A practical guide to management in
primary care
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Science bit
Clinical presentation and complications
Investigations
Management
Discussion of guidelines
Mini audit of our patients
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Derived from the diet – found in meat, fish,
eggs, milk but not in plants
Up to 2yrs worth are stored in the liver.
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Impaired absorption
Pernicious anaemia
 Gastrectomy
 Ileal disease or resection
 Malabsorption syndromes
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Low dietary intake
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Vegans
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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
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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
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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
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B12 Deficiency without neurological
involvement:
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1mg Hydroxocobalamin 3 times a week for 2 weeks
then every 3 months.
B12 Deficiency with neurological involvement:
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1mg Hydroxocobalamin very other day until no
further improvement then every 2months.
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Prodigy (CKS) guidelines
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60 patients with ‘Hydroxocobalamin’
prescribed.
Ave age 70yrs (34-95)
58% female 42% male
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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?
Monitoring, 24
No monitoring,
36
12
6
2
5
3
3
1
1
No. injections
Te
n
El
ev
en
Tw
el
ve
6
x
Se
ve
rn
Ei
gh
t
Ni
ne
8
Si
4
Tw
o
Th
re
e
Fo
ur
Fi
ve
O
ne
Ze
ro
no. patients
14
12
10
10
7
5
3
2
0
2
5
ie
t
5
?D
al
lb
ow
el
re
se
ct
io
n
Cr
oh
ns
y
ia
re
ct
om
an
ae
m
10
Sm
ou
s
re
co
rd
ed
20
G
as
t
Pe
rn
ici
Ni
l
30
28
25
18
15
5
2
2
0
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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.