Continuing Education Activity
Vitamin B12, also known as cobalamin, is a water-soluble vitamin that is derived from animal products such as red meat, dairy, and eggs. Intrinsic factor is a glycoprotein produced by parietal cells in the stomach and necessary for the absorption of vitamin B12 in the terminal ileum. Once absorbed, vitamin B12 is used as a cofactor for enzymes that are involved in the synthesis of deoxyribonucleic acid (DNA), fatty acids, and myelin. Vitamin B12 deficiency can lead to hematologic and neurological symptoms. Vitamin B12 is stored in excess in the liver, decreasing the likelihood of deficiency. However, in cases in which vitamin B12 cannot be absorbed, for example, due to dietary insufficiency, malabsorption, or lack of intrinsic factor, hepatic stores are depleted, and deficiency ensues. This activity describes the evaluation and management of vitamin B12 deficiency and highlights the role of the interprofessional team in improving care for affected patients.
Objectives:
- Explain the pathophysiology of vitamin B12 deficiency.
- Review the risk factors for developing a vitamin B12 deficiency.
- Describe the typical presentation of a patient with vitamin B12 deficiency.
- Explain the importance of improving care coordination amongst the interprofessional team to enhance the delivery of care for patients with vitamin B12 deficiency.
Introduction
Vitamin B12 (cobalamin) is a water-soluble vitamin that is derived from animal products such as red meat, dairy, and eggs. Intrinsic factor is a glycoprotein that is produced by parietal cells in the stomach and necessary for the absorption of B12 in the terminal ileum. Once absorbed, B12 is used as a cofactor for enzymes that are involved in the synthesis of DNA, fatty acids, and myelin. As a result, B12 deficiency can lead to hematologic and neurologic symptoms. B12 is stored in excess in the liver; however, in cases in which B12 cannot be absorbed for a prolonged period (e.g., dietary insufficiency, malabsorption, lack of intrinsic factor), hepatic stores are depleted, and deficiency occurs.[1][2][3]
Etiology
Vitamin B12 deficiency has 3 primary etiologies:
- Autoimmune: Pernicious anemia is an autoimmune condition in which antibodies to intrinsic factor are produced. Anti-intrinsic factor antibodies bind to and inhibit the effects of intrinsic factor, resulting in an inability of B12 to be absorbed by the terminal ileum.
- Malabsorption: Parietal cells in the stomach produce intrinsic factor; therefore, any patient with a history of gastric bypass surgery may be at risk for developing a B12 deficiency because their new alimentary pathway bypasses the site of intrinsic factor production. In patients with normal intrinsic factor production, any damage to the terminal ileum, such as surgical resection due to Crohn's disease, will impair the absorption of B12 and lead to a deficiency. Other damage to the small intestine, such as inflammation from celiac disease or infection with the tapeworm Diphyllobothrium latum, may also result in a B12 deficiency.
- Dietary Insufficiency: Vitamin B12 is stored in excess in the liver; however, patients who have followed a strict vegan diet for approximately three years may develop a B12 deficiency from a lack of dietary intake.
Epidemiology
The epidemiology of vitamin B12 deficiency varies based on the etiology. In the general population, some studies have shown that among patients with anemia, approximately 1% to 2% is due to B12 deficiency. Other studies have shown that among patients with clinical macrocytosis (defined as an MCV > 100), 18% to 20% were due to B12 deficiency. Vitamin B12 deficiency is more common in the elderly, regardless of the cause.
B12 deficiency due to pernicious anemia is more common in people of Northern European ancestry. The incidence of pernicious anemia is lower in people of African descent or people from other areas of Europe.[4][5]
Pathophysiology
In healthy patients, dietary vitamin B12 binds to a protein called R-factor, which is secreted from salivary glands. Once the complex arrives at the small intestine, B12 is cleaved from R-factor by pancreatic enzymes, allowing it to bind to a glycoprotein called intrinsic factor, which is secreted by gastric parietal cells. The newly formed complex of B12 and intrinsic factor can then bind to receptors on the ileum, which allows for absorption of B12. Once absorbed, B12 is involved in metabolic pathways important in both neurologic and hematologic functions. If B12 cannot be absorbed, regardless of the etiology, many impairments may occur.
Vitamin B12 is a cofactor for the enzyme methionine synthase, which is used in the conversion of homocysteine to methionine. As a byproduct of this reaction, methyl-THF is converted to THF, which is converted to intermediates used in the synthesis of pyrimidine bases of DNA. In B12 deficiency, homocysteine cannot be converted to methionine, and thus, methyl-THF cannot be converted to THF. As a result, homocysteine levels accumulate, and pyrimidine bases cannot be formed, slowing down DNA synthesis and causing megaloblastic anemia. The anemia then leads to symptoms such as fatigue and pallor that are commonly seen in patients with B12 deficiency. The impaired DNA synthesis causes problems for other rapidly proliferating cell lines, such as polymorphonuclear leukocytes (PMNs). Thus, B12 deficiency characteristically results in the formation of hypersegmented neutrophils.
Vitamin B12 is also used as a cofactor for the enzyme methylmalonyl-CoA mutase, which converts methylmalonyl-CoA to succinyl-CoA. In patients with B12 deficiency, methylmalonic acid (MMA) levels will accumulate, as it cannot be converted to succinyl-CoA. It is hypothesized that elevated levels of MMA, along with elevated levels of homocysteine, contribute to myelin damage, accounting for the neurologic deficits, such as neuropathy and ataxia, seen in these patients. The damage to the myelin results in a condition known as subacute combined degeneration of the spinal cord (SCDSC). This condition affects various parts of the spinal cord, including the dorsal columns, the lateral corticospinal tracts, and the spinocerebellar tracts, resulting in a loss of proprioception, ataxia, the development of peripheral neuropathy, and dementia.[6][7]
History and Physical
A thorough evaluation of vitamin B12 deficiency should include a complete history and physical with an increased emphasis on gastrointestinal (GI) and neurologic findings. B12 deficiency manifests as macrocytic anemia, and thus, the presenting symptoms often include signs of anemia, such as fatigue and pallor. Due to the increased hemolysis caused by impaired red blood cell formation, jaundice may also be a presenting symptom. Therefore, a thorough dermatologic exam may also be helpful. Other presenting complaints may include peripheral neuropathy, glossitis, diarrhea, headaches, and neuropsychiatric disturbances.
When obtaining a complete GI history, it is important to look for a past medical history of celiac disease or Crohn's disease. Any surgical history of gastrectomy or bowel resection, especially resection of the ileum, should increase suspicion for B12 deficiency. In addition, a dietary history may reveal that a patient has switched to a strict vegan diet within the last few years, which would also increase suspicion for B12 deficiency.
In more severe cases, the disease process can progress to involve the nervous system. As mentioned above, SCDSC can result from B12 deficiency, causing damage to various segments of the spinal cord. A complete neurologic exam should evaluate for dementia, peripheral neuropathy, ataxia, and a loss of proprioception. A mental status exam may also be useful to evaluate any neuropsychiatric changes.
Evaluation
In patients with suspected B12 deficiency, initial lab tests should include a complete blood count (CBC) with a peripheral smear and serum B12 and folate levels. In cases where the diagnosis is still unclear after initial testing, other lab tests, such as MMA and homocysteine levels, are available.
In patients who are deficient in B12, the CBC would show anemia, which manifests as a decrease in both hemoglobin and hematocrit. In addition, the mean corpuscular volume (MCV), which measures the size of red blood cells, would be increased to a level greater than 100. This is consistent with a diagnosis of macrocytic anemia. A peripheral blood smear would show hypersegmented neutrophils, with a portion of the neutrophils having greater than or equal to five lobes.
Serum B12 and folate levels also should be obtained. Folic acid deficiency also presents as macrocytic anemia and is often confused with B12 deficiency. Ordering serum levels of both B12 and folate can help differentiate between the two disease processes. A serum B12 above 300 pg/mL is interpreted as normal. Patients with B12 levels between 200 and 300 pg/mL are considered borderline, and further enzymatic testing may be helpful in diagnosis. Patients with B12 levels below 200 pg/mL are considered deficient. However, a low serum B12 level does not determine the etiology of the deficiency. If the etiology is uncertain, further testing should be done to investigate.
In patients with borderline B12 levels (200 to 300 pg/mL), further enzymatic testing should be performed. As described, B12 deficiency results in the accumulation of MMA and homocysteine. Thus, serum levels of MMA and homocysteine both should be elevated in cases of B12 deficiency. These lab values also can help to distinguish B12 deficiency from folate deficiency, in which homocysteine levels are elevated, but MMA levels are normal.
After a B12 deficiency confirmation, the etiology must be addressed. Often, a surgical history including a gastrectomy, resection of the terminal ileum, or gastric bypass will be the cause. If there is no pertinent surgical history, an appropriate GI workup for causes of malabsorption, such as Crohn's or celiac disease should be performed. In other cases, a history of adherence to a strict vegan diet may be the source. If both the GI and dietary workup is negative, then the cause is likely autoimmune. Blood tests for serum levels of anti-intrinsic factor antibodies may lead to the diagnosis of pernicious anemia. Classically, a test known as the Schilling test was used to diagnose pernicious anemia; however, this test is no longer performed. It involved having the patient orally ingest radiolabeled B12. If the patient excreted the radiolabeled B12 in the urine, it indicated normal B12 absorption. A problem with B12 absorption prevents radiolabeled B12 excretion into the urine, indicating a cause of malabsorption or pernicious anemia.[8][9][10]
Treatment / Management
Treatment of vitamin B12 deficiency involves repletion with B12. However, depending on the etiology of the deficiency, the duration and route of treatment vary. In patients who are deficient due to a strict vegan diet, an oral supplement of B12 is adequate for repletion.
In patients with a deficiency in intrinsic factor, either due to pernicious anemia or gastric bypass surgery, a parenteral dose of B12 is recommended, as oral B12 will not be fully absorbed due to the lack of intrinsic factor. A dose of 1000 mcg of B12 via the intramuscular route is recommended once a month. In newly diagnosed patients, 1000 mcg of B12 is given intramuscularly once a week for four weeks to replenish stores before switching to once-monthly dosing. Studies have shown that at doses high enough to fully saturate intestinal B12 receptors, oral B12 is also effective, despite a lack of intrinsic factor.
In anyone at risk of developing a B12 deficiency, such as patients with Crohn's disease or celiac disease, routine monitoring of B12 should be performed. If the severity of the disease worsens and B12 levels begin to decline, treatment is then started. However, prophylactic treatment before B12 levels fall is not indicated.[11][12][13]
Differential Diagnosis
- Lead toxicity
- Syphilis
- HIV myelopathy
- Multiple sclerosis
Prognosis
For patients who are promptly treated with vitamin B12, the prognosis is good. In general, younger patients have better outcomes compared to older individuals. The best response is obtained in people with the absence of severe neurological deficits.
Complications
- Heart failure due to the anemia
- Severe disabling neurological deficits
- Risk of gastric cancer
- Risk of developing an autoimmune disorder like type 1 diabetes, myasthenia gravis, Hashimoto disease, or rheumatoid arthritis
Deterrence and Patient Education
Patients should be educated on the importance of B12 supplement adherence and close follow-up with their primary clinician. Patients that are on a strictly vegan diet should be made aware of the importance of supplementation to prevent B12 deficiency. All patients with risk factors for the various etiologies of vitamin B12 deficiency should be monitored routinely with lab tests.
Enhancing Healthcare Team Outcomes
Vitamin B12 deficiency is a serious disorder, which if not treated can lead to severe neurological symptoms. The ideal way to manage the disorder is with an interprofessional team that includes a primary clinician, gastroenterologist, neurologist, surgeon, pharmacist, dietitian, and a nurse. The primary focus today is to try to prevent the disorder in the first place. The nurse, dietitian, and pharmacist can help educate the patient that there is an increased risk among family members, who should be screened for the disorder. Further, any patient who has undergone gastric resection surgery is also at risk for vitamin B12 deficiency and should be regularly tested. The pharmacist should also recommend testing in patients treated with metformin and proton pump inhibitors. Finally, vitamin B12 deficiency is common in seniors because of poor nutrition, dementia, rigid vegetarian diet or lack of access to care. These individuals should be proactively screened for vitamin B12 deficiency. Once treated, the individuals should be followed by a visiting home care nurse to make sure that the neurological symptoms are improving.[14]
Outcomes
For patients who are promptly treated with vitamin B12, the neurological symptoms of subacute combined degeneration partially resolve, and the progression may stop. In general, younger patients have better outcomes compared to older individuals. The best response is obtained in people with the absence of severe neurological deficits. In addition, in patients with magnetic resonance imaging (MRI) showing mild cord swelling or less than 7 spinal segment involvement, the prognosis is good. However, the clinical improvement may take months or even years. [Level 5][15][16]
Vitamin B12 Deficiency