a practical guide to management in primary care. science bit clinical presentation and...
TRANSCRIPT
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.
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.