awareness, advocacy, and partnership with healthcare professionals to achieve the best outcomes. Would you like advice on applying these principles to your specific needs?
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Never delay seeking advice or dialling emergency services because of something that you have read on HealthUnlocked.
Excess Folic Acid and Vitamin B12 Deficiency: Clinical Implications?
Is it ok to self-inject everyday when starting treatment?
Great blog post on B12 and videos from Prof Bruce HR Wolffenbuttel
