Treatment should be individual. This is easily explicable given the varied pathogenesis of vitamin B12 deficiency - ranging from enzyme defects to insufficient intake - and variation and severity of symptoms.

Haematological symptoms generally respond rapidly to treatment.

Neuropsychiatric deficiency symptoms, on the other hand, may become irreversible if not treated rapidly and aggressively. If parenteral cobalamin treatment is initiated within three to six months of the appearance of the neurological or psychiatric symptoms, most patients will achieve remission, whereas symptoms present for one year or longer tend to be largely irreversible. In the presence of neuropsychiatric symptoms, it is therefore advisable to give an aggressive intramuscular treatment to ensure a sufficient supply regardless of the underlying reasons for the deficiency.

Hydroxocobalamin is found to be better retained, and more efficiently converted to active coenzyme forms than cyanocobalamin.

Some recommendations for vitamin B12 treatment of neuropsychiatric deficiency symptoms have been given in recent literature and reference books:

Martin and co-workers (1992) recommend:

1 mg intramuscularly a day for one week, then 1 mg weekly for four weeks, thereafter 1 mg monthly for at least six months. Martin observed that patients with a short history of disease achieved the best results whereas symptoms present for over one year tended to be irreversible.

Regland & Gottfries (1992) recommend:

1 mg intramuscularly a day for one to two weeks, then 1 mg weekly for four to six months. They stress that, to justify this intensive treatment, active observation and assessment of the results of treatment are important.

Martindale the Extra Pharmacopoiea recommends:

1 mg intramuscularly on alternate days as long as improvement in the neurological symptoms is seen.

In isolated vitamin B12 deficiency, substitutional therapy with vitamin B12 normalises tHcy and MMA within one to threeweeks. If the tHcy remains elevated, folate deficiency must be suspected, even if serum folate is normal or even high. In vitamin B12 deficiency, serum folate levels are often high, whereas whole blood folate may be low. When vitamin B12 treatment is initiated, serum folate levels fall, as intracellular folate accumulates. Folate supplementation may then be indicated.

Early treatment may be essential to prevent neurological damage becoming irreversible.

News

Coming Soon !  The full video recording of the Euromedlab 2007 Active B12 workshop will be available in the next few weeks, register for your copy.

Live CME Web Conference on vitamin B12 deficiency, Prof. Ralph Green, Dec 13th 2007, register now.

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Meetings

8-11 December, 2007
American Society of Hematology, Atlanta, booth 544
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