CME Tutorial on Detection of B12 Deficiency in Clinical Settings

Why Vitamin B Deficiency Should Be 12
on Your Radar Screen

A Continuing Education Update

Course WB1349

Prepared for the

National Center on Birth Defects and Developmental Disabilities
Centers for Disease Control and Prevention

by

1 Marian L. Evatt, MD
2Patricia W. Mersereau, MN, CPNP
3 Janet Kay Bobo, PhD
4 Joel Kimmons, PhD
5 Jennifer Williams, MSN, MPH, FNP-BC


The findings and conclusions in this report are those of the authors
and do not necessarily represent the views of the
Centers for Disease Control and Prevention.


1 Department of Neurology, Emory University, Atlanta, Georgia.
2SciMetrika, LLC, Atlanta, Georgia.
3 Battelle Centers for Public Health Research and Evaluation, Atlanta, GA and Seattle, Washington.
4 National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia.
5National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia.
iVitamin B Deficiency 12

Contents



Goal and Objectives .................................................................................1
Accreditation ...........................................................................................2
Introduction ............................................................................................3
Case Studies6
Deficiency......................14 Natural History and Prevalence of Vitamin B12
Risk Factors for Vitamin B Deficiency..................................................20 12
Manifestations of Low Vitamin B Levels ..............................................23 12
Screening Patients.................................................................................27
Detection and Diagnosis ........................................................................28
Managing Patients With Evidence of a Vitamin B Deficiency................35 12
Prevention of Vitamin B Deficiencies...................................................40 12
Summary ...............................................................................................42
References.............................................................................................43 es for Text in Boxes .................................................................49
Appendix A: Answers to Case Study Questions ......................................51
Appendix B: Additional Articles on Vitamin B Deficiency .....................53 12
Appendix C: Evaluation Questionnaire, Pretest, and Posttest ................56

2/11/2010 ii Vitamin B Deficiency 12
Figure and Tables

Figure 1. The Biochemical Role of Cobalamin........................................ 16

Table 1. Neurologic and Psychiatric Symptoms of Vitamin B 12
Deficiency and Parkinson Disease (PD) ................................... 13

Table 2. Typical Stages in the Development of a
Vitamin B Deficiency.............................................................. 17 12

Table 3. Prevalence of Vitamin B Serum Levels for the U.S. 12
Population By Age, National Health and Nutrition Examination
Survey 2001–2004 …………………………… 19

Table 4. Prevalence of National Health and Nutrition Examination Survey
Participants With Biochemically Defined Vitamin B Deficiency* 12
By Age Group, United States, 2001–2004 …………………………… 31

Table 5. Tailored Diagnostic Approach for Vitamin B Deficiency………34 12

Table 6. Examples of Treatment Regimens for Vitamin B Deficiency…38 12






Disclosure

CDC, planners, and other content experts wish to disclose
they have no financial interests or other relationships with the
manufacturers of commercial products, suppliers of commercial
services, or commercial supporters.
This module will not include any discussions of the unlabeled use
of a product or a product under investigational use.
2/11/2010 iii Why Vitamin B Deficiency 12
Should Be on Your Radar Screen:
A Continuing Education Update

Goal and Objectives

The goal of this continuing education activity is to
increase the number of primary care providers
(physicians and midlevel providers) who prevent, detect,
and treat vitamin B deficiencies among their high-risk 12
patients.

After completing this continuing education material, you
should be able to

• Describe the prevalence in the United States of
vitamin B deficiency among adults 51 years of 12
age or older.
• List three neurologic effects of a vitamin B 12
deficiency.
• List three hematologic effects of a vitamin B 12
• Identify the most common presentation of a
vitamin B deficiency. 12
• Discuss the changes in absorption of vitamin B 12
that occur with age.
• List at least two pharmacologic options for
treatment of a vitamin B deficiency. 12
















1
2/11/2010 Vitamin B Deficiency 12
Accreditation
Continuing Medical Education (CME): This
activity for 1.5 credits is provided by the Centers
for Disease Control and Prevention (CDC),
accredited by the Accreditation Council for
Continuing Medical Education to provide category 1
credits towards the American Medical Association
(AMA) Physician’s Recognition Award.

Continuing Nursing Education (CNE): This
activity for 1.5 contact hours is provided by CDC,
which is accredited as a provider of continuing
education in nursing by the American Nurses
Credentialing Center’s Commission on
Accreditation (ANCC).

Registration
To register for the course and receive free continuing
education credit:
 Go to http://www.cdc.gov/tceonline..
 Log in as a participant (note: the first time you use
the online system you will need to log in as a new
participant and create a participant profile).
 Find the course by searching the catalog using the
following course number: WB1349.
 You will need to enter the verification code (B12)
to complete the course.
 Select the type of credit you wish to receive and
register for the course.
 Take the examination and complete the course
evaluation.
 Print your continuing education certificate.
To receive continuing education credit, you must
complete the entire course, take the post-test, and
complete the evaluation online.

During this lesson, you will find highlighted
terms. Roll your mouse over each term for
further information.
2 Vitamin B Deficiency 12
Introduction

Vitamin B (cobalamin) deficiency should be on your 12
radar screen for several reasons. Prevention, early
detection, and treatment of vitamin B deficiency are
important public health issues, because they are
essential to prevent development of irreversible
neurologic damage which can impact quality of life.
Although most health care providers already recognize
the occasional person who presents with obvious signs
and symptoms, they are far less likely to screen and
diagnose the majority of patients who have a subclinical
or mildly symptomatic vitamin B deficiency. Vitamin 12
B deficiency is more common among older adults than 12
many health care providers realize. Unpublished
analysis at the Centers for Disease Control and
Prevention (CDC) of laboratory data from community-
based samples of U.S. adults 51 years of age or older
suggest about 1 (3.2%) of every 31 persons have serum
vitamin B levels below 200 picograms per milliliter 12
(pg/mL).

Vitamin B has profound effects on human health. 12
Adequate body stores are essential for several crucial
neurologic and hematologic functions. Delays in the
diagnosis and treatment of vitamin B deficiencies can 12
lead to development of severe, irreversible neurologic
damage.

The clinical importance of vitamin B was established 12
over 50 years ago, when ingesting raw animal liver (the
primary storage organ for vitamin B ) was found to be 12
an effective treatment for pernicious anemia. Research
has shown that the water-soluble vitamin B is required 12
for the completion of several biochemical processes (see
Figure 1).

The following five top things to remember about vitamin
B in primary care practice summarize the implications 12
of these and other cobalamin-related findings.
3 Vitamin B Deficiency 12


The top five things to remember
about vitamin B 12

1. Vitamin B deficiencies occur in adults 51 years of 12
age or older at a frequency of 1 (3.2%) in every 31
persons, and manifest as serum vitamin B levels 12
below the cutpoint of 200 picograms per milliliter.

2. All patients with unexplained hematologic or
neurologic signs or symptoms should be evaluated for
a vitamin B deficiency. If found, the cause should 12
should be determined.

3. Today, megaloblastic anemia is most likely due to
vitamin B deficiency and needs prompt evaluation. 12
In the United States, folic acid fortification has made
folate deficient megaloblastic anemia a very rare
condition.

4. Although the body’s ability to absorb naturally
occurring vitamin B decreases with age, most people 12
can readily use the synthetic form of cobalamin.

5. All people 51 years of age or older should get most of
their daily vitamin B through supplements 12
containing vitamin B or foods fortified with 12
vitamin B . 12
















4 Vitamin B Deficiency 12
This update has been prepared and organized to address
four questions pertinent to primary health care
providers:

 Why should I be concerned about my patient’s
vitamin B status? 12
o Introduction
o Case studies
o Natural history and prevalence of vitamin B 12
deficiencies
o Manifestations of low vitamin B levels 12

 Which of my patients are at high risk for vitamin B 12
deficiency?
o Risk factors for a vitamin B deficiency 12

 How do I detect and diagnose a vitamin B 12
deficiency?
o Screening patients
o Detection and diagnosis

 How should I manage a patient with evidence of
vitamin B deficiency? 12
o Managing patients with evidence of a vitamin
B deficiency 12
o Preventing vitamin B deficiencies 12


5 Vitamin B Deficiency 12
Case Studies

The following case studies are not actual patients. They
combine elements from different cases to emphasize
important aspects of vitamin B deficiency. 12

Case Study 1

Presentation

During a checkup for hypertension, a 65-year-old female
reports a 2-month history of tiredness, feeling faint from
“getting up too fast”, and “memory problems”.

Case Study Question 1

Do any of the presenting complaints raise your index of
suspicion about a possible vitamin B deficiency? If so, 12
why?

History

On review of systems, she reports difficulty
concentrating, fatigue, feeling faint when she stands
quickly, and vague gastrointestinal discomfort with some
decrease in appetite.

She denies any history of previous trauma, diplopia,
dysphagia, vertigo, vision loss, loss of consciousness,
back pain, or symptoms of bowel or bladder dysfunction.

Her family history is negative for neurologic, psychiatric,
and autoimmune diseases. Her medications include an
antihypertensive, as well as an occasional anti-
inflammatory drug for episodic headaches. Her social
history reveals a single woman who smokes about one-
half pack of cigarettes per day, drinks alcohol only
socially, and denies illicit drug use. She has a high
school education and, until recently, had worked in the
office of a trucking company.

6 Vitamin B Deficiency 12
Case Study Question 2

What risk factors does this woman appear to have for a
vitamin B deficiency? 12

Physical Examination

Pale 65 y.o. WF who appears well-nourished, alert, and
oriented.

Vital Signs T-98.6, HR-76, R-18, B/P-130/80 supine
and 95/52 upon standing,
Height/Weight 5’4”/120 lbs.
Head Normocephalic; oropharynx clear but
pale; palpebral conjunctivae pale.
Neck Supple, full active and passive ROM
without pain, without audible bruits; no
lymphadenopathy; no thyromegaly
Back No spine tenderness
Lungs Clear to auscultation
Heart Regular rate and rhythm; no murmurs
Abdomen Soft, nontender; no organomegaly
Rectal Normal rectal tone; no fissures
Extremities No clubbing, cyanosis, or edema; FROM
Skin Pale; no rash

The general physical examination is unremarkable
except for orthostatic hypotension and a weight loss of 3
pounds since her last visit 6 months ago. She is alert
and oriented times three. Her Mini-Mental Status Exam
score is 26 out of 30. She misses one point on serial 7s
and is able to recall three of three items. There is
evidence of bilateral mildly diminished vibration and
proprioception. Her reflexes are 3+/4+ throughout, with
negative Babinski reflex.

Cranial II—Visual acuity 20/25 in both eyes
Nerves (corrected); normal fundoscopic
examination; visual fields intact with no
central scotoma
III, IV, VI—Extraocular movements
intact; pupils equal, round, and reactive
to light with no afferent pupillary defect
V, VII, XII—Intact facial sensation; intact
7