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 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?

 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.