1. Diagnosis of Megaloblastic Anemia

2. Diagnostic Tests Serum Cobalamine:
Uses ELISA assay
Normal Range: 118 – 148 pmol/L
Cobalamine Deficiency: < 74 pmol/L
Serum methylmalonate and Homocysteine
Schilling Test
Test for urinary excretion
Studies absorption of Cobalamin
Schilling Test: Patient fasts over night. Radioactive cyanocobalamin given orally. 2 hours later an IM injection of cyanocobalamin of 1 mg is given. A 24 h urine specimen is collected for determination of radioactivity; low excretion shows malabsoption; the oral dose is then given again after 48 hours with IF. Results distinguish between gastric and intestinal causes of cobalamin malabsorption.

3. Diagnostic Tests Serum Folate Red Cell Folate: Uses ELISA
Normal range: 11 nmol/L to 82 nmol/L
Can be elevated from severe cobalamin deficency
Red Cell Folate:
Valuable test for body folate stores.
Less affected than serum assay by diet and traces of hemolysis.
Normal adult conc.: micrograms/L
Subnormal levels occur in patients with Megaloblastic Anemia due to folate deficiency but also in nearly 2/3 of patient with severe cobalamine deficiency.

4. Treatment of Megaloblastic Anemia

5. Treatment Establish if it is a folate or cobalamine deficiency.
In patients who are severely ill, it may be necessary to treat with both vitamins in large doses
Transfusion is usually unnecessary and inadvisable.

6. Treatment of Cobalamine Deficiency
Hydroxocobalamine
Six 1000 micrograms IM injections given at 3-7 day intervals should replenish body stores.
For maintenance therapy 1000 micrograms IM injection every three months.
Cyanocobalamin
Large daily oral doses ( micrograms)

7. Treatment of Folate Deficiency
Folic Acid
Oral doses of 5-15 mg daily.
Continue therapy for 4 months
Cobalamine Deficincy must be excluded before large doses are given, otherwise cobalamine neuropathy may develop
Folinic Acid
A stable form of fully reduced folate.
Given orally or parenterally to overcome toxic effects of methotrexate or other DHF reductase inhibitors.