Hey all, just a random question that occurred to me today. I wanted to ask thr brain trust to see if you all knew the reason why. So if PA is usually a b12 deficiency but also needs (a form of) folate, why can't the folate be in the b12 injections as well? They're often paired together in pill/tablet/ capsule form but why can't they put in the injection as well? Just curious...And I'm also curious that many of us need b12 injected due to malabsorption. But how are we then able to supplement with oral folate and that absorb? How are we able to absorb folate but not b12?
I realize none of you all are doctors, but many of us are more informed than most doctors on this topic, so i was just curious if any of you knew the answers to these questions to this perplexing disorder. Thanks! And thanks for listening to my random tangent haha.
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Mrl1234
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Trust you to ask complicated questions first thing in the morn. š¤£
Question 1, I googled.........
Folate is not typically included in B12 injections because of a potential risk: taking folate can mask symptoms of B12 deficiency, potentially leading to irreversible neurological damage if the underlying B12 deficiency is not addressed. B12 and folate are both important for red blood cell production, but B12 also plays a crucial role in nerve function, and a deficiency can cause serious nerve damage. While folate and B12 both contribute to healthy red blood cells, B12 is also essential for nerve function. A deficiency in B12 can cause nerve damage. Folate supplementation can improve symptoms related to anemia, but it can also mask the symptoms of B12 deficiency, potentially delaying diagnosis and treatment of the underlying B12 issue.
Even I was surprised at the answer to your second question, so thankyou, I have learnt something this morn..........
Yes, patients with pernicious anemia and absorption issues can absorb sublingual B12, even if they have trouble absorbing it through the regular digestive system. Sublingual B12 bypasses the stomach and intrinsic factor, allowing absorption through the mucous membranes of the mouth.
Sublingual Absorption:
B12 can be absorbed through the mouth, especially if it's in a sublingual (under the tongue) form. This absorption bypasses the stomach and the need for intrinsic factor.
Effectiveness:
Oral and sublingual B12 supplements can be effective for individuals with malabsorption issues, including pernicious anemia, as long as high doses are used to compensate for reduced absorption.
It makes me question why so many of us have the need to inject. š¤
You have got me thinking !
So if we can absorb sublingal 'how or why' do we become deficient in the first place ?
I got by with the sublingual B12 for several years. But eventually I stopped absorbing enough from it. My toes were tingly and I had to start injections. B12 needs intrinsic factor to get into the body from your digestive tract. Folate does not. That is why we can absorb folate but not B12.
While autoimmune gastritis probably affects the absorption of many nutrients, the absorption of no other nutrient appears to be wiped out in the same dramatic way that occurs with B12 due to loss of production of intrinsic factor.
Hence you could well need injected B12 but manage on oral delivery of everything else.
I still cannot get my head around how PA patients can absorb sublingal B12 - If patients are able to absorb sublingal without intrinsic factor it makes me wonder why the need for injections ?
It makes me wonder after reading what I had google if this is the reason so many Drs are prescribing sublingal and withdrawing injections. Vit B tablets taste fowl so wouldn't want to be putting them under my tongue. š
I only have to miss an injection and my symptoms return !
I've been reading claims about sub-lingual absorption of several substances for many years.
One notable aspect is that few claims are supported by good evidence. Evidence which proves that absorption occurs in the mouth, under the tongue, and not elsewhere such as in the stomach and beyond after having been swallowed.
The whole process of holding a substance in the mouth for minutes to hours might have its own effects. Think simple dissolving. Think very slow delivery to the stomach. Think haptocorrin!
I'd have much more time for GPs trying to switch to oral products if they actually tested to ensure the patient does absorb the B12 in the form offered/suggested. (I withdraw from identifying a suitable approach as so many others know far more about B12 testing.)
I'd also have more time if we knew why some appear NOT to absorb any oral product in appreciable quantities. Or, maybe, they need gigantic doses - such as 5000 microgram B12, possibly more than once a day, possibly in multiple forms (methly- adenosyl-, hydroxo-). Which are never offered by GPs.
I've had several lots of B12 formulated to taste really nice! Typically cherry. But many B vitamin products are, as you say, disgusting.
The Origins of Salivary Vitamin A, Vitamin B12 and Vitamin D-Binding Proteins
Abstract
Vitamin A- (retinol), vitamin B12- (haptocorrin) and vitamin D-binding proteins are the major circulatory transporters of their respective ligands; they are also constituents of the salivary proteome, the origins of which, remain unclear. The aim of this study was to explore how these proteins enter saliva and their relationship (if any) with vitamin status. Firstly, the three vitamin-binding proteins were quantified in resting whole mouth saliva and chewing-stimulated saliva from healthy donors (n = 10) to determine if they enter the mouth by salivary secretion or from the circulation. Secondly paired whole mouth saliva and serum samples were analysed from healthy donors (n = 14) to determine the relationships between the vitamin-binding proteins and vitamin status. Salivary output of all three vitamin-binding proteins studied increased when secretion was stimulated, suggesting they are secreted by the salivary glands. Whilst retinol-binding protein and haptocorrin were secreted by all major salivary glands, vitamin D-binding protein was restricted to the mucus glands. Salivary vitamin-binding protein concentrations were not found to be indicative of systemic vitamin status.
Just adding that there used to be a considerable number of people who claimed that desiccated thyroid products could be absorbed sublingually. But self-reported experiences have the problem that we can never know how much is absorbed and where. Sure, an almost immediate effect does seem to imply some oral absorption. But beyond that, it is difficult.
However, many found that they did better even briefly chewing the tablets rather than swallowing whole. Could the poor disintegration of some tablets have been the most significant factor - rather than genuine sublingual absorption?
This is very interesting but iv'e got to go and google haptocorrin ? š¤
I agree Drs dish out sublingal far to willy nilly without checking the patients progress. Iv'e not had time to look fully into your reply as yet but what about somebody like myself with Sjogrens which affects the mucus glands ?
More research is needed but it's all down to š°.
Who's a clever girl ? I googled........
Haptocorrin, also known as R-protein or transcobalamin I, is secreted by salivary glands. It plays a role in binding to vitamin B12 in the stomach and protecting it from degradation as it travels through the digestive system, eventually binding to intrinsic factor in the small intestine for absorption.
Completely agree - it assumes "normal" functioning of everything else.
By way of hypothesis, what if low B12 levels impair the ability to absorb more B12 sublingually/orally? Could end up that is a barrier to ever managing to switch to non-injected forms.
I once spoke with a senior ENT consultant - who not only had read my GP's detailed report, but could quote from it (!)
He encouraged me to continue with my frequent (EOD at that time) B12 injections, that it would take a long time to improve but to be persistent and not give up. He told me that it was clear to him that I had severe B12 deficiency. This conclusion came from observation of a few photos and of my mouth, tongue, throat. From professional experience. Uniquely, NO blood tests or other examination necessary.
He also agreed with me that YES, having salivary duct strictures would impact on my ability to absorb B12 from food (extrinsic factor) - because of the reduced haptocorrin.
This might explain why previously, when trying to survive for the 3 months between NHS maintenance injections, I found that the (quite expensive) B12 boost spray did absolutely nothing to help me get there.
( Or, as was often discussed here; the theory that B12 molecules are too large to be able to be absorbed through mucus membranes under the tongue or in the mouth)
Thanks to the ENT consultant, who praised my GP on a thorough report (instead of rolling his eyes at the length of it ) - and stopped me from giving up on frequent B12 injections as a way back !
I got to see him again some three years later - and so was able to thank him in person. Some much-needed advice at a crucial time.
Last night I watched a fascinating programme about support for patients wanting facial alteration, in which one patient was advised that it would take about 18 months for facial nerve damage to repair after facial surgery to reduce their jawline.
So why do some GPs appear to believe that the recommended three-week review for those with B12 deficiency that includes nerve damage on EOD B12 injections is a signal to start the maintenance frequency ?
Surely nerves cannot possibly repair within that time-frame ? Enough to have reached a level of repair that the patient would wish to maintain permanently ?
There is so much to learn still and so few involved in the research.
So, Mrl1234 - questions aplenty here. No answers yet.
I went privately for migraines as not coping with daily pain and the NHS one just wanted me on amytripyline uo to 50mg ( I wax too drugged on 10mg but still in pain
Took me months to try it but desperate and they put pressure for me to trial it .
A mistake for me .
I weaned off it with great difficulty over 2 weeks . G.p agreed. And also shocked.
Did help my daughter for a while as got sleep.
Every one my daughter saw were useless to her and sent back to G.p .
Never ending cycles.
A general medical consultant seen in A + E helped her.
Until its better understood and research done its hit and miss it seems .
B12 is the only nutrient that requires intrinsic factor for absorption from food or oral supplements. If the stomach's parietal cells are damaged by autoimmune gastritis they can't produce this, and therefore the B12 isn't absorbed (or possibly only the tiniest percentage may be...). But stomach acid is also important for iron absorption, and production of that is also reduced or non-existent with ag. In addition, we are vulnerable to poor absorption of Vitamin D, calcium and folate, but seemingly can absorb enough by increasing our intake with oral supplements as they don't require intrinsic factor like B12.
Re a combined injection, I imagine it would be difficult to find a 'one size fits all' combination of B12 and folate, as we seem to need/tolerate quite varied amounts of folate. And no-one seems willing to spend money on developing B12 related pharmaceuticals - if only they helped anxiety and depression or lowered your cholesterol we'd be inundated with snazzy new self injecting versions! (Spoiler alert- B12 deficiency symptoms include all of the above, so....go figureš¤·š¼āāļø!)
Drs are more than eager to dish out cholesterol tablets be it raised or not ! Try and get them to address a B12 deficiency is completely a different ball game. I have diagnosed Errosive Gastritis together with Crohns and absorb my prescribed Folic Acid, vit D3 and Calcium well. If what I Googled is correct 'why am I not absorbing B12' ? Iv'e tried sublingal in the past to no avail ! My fuzzy brain fogged head cant - figure it out. š¤·
It's no good me asking my Dr, he hasn't a clue ! šµāš«
It's all very confusing but a good question raised by Mr1234. I was prescribed Folic Acid by my heamatologist which masked my B12 decline and now suffer the unpleasant consequence ! ā¹
In detail, B6, vitamin B12, folic acid Hidden Ā® iV contains
5 mg of vitamin B6
1 mg vitamin B12
1.05 mg folic acid
Hidden Ā® thus offers exactly the composition of building blocks that the body needs to regain lost energy.
Good to know: The combination of the three vitamins B6, B12 and folic acid is more effective than vitamin B12 alone.
Why as a syringe?
B6, vitamin B12, folic acid Hidden Ā® is an exclusive B vitamin regimen that is administered by the doctor by injection. Alternatively, Hidden Ā® iV can be administered via infusion.
The valuable vitamins B6, B12 and folic acid get into the blood directly and in full in this form - 100 percent. The detour via the digestive tract, as z. B. is required for tablets or drinking ampoules, is omitted.
This is how Hidden fillsĀ® effectively stores B vitamins and works faster and more effectively than tablets or drinking ampoules. Many patients report a noticeable effect after the first injection.
Just out of interest , I have seen that there is an injection made by the German company Hevert that combines B12 and folic acid . The B12 concerned is Cynocobalamin , not Hydroxocobalamin.
The mechanism for absorbing B12 is extremely specialised. It uses the terminal ileum and, as folate is also absorbed in the ileum, the damage caused by PA can commonly also affect folate. It can also affect other micronutrients because it also results in lowered stomach acidity. However, the mechanisms that are used to absorb these micronutrients are generally impaired rather than destroyed so just a bit less efficient.
B12 isn't toxic but other micronutrients can cause toxicity so including them in an injection could be dangerous. In the case of folate over consumption can result cellular B12 being trapped in the wrong form meaning that processes only run in part, or that the cell can't run other processes that require a different form.
Some injections are available that include other micronutrients but I would not recommend using these unless under medical supervision/advice.
The mechanism involved with high dose oral is called passive absorption. It can be effective (not the same as will be) but there is plenty of evidence out there that passive absorption isn't effective for everyone - this comes from small scale studies and there are a few comparisons across B12 absorption problems that show that this isn't specific to PA as the source of B12 absorption problems. It seems to be effective for about 60-70% of people. Even if it is effective it is a very slow way of raising B12 levels so in the case of a severe deficiency loading shots will always be the way to go.
I am aware of one relatively large scale study in Canada which showed that 60^ of patients preferred using high dose oral to having to go for injections. However, I don't think it was specific to people with PA, but I defer to the smaller scale studies that showed passive absorption as being ineffective in 30-40% of patients regardless of type of absorption problem.
Passive absorption of molecules though the gut mucosa is largely dependent on size. Molecules less than 600 daltons can usually be absorbed (depending on whether they have a neutral charge). (A dalton is just a measure of size equal to 1g/mol).(Cyano)Cobalamin has a molecular size of 1355 daltons. Therefore, it won't fit through the gaps between the cells in the mucosa and cannot be absorbed passively.
This is why vitamin b12 has an active transport mechanism in our bodies, otherwise it won't get in. It's possible that so called "passive absorption" is the b12 molecule piggy backing into other active transport mechanisms to be absorbed in small quantities (but we don't yet know for sure).
I don't believe that b12 is absorbed through the mucosa in the mouth due to its large molecular size. It's far more likely that the b12 is inadvertently swallowed and absorbed through the gut (or not, if you have pernicious anaemia).
Passive absorption of molecules though the gut mucosa is largely dependent on size.
As does wallpaper.
But can you simply take the listed molecular size without considering things like polarity, hydration, etc.?
I ask because when discussing levothyroxine it has been obvious that the water molecules that will always be present (at least five even in the solid form as if there are fewer, it will attract from the environment) profound impacts on how it acts. Adding to that, it is a zwitter-ion which also makes it behave somewhat atypically for molecules of its size.
Agreed, there are additional factors which will influence passive absorption. But i don't think they will make an already very large molecule more likely to be absorbed. I believe that has more effect on making smaller molecules less absorbable.
If my memory serves me right, I believe that the B12 specialist I saw, along with similar minded people, is against the government fortifying staples with folic acid, B9, to address B9 deficiency in the population.
The reason being that fortifying staple foods with B9 will make it harder to detect B12 deficiency.
Please anyone jump in if my recall cannot be right!
We'd also need it to be the right form of folate, and the risk would be getting far too much of it. Folic just put my serum folate up towards the top of the range, but taking methylfolate stopped some of my neuro symptoms and my serum folate dropped. Even very high doses of oral/sublingual B12 did not work for me by this point and I am now making improvements on B12 injections, rather than getting worse slower on oral/sublingual.
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