New detailed NICE guidelines on vitamin B12 deficiency could lead to more standardised care but will be ‘challenging’ for GPs to implement, Pulse has been told.
The guidance sets out a detailed pathway for the diagnosis and management of the condition including a recommendation that GPs should offer a blood test for vitamin B12 deficiency if they have one symptom and at least one risk factor.
The recommendations also set out which treatment option to use depending on the cause of the deficiency and notes that the condition can lead to a wide range of symptoms and complications, including mental health problems and neurological problems such as cognitive impairment.
It also urges caution in interpreting total or active B12 test results in people who are already using an over-the-counter B12 preparation and those taking the combined oral contraceptive pill.
GPs should consider a further test to measure serum MMA concentrations in people who have signs or symptoms of vitamin B12 deficiency but for whom initial test results were indeterminate, NICE said.
The recommendations also point to guidance from the Medicines and Healthcare Regulatory Agency which advised GPs to consider periodic vitamin B12 testing of higher risk patients taking metformin even if they have no symptoms.
Professor Azeem Majeed, a GP and professor of primary care and public health at Imperial College London said the guidelines provided standardised criteria for diagnosing vitamin B12 deficiency, including recognising clinical manifestations and interpreting laboratory results.
‘This could lead to improved diagnosis of vitamin B12 deficiency. By outlining specific treatment regimens, including the dosages and durations for vitamin B12 supplementation, the guidelines could also better standardise care for patients with confirmed vitamin B12 deficiency,’ he said.
And guidance on monitoring requirements and follow-up intervals could also lead to reduced variation in care, he added.
But it would potentially be difficult for primary care teams to implement – including the updated protocols, education and training needed – at a time when the NHS is very stretched, he said.
‘One area that might be challenging is deciding when to use oral versus injected vitamin B12.
‘For people who do need injected vitamin B12, it may be possible to consider self-injection to reduce the workload for primary care teams.’
He also explained that when it comes to people with low/borderline readings in association with no or vague symptoms, many GPs will ‘err on the side of caution’ and recommend vitamin B12 treatment because the risks from under-treatment will be much higher than from over-treatment.
‘Overall, there is a lot to take in and high-quality education will be essential for their effective implementation.’
Dr Paul Evans, a GP in Gateshead, said it was yet more unfunded workload in doing and interpreting tests and prescribing with the potential for high patient demand.
‘There is also likely conflict when patients who are borderline or deficient are told to improve their diet and buy OTC supplements, rather than getting a script.’
He added that MMA testing was ‘not universal much like FeNO is not despite NICE guidance stipulating it for asthma’.
Dr Richard Cook, a GP in Sussex, said the level of detail could potentially be very useful.
‘Like much of the NICE guidance, it is not necessarily designed with GPs in mind, but I often find it useful if I need more detail. Overall, I think it will be a useful adjunct to managing these cases in primary care.’
When to test for B12 deficiency
1.2.1 Be aware that symptoms and signs of vitamin B12 deficiency:
- can vary from person to person and
- are often not exclusive to vitamin B12 deficiency.
1.2.2 Take into account that vitamin B12 deficiency is highly likely in people after total gastrectomy or complete terminal ileal resection, if they are not receiving either oral or intramuscular B12 replacement.
1.2.3 Do not rule out a diagnosis of vitamin B12 deficiency based solely on the absence of either anaemia or macrocytosis.
1.2.4 Be aware that vitamin B12 deficiency can be associated with mental health problems, including symptoms of depression, anxiety or psychosis.
1.2.5 Offer an initial diagnostic test for vitamin B12 deficiency to people who have:
- at least 1 common symptom or sign (see box 1) and
- at least 1 common risk factor for the condition (see box 2).
1.2.6 Use clinical judgement when deciding whether to test people who have at least 1 common symptom or sign but no common risk factors.
Source: NICE
READERS' COMMENTS [3]
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At the bottom of the list of Common Symptoms, there it is……….
“Unexplained fatigue”
So now every TATT will be expecting a B12 test.
First the Vit D hysteria, now this………..
Let’s sort out the countless patents who are on B12 injections for absolutely no reason first, wink wink
In reply to David Banner, who is concerned that all TATT patients will be expecting a B12 test. The guideline also states that you have to have the symptom AND also the risk factor. So we only need to check B12 in those patients with a common symptom of B12 deficiency who also have a risk factor for B12 deficiency. Thus luckily not every patient as the test is relatively unreliable without also adding in a MMA level if the test is below a certain level.