Controversies Around Vitamin B12 in Sweden

Shifts in B12 opinions in primary health care of Sweden

Aims: The diagnosis and management of vitamin B12 deficiency varies between countries and within countries. The aim of the study was to map current attitudes and values behind clinical decision-making in Swedish primary health care, which has a unique B12 tradition: two patients out of three are treated with oral high-dose cyanocobalamin. Most patients with B12-associated problems are managed in primary health care by general practitioners (GPs). Methods: The study was designed to elucidate possible opinion shifts among GPs during the period 1996- 1998. GPs ( n=499), stratified and randomized, received a questionnaire with 24 statements on B12-associated clinical and laboratory problems, to be evaluated by a visuo-analogue scale. Results: The majority of GPs in primary health care in Sweden accepted homocysteine and methylmalonic acid (MMA) as markers for functional deficiency of vitamin B12. The evaluation of classical markers of B12 deficiency was wary and balanced. There was a consensus of the need for B12 therapy to risk groups such as patients with atrophic gastritis or previous gastric surgery. The answers also appeared to refl ect an improvement of professional knowledge and competence concerning B 12-associated problems among Swedish GPs between 1996 and 1998. Conclusions: The overriding conclusion was that B12-associated opinions of Swedish GPs were stable within the period studied, with marginal improvements of knowledge and competence.

Oral vitamin B12 therapy in the primary care setting: a qualitative and quantitative study of patient perspectives

BACKGROUND

Although oral replacement with high doses of vitamin B12 is both effective and safe for the treatment of B12 deficiency, little is known about patients' views concerning the acceptability and effectiveness of oral B12. We investigated patient perspectives on switching from injection to oral B12 therapy.

METHODS

This study involved a quantitative arm using questionnaires and a qualitative arm using semi-structured interviews, both to assess patient views on injection and oral therapy. Patients were also offered a six-month trial of oral B12 therapy. One hundred and thirty-three patients who receive regular B12 injections were included from three family practice units (two hospital-based academic clinics and one community health centre clinic) in Toronto.

RESULTS

Seventy-three percent (63/86) of respondents were willing to try oral B12. In a multivariate analysis, patient factors associated with a "willingness to switch" to oral B12 included being able to get to the clinic in less than 30 minutes (OR 9.3, 95% CI 2.2-40.0), and believing that frequent visits to the health care provider (OR 5.4, 95% CI 1.1-26.6) or the increased costs to the health care system (OR 16.7, 95% CI 1.5-184.2) were disadvantages of injection B12. Fifty-five patients attempted oral therapy and 52 patients returned the final questionnaire. Of those who tried oral therapy, 76% (39/51) were satisfied and 71% (39/55) wished to permanently switch. Factors associated with permanently switching to oral therapy included believing that the frequent visits to the health care provider (OR 35.4, 95% CI 2.9-432.7) and travel/parking costs (OR 8.7, 95% CI 1.2-65.3) were disadvantages of injection B12. Interview participants consistently cited convenience as an advantage of oral therapy.

CONCLUSION

Switching patients from injection to oral B12 is both feasible and acceptable to patients. Oral B12 supplementation is well received largely due to increased convenience. Clinicians should offer oral B12 therapy to their patients who are currently receiving injections, and newly diagnosed B12-deficient patients who can tolerate and are compliant with oral medications should be offered oral supplementation.

News and views on folate and elderly persons

Elderly persons are especially exposed to folate deficiency, where normal/subnormal folate levels do not exclude tissue deficiency. Accompanying diseases, medication, and lifestyle factors may contribute to/cause deficiency. Symptoms of deficiency can be hematological, neurological, or neuropsychiatric, but it is likely that there are also cardiovascular manifestations as well as associations with malignancies. The physician should make an individualized investigation to establish the probable cause. Among the available determinants of the folate/cobalamin state, plasma homocysteine (Hcy) is a swift and sensitive marker and has the strongest connection to cognitive function. The association is generally stronger between Hcy levels and symptoms than between vitamin-related levels and symptoms. The duration as well as the severity of symptoms are of importance in terms of the improvement of neurological and neuropsychiatric symptoms when substitution is performed. The issue of general folate fortification of flour is complex, and there are as many pros and cons as there are countries in which it is considered to be launched. It is important to bear in mind that in our modern society, deficiency of folate/cobalamin--overt or latent--mainly is a problem of the elderly and a challenge to the doctor.

Vitamin B12 in primary health care and geriatrics--attitudes, knowledge and competence

OBJECTIVES

The objective of the study was to test attitudes, knowledge and competence of Swedish general practitioners and geriatricians concerning B12-associated problems in 1998.

METHODS

Postal questionnaires were sent to a random sample of 485 GPs and a total sample of 613 geriatricians. The response rates were 70% in the GP group and 69% in the geriatrician group. The questionnaire contained 24 statements to be evaluated by a visuo-analogue scale.

RESULTS

There were small numerical differences between the two physician groups. The geriatricians were more aware of risk groups for B12 deficiency. GPs were less categorical concerning low hit rate in the laboratory testing of clinical conclusions. There were statistical differences in both directions for statements on pitfalls in laboratory diagnostics. GPs were somewhat less prone to give risk groups prophylactic B12 therapy.

CONCLUSIONS

GPs and geriatricians appeared to be familiar with the current debate on B12-associated problems, suggesting that health care quality will be unaffected by patient transfer from hospital care to primary health care.