A practical guide to management in primary care

Science bit Clinical presentation and complications Investigations Management Discussion of guidelines Mini audit of our patients

Derived from the diet – found in meat, fish, eggs, milk but not in plants

Up to 2yrs worth are stored in the liver.

Impaired absorption Pernicious anaemia Gastrectomy Ileal disease or resection Malabsorption syndromes

Low dietary intake Vegans

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

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

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

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.

Prodigy (CKS) guidelines

60 patients with ‘Hydroxocobalamin’ prescribed.

Ave age 70yrs (34-95) 58% female 42% male

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

3

1

65

1

10

3

7

5

32 2

0

2

4

6

8

10

12

14

Zero

One Two

Three

Four

Five Six

Severn

Eight

Nine

Ten

Eleven

Twelve

No. injections

no

. p

atie

nts

28

18

5 52 2

0

5

10

15

20

25

30

Nil rec

orded

Pernici

ous a

naem

ia

Gastre

ctom

y

Crohn

s

Small

bowel

rese

ction

?Diet

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.