Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten
17 November 2004

EASIER VITAMIN B-12 REPLACEMENT

     Several years ago, I wrote a column on a disease called pernicious anemia.  This is a condition in which the patient has become allergic to a certain cell type in their stomach.  This particular cell type secretes acid for the stomachs use and also secretes a protein called intrinsic factor.  Intrinsic factor is a protein which facilitates Vitamin B-12 absorption.  Without this protein, patients become Vitamin B-12 deficient.

     Vitamin B-12 deficiency can be a subtle condition in which the person develops symptoms that look very much like Alzheimer’s disease.  Short term memory may be impaired.  Dizziness and unsteady gait may develop.  The patients develop a strange tingling sensation in their hands and their feet.  Not everyone with these types of symptoms has Vitamin B-12 deficiency but these are symptoms that are characteristic of Vitamin B-12 deficiency when it occurs.  The person may frequently develop these symptoms before an anemia develops. The important step in care is to recognize the B-12 deficiency at an early time and prevent progression of these symptoms.

     Diagnosis of Vitamin B-12 deficiency depends upon a blood test that will document the blood level of Vitamin B-12.  Laboratory parameters vary but anyone with a value below 400 pg/ml has a significant chance of having Vitamin B-12 deficiency.  If a value this low is obtained, the person should then have a serum methylmalonic acid level checked and a homocystine level checked.  If these are both low, then the person almost certainly has true Vitamin B-12 deficiency even if the Vitamin B-12 level is near the laboratory range of normality.  Supplementation should be undertaken if a B-12 deficiency is noted.

     Vitamin B-12 was first marketed in 1948 and came in an injectable form at that time.  It was the belief of the medical profession that in order to treat Vitamin B-12 deficiency, an injectable vitamin was necessary.  Over the past 56 years, the injectable form of the vitamin has been the mainstay of therapy.  Patients generally get a 1000 mcg dose injected once a month.  Cost is around $16.00 for each injection.  Some patients take their Vitamin B-12 supply home and do their own injections.  Most patients come to the clinic and have their injections done there.

     There is now a much easier way to provide the Vitamin B-12 supplementation. There is a form of the tablet that is put under the tongue and the Vitamin B-12 actually enters the blood stream through the skin of the floor of the mouth.  This is done on a daily basis and prevents the need for the monthly injections.  The sublingual (under the tongue) form of the vitamin comes as 500 mcg tablets that cost $3.96 for 200 of them.  Thus for only $8.00 a year, one can avoid 12 shots costing $192.00 and 12 trips to the clinic.

    For those who forget to take their medications, perhaps continuing to take the injections is a wiser choice if the habit is well established.  For an individual who has a good memory and can take a sublingual tablet each day, Vitamin B-12 supplementation can be provided with a simple once a day pill. It is known from the past that if the stomach receives very large doses of Vitamin B-12, enough will absorb through the stomach wall without the presence of intrinsic factor. Administering a 250 microgram tablet once a day is a very large dose and is another way to treat this problem.  For $4.49 for 100 pills, the person can take a 250 mcg tablet each day that is absorbed through the stomach wall.  By this method, so much Vitamin B-12 is present that intrinsic factor is not required.  While this method costs about twice the amount of the sublingual tablet mentioned above, it is also effective and doesn’t require waiting for the sublingual tablet to dissolve.

    The good news is that the injections are no longer necessary for those who don’t want to do that and save money.  Monitoring a serum Vitamin B-12 level at least once a year is strongly recommended to ensure that correction of the deficiency is achieved. The healthcare professionals at your local clinics are aware of these considerations and can help individuals avoid the problems of Vitamin B-12 deficiency.