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Vitamin B12 Deficiency

Vitamin B12 Deficiency. A practical guide to management in primary care. Plan . Science bit Clinical presentation and complications Investigations Management Discussion of guidelines Mini audit of our patients. Source .

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Vitamin B12 Deficiency

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  1. Vitamin B12 Deficiency A practical guide to management in primary care

  2. Plan • Science bit • Clinical presentation and complications • Investigations • Management • Discussion of guidelines • Mini audit of our patients

  3. Source • Derived from the diet – found in meat, fish, eggs, milk but not in plants • Up to 2yrs worth are stored in the liver.

  4. Absorption

  5. Metabolism

  6. Causes of B12 deficiency • Impaired absorption • Pernicious anaemia • Gastrectomy • Ileal disease or resection • Malabsorption syndromes • Low dietary intake • Vegans

  7. Pernicious anaemia • Autoimmune disease – antibodies are formed against the parietal cells. This produces atrophic gastritis and reduced IF production. • 1:8000 of over 60s • F>M • All races but more common in fair skin, blue eyed people • Associated with other AA diseases – particularly thyroid diseases, addison’s and vitiligo

  8. Pernicious AnaemiaClinical features • Slow onset – symptoms of anaemia • ‘Lemon yellow’ colour due to pallor and mild jaundice (due to ineffective erythropoiesis) • Glossitis and angular stomatitis • Neurological changes (B12 <60ng/L) (SCDC) • Glove and stocking parasthaesia • Early loss of vibration sense • Progressive weakness and ataxia • Dementia

  9. Pernicious anaemiaInvestigations • FBC – Megaloblastic anaemia with hypersegmented neutrophils. • B12 levels – low • Parietal cell antibodies - +ve in 90% • Bilirubin may be raised • Serum Folate – may be normal or high • Shilling test • Endoscopy – shows atrophic gastric mucosa

  10. Treatment • B12 Deficiency without neurological involvement: • 1mg Hydroxocobalamin 3 times a week for 2 weeks then every 3 months. • B12 Deficiency with neurological involvement: • 1mg Hydroxocobalamin very other day until no further improvement then every 2months.

  11. Monitoring?

  12. Guidelines • Prodigy (CKS) guidelines

  13. Mini – Audit Our Patients • 60 patients with ‘Hydroxocobalamin’ prescribed. • Ave age 70yrs (34-95) • 58% female 42% male

  14. Mini-audit • Do we routinely monitor patients on B12 injections? • Do we consistently give B12 every 3months? • Do we document (or investigate) the cause of the B12 deficiency?

  15. How many patients had B12 levels in the last 12 months?

  16. How many injections have they each had over the last 2 years?

  17. Whats the documented cause of B12 deficiency

  18. Conclusions • We’re a bit inconsistent with monitoring. • We’re a bit inconsistent with dosing. • BUT: Does this simply reflect tailoring tests and doses to patients individual needs? • We should probably pursue the cause of the B12 deficiency (and document this) more often.

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