How to manage vitamin B12 deficiency in a 79-year-old female?

From the Guidelines

To manage vitamin B12 deficiency in a 79-year-old female, I recommend treating the deficiency immediately with hydroxocobalamin 1 mg intramuscularly three times a week for 2 weeks, followed by maintenance treatment with 1 mg intramuscularly every 2–3 months for life, as per the guidelines from the British Obesity and Metabolic Surgery Society 1. This approach prioritizes the patient's morbidity, mortality, and quality of life by promptly addressing the vitamin B12 deficiency and preventing potential complications such as neurological involvement. Key considerations in managing vitamin B12 deficiency include:

• Investigating the underlying cause of the deficiency, which may be related to decreased intrinsic factor production, atrophic gastritis, pernicious anemia, or medication effects from proton pump inhibitors or metformin
• Evaluating for neurological symptoms like peripheral neuropathy, balance issues, or cognitive changes, and seeking urgent specialist advice from a neurologist and haematologist if necessary 1
• Emphasizing dietary counseling to include B12-rich foods like meat, fish, eggs, and fortified cereals, as well as considering fortification with vitamin B12 to optimize status 1
• Monitoring for improvement in symptoms and laboratory values every 6-12 months, with treatment continuing indefinitely if the cause is irreversible.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Parenteral vitamin B12 is the recommended treatment and will be required for the remainder of the patient's life. A dose of 100 mcg daily for 6 or 7 days should be administered by intramuscular or deep subcutaneous injection. If there is clinical improvement and if a reticulocyte response is observed, the same amount may be given on alternate days for seven doses, then every 3 to 4 days for another 2 to 3 weeks. By this time hematologic values should have become normal This regimen should be followed by 100 mcg monthly for life. Folic acid should be administered concomitantly if needed.

Management of Vitamin B12 Deficiency: For a 79-year-old female with vitamin B12 deficiency, the recommended treatment is parenteral vitamin B12.

• The initial dose is 100 mcg daily for 6 or 7 days, administered by intramuscular or deep subcutaneous injection.
• If clinical improvement is observed, the dose can be given on alternate days for seven doses, then every 3 to 4 days for another 2 to 3 weeks.
• After hematologic values have become normal, the patient should receive 100 mcg monthly for life.
• Folic acid should be administered concomitantly if needed, as indicated in the drug label 2. It is essential to monitor the patient's condition and adjust the treatment regimen accordingly, as described in the precautions section of the drug label 2.

From the Research

Management of Vitamin B12 Deficiency

• The management of vitamin B12 deficiency in a 79-year-old female involves correcting the deficiency through supplementation, either orally or intramuscularly 3.
• Oral administration of high-dose vitamin B12 (1 to 2 mg daily) is as effective as intramuscular administration for correcting anemia and neurologic symptoms 3.
• However, intramuscular therapy leads to more rapid improvement and should be considered in patients with severe deficiency or severe neurologic symptoms 3.

Screening and Diagnosis

• Screening for vitamin B12 deficiency may be warranted in patients with one or more risk factors, such as adults older than 75 years 3.
• Initial laboratory assessment should include a complete blood count and serum vitamin B12 level, and measurement of serum methylmalonic acid should be used to confirm deficiency in asymptomatic high-risk patients with low-normal levels of vitamin B12 3.
• Diagnosis of vitamin B12 deficiency is not straightforward, and laboratory tests have certain limitations, but it is most often based on the clinical symptoms together with laboratory assessment and the response to treatment 4.

Treatment and Prevention

• Treatment and replacement with oral vitamin B12 can be as effective as parenteral administration even in patients with pernicious anaemia, with a suggested oral vitamin B12 dose of 1 mg daily for a month, and then maintenance dose of 125 to 250 µg for patients with dietary insufficiency and 1 mg daily for those with pernicious anaemia 4.
• Elderly people should try to obtain their vitamin B12 from either supplements or fortified foods to ensure adequate absorption from the gastrointestinal tract 5.
• Public health strategies are needed to improve vitamin B12 status in order to decrease the risk of deficiency and any potentially adverse interactions with folic acid 6.