Incidence Of B12 Deficiency Research Articles

PB1964 ROLE OF HOMOCYSTEINE AND METHILMALONIC ACID IN NEUROLOGICAL PATHOLOGY

Background:Vitamin B12 (B12) deficiency causes hematological and non‐hematological disorders. The latter include neurological syndromes such as polyneuropathies, subacute combined degeneration, basal ganglia lesions, dementia or ischemic stroke. These symptoms can be present even in the absence of anemia or macrocytosis, and the lack of these hematologic changes cannot exclude B12 deficiency as a cause of neurological symptoms..There may be deficiency of B12 with normal or borderline serum levels, hence the relevance of assessing its metabolites homocysteine (HCY) and methylmalonic acid (MMA), that increase in case of B12 deficiency.Aims:To determine the value of HCY and MMA in the diagnosis of B12 deficiency in patients with neurological symptoms.Methods:A retrospective analysis of the cases in which evaluation of B12 and folic acid was requested from the Neurology department during a period of thirteen months was performed.Analytical (complete blood count –CBC–, serum B12, serum folate, erythrocyte folate –when serum folate was low–, HCY, MMA, serum creatinine and estimated glomerular filtration rate –eGFR–) and demographic parameters were evaluated. B12 levels under 150 pg/L were considered low (LB12); between 150 and 200 pmol/L, borderline (BB12); and higher than 200 pmol/L, normal (NB12).Results:One thousand thirty nine (7.8%) of the 14644 requests came from the Neurology department. LB12 was found in 101 (9%) of these cases, BB12 in 177 (15.5%) and NB12 in 861 (75.6%). Folate deficiency was found in 11 (1%) patients.Regarding to patients with LB12, 62% had no alterations in the CBC, 25% had non‐macrocytic anemia and 8% had macrocytic anemia or macrocitosis. These results were similar in the group with BB12. Considering the patients with NB12, 72% of them had a normal CBC, 11,5% had non‐macrocytic anemia, and macrocytic anemia or macrocytosis was observed in 6%. Hematological alterations in these three groups were mild or moderate in 90% of cases; in none was severe (considered if hemoglobin <7 gr/dL, platelets <50x10e9/L, neutrophils <0.5x10e9/L).The metabolite levels were available in 162 cases of the NB12 group. In these patients, high HCY (>14.5 umol/L) was found in 18.8%. Folate levels were normal for all of them, although 32% had an abnormal eGFR that may contribute to the increase in HCY. Mutational status of the MTHFR gene is unknown in these patients. MMA was measured in 7.8% of the patients with NB12; increased levels (>0.4 umol/L) were found in 23.5%. In the NB12 group, 10 patients showed an increase in both metabolites (table 1), suggesting an actual B12 deficiency despite the normal B12 levels. Sensory polyneuropathy was the neurological finding in 9 of these patients and B12 deficiency was assumed the cause in 4 of them, who were given supplementary treatment.Summary/Conclusion:The incidence of B12 deficiency in patients with neurological symptoms is high. Most of these B12‐deficient patients did not show hematological changes or these were mild, and some of them presented with normal serum B12. Assessment of the metabolites is essential in these patients with normal serum B12 and neurological symptoms. This situation represents a true diagnostic and therapeutic challenge.imageTherefore, in the context of a high clinical suspicion, a normal or borderline B12 does not rule out a functional deficiency and metabolites should be assessed.

PTU-112 Proton Pump Inhibitors – A Risk for Micronutrient Deficiency. But Are We Looking Out for This?

Introduction Proton pump inhibitors (PPIs) have long been established as an effective evidence based therapy for many upper gastrointestinal diseases including peptic ulcer disease, gastro-oesophageal reflux disease, oesophagitis and dyspepsia. However, nonjudicious use of PPIs creates both preventable financial as well as medical concerns. There are several studies that point to potential micronutrient deficiencies including iron, vitamin B12, magnesium and calcium as a consequence of long-term PPI use. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients on PPIs. Although high quality evidence for the true burden of deficiency is scarce, clinicians should have an awareness of the potential for these side effects in patients, particularly those on long-term PPIs. We hypothesised that despite increasing evidence of micronutrient deficiency in patients on long term PPIs, this is not assessed in clinical practice. Methods A single centre, retrospective analysis of all patients on long term PPIs usage in a large NHS North London trust was performed. Patients with Barrett’s oesophagus were used as a database of patients on long term PPIs. Their names were identified from the Unisoft endoscopy reporting system as undergoing endoscopic surveillance for Barrett’s. We reviewed their electronic patient records to see if they had ever had their indices for B12, ferritin or magnesium tested whilst they had been undergoing outpatient clinical review. Results Of 41 patients identified, 38 (92.7%) had not had serum magnesium checked in the last 12 months including 15 (36.59%) who had never had it checked. 32 (78.1%) had not had serum ferritin or B12 checked in the past 12 months. Including 9 (21.95%) whom had never had it checked. The median magnesium level was low (0.77, range 0.76–0.89). The median ferritin was normal (106, range 13–196). There was one incidence of B12 deficiency (2.44% all patients, 31.3% of all those tested). Median serum B12 was normal (351, range 10.6–645). Conclusion Despite evidence in the literature of an association between long term PPI use and micronutrient deficiency, the investigation for this by clinicians in a high-risk group was poor and inconsistent. Even in this small cohort, magnesium and B12 deficiency was detected. We would recommend that clear guidance from the British Society of Gastroenterology and other national Gastroenterology bodies on micronutrient monitoring in patients on long term PPIs is required. This may improve screening of micronutrients in long term PPI usage and identify those requiring supplementation. Disclosure of Interest None Declared