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Doctor you have patients that need B12 injections

In your practice right now there are people that clinically need B12 injections.  Some of the data suggests that it could be 3% of your practice. Plus there are additional patients that could need supplementation of B12 due to disease process or treatment regimen. An example of this would be the number of people you have on metformin or proton pump inhibitors.  We know that these drugs deplete B12.  Now consider how many people in your practice are 60 or older.  Another population that probably needs B12 due to aging and GI dysfunction.  How many people can you think of that complain of fatigue?  Are you getting it?  You have people that need B12 injections in your practice right now.

B12, Methylcobalamin and Cyanocobalamin

Cobalamin, is a water soluble vitamin that is involved in multiple reactions in the body.  Cobalamin, vitamin B12, also is used for red blood cells, DNA, and maintaining the health of nerves.  One of the most important functions of cobalamin, vitamin B12, is as a methyl donor during the main detoxification pathways.  There are two forms of cobalamin, vitamin B12, that are used cyanocobalamin and methylcobalamin. The main issue with cyanocobalamin is that it needs to be converted to methylcobalamin and about 50% of the population has a gene variant at the MTHFR gene, which means those people may have difficulty converting cyanocobalamin to methylcobalamin.  The more variants a person has at the MTHFR gene the more problems there are with conversion, thereby requiring additional supplementation with methylcobalamin, folate and B6. According to an article in the Scandinavian Journal of Gastroenterology methylcobalamin is absorbed at a slower rate in the body than cyanocobalamin but methylcobalamin is retained at a greater percentage than cyanocobalamin.  

Things your patients are saying when they are B12 deficient. Signs and Symptoms of B12 Deficiency

There are many signs and symptoms of B12 deficiency that are seen in patients every day.  Many of these signs and symptoms are overlooked and the patient suffers needlessly. In order to be an exceptional diagnostician it is imperative to listen to the patient and then assimilate what is said into the diagnosis.  Here are a few key phrases that a patient will share when they are deficient in B12.

 

• Doctor I have noticed that I have been short of breath lately

 

• Doctor I haven’t felt like eating

 

• Doctor I have been have diarrhea or constipation

 

• Doctor I never have any energy

 

• Doctor I feel like it is a struggle to do anything

 

• Doctor I have been having tingling in my hands/feet

 

• Doctor I feel like I am in a fog

 

• Doctor I am having difficulty remembering things

 

• Doctor I have been feeling down and depressed

 

• Doctor I feel my heart beating fast once in a while

 

• Doctor I have been getting bruises

These are just of the few symptoms that a physician may see in practice.  A B12 deficiency can lead to permanent nerve damage and brain damage. It has been noted that some B12 deficiencies have been misdiagnosed as Alzheimer’s, autism, bipolar disorder or multiple sclerosis.

Causes of B12 Deficiency

Diet both vegan and vegetarian.  It has been estimated that up to 90% of the people on this type of diet have a deficiency of B12.  Other causes of B12 disease include:

 

• Pernicious anemia

 

• Crohn’s disease

 

• Celiac disease

 

• Small intestine bacterial overgrowth

 

• Bariatric surgery

 

• MTHFR gene mutations

 

• Graves’ disease

 

• Systemic lupus erythematosus

 

• Low stomach acid from extended use of proton pump inhibitor or antacids

Labs to consider in B12 deficiency

In a study reported in American Family Physician (2003) it was found that 50% of people with subclinical B12 deficiency showed a normal B12 level.  This information should prompt physicians to use different and more accurate methods to diagnose B12 deficiency. Some additional labs to consider would be:  

 

• Complete blood count:  red blood cell size will be large.  Differential diagnosis would be megaloblastic anemia which can be either a folate deficiency or a B12 deficiency.

 

• Homocysteine test:  will typically be elevated early in B12 deficiency.  May also indicate B12, B6 or folate deficiency.

 

• MTHFR genetic testing:  This will show if there are alterations in the gene.  One mutation can reduce the ability to methylate by 30% and two mutation can alter methylation by up to 70%.

Drug Interactions

B12 may interact with the following:

• Aspirin
• Antibiotics
• H2 receptor antagonists
• Metformin
• Proton pump inhibitors
• Oral contraceptives

Conclusion

If you are not providing B12 injections in your practice you should be.  It is a simple therapy that will improve your patients life and improve the bottom line of your practice.  The delivery can be performed by staff so physician time is not reduced.  B12 injections could improve your practice, increase referrals and most of improve patient lives.

References

Vitamin B12 deficiency.  AM Fam Physician. Mar 2003; 67(5)979-986.  Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12643357

Absorption of cyanocobalamin, coenzyme B12, methylcobalamin, and hydroxocobalamin at different dose levels.   Scand J Gastroenterol. 1971;6(3):249-52. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/5560708