Changes in serum vitamin B12 levels in patients with megaloblastic anaemia treated with folic acid

Effective Treatment of Cobalamin Deficiency With Oral Cobalamin

Because cobalamin deficiency is routinely treated with parenteral cobalamin, we investigated the efficacy of oral therapy. We randomly assigned 38 newly diagnosed cobalamin deficient patients to receive cyanocobalamin as either 1 mg intramuscularly on days 1, 3, 7, 10, 14, 21, 30, 60, and 90 or 2 mg orally on a daily basis for 120 days. Therapeutic effectiveness was evaluated by measuring hematologic and neurologic improvement and changes in serum levels of cobalamin (normal, 200 to 900 pg/mL) methylmalonic acid (normal, 73 to 271 nmol/L), and homocysteine (normal, 5.1 to 13.9 μmol/L). Five patients were subsequently found to have folate deficiency, which left 18 evaluable patients in the oral group and 15 in the parenteral group. Correction of hematologic and neurologic abnormalities was prompt and indistinguishable between the 2 groups. The mean pretreatment values for serum cobalamin, methylmalonic acid, and homocysteine were, respectively, 93 pg/mL, 3,850 nmol/L, and 37.2 μmol/L in the oral group and 95 pg/mL, 3,630 nmol/L, and 40.0 μmol/L in the parenteral therapy group. After 4 months of therapy, the respective mean values were 1,005 pg/mL, 169 nmol/L, and 10.6 μmol/L in the oral group and 325 pg/mL, 265 nmol/L, and 12.2 μmol/L in the parenteral group. The higher serum cobalamin and lower serum methylmalonic acid levels at 4 months posttreatment in the oral group versus the parenteral group were significant, with P < .0005 and P < .05, respectively. In cobalamin deficiency, 2 mg of cyanocobalamin administered orally on a daily basis was as effective as 1 mg administered intramuscularly on a monthly basis and may be superior.

© 1998 by The American Society of Hematology.

Effective Treatment of Cobalamin Deficiency With Oral Cobalamin

Because cobalamin deficiency is routinely treated with parenteral cobalamin, we investigated the efficacy of oral therapy. We randomly assigned 38 newly diagnosed cobalamin deficient patients to receive cyanocobalamin as either 1 mg intramuscularly on days 1, 3, 7, 10, 14, 21, 30, 60, and 90 or 2 mg orally on a daily basis for 120 days. Therapeutic effectiveness was evaluated by measuring hematologic and neurologic improvement and changes in serum levels of cobalamin (normal, 200 to 900 pg/mL) methylmalonic acid (normal, 73 to 271 nmol/L), and homocysteine (normal, 5.1 to 13.9 μmol/L). Five patients were subsequently found to have folate deficiency, which left 18 evaluable patients in the oral group and 15 in the parenteral group. Correction of hematologic and neurologic abnormalities was prompt and indistinguishable between the 2 groups. The mean pretreatment values for serum cobalamin, methylmalonic acid, and homocysteine were, respectively, 93 pg/mL, 3,850 nmol/L, and 37.2 μmol/L in the oral group and 95 pg/mL, 3,630 nmol/L, and 40.0 μmol/L in the parenteral therapy group. After 4 months of therapy, the respective mean values were 1,005 pg/mL, 169 nmol/L, and 10.6 μmol/L in the oral group and 325 pg/mL, 265 nmol/L, and 12.2 μmol/L in the parenteral group. The higher serum cobalamin and lower serum methylmalonic acid levels at 4 months posttreatment in the oral group versus the parenteral group were significant, with P &lt; .0005 and P &lt; .05, respectively. In cobalamin deficiency, 2 mg of cyanocobalamin administered orally on a daily basis was as effective as 1 mg administered intramuscularly on a monthly basis and may be superior.

© 1998 by The American Society of Hematology.

Investigation of macrocytic anemia

The three most common causes of macrocytosis--vitamin B12 or folate deficiency, liver disease, and reticulocytosis--usually can be differentiated on the basis of red cell indexes and morphologic findings. Bone marrow studies are not indicated. In reticulocytosis, the mean corpuscular volume (MCV) rarely exceeds ll0 cu mu and a reticulocyte count quickly establishes the diagnosis. In liver disease, macrocytosis is also mild and uniform. The RBCs are round. In megaloblastic anemia, the MCV may exceed 150 cu mu. The RBCs vary considerably in size and shape. The macrocytes tend to be oval. Serum vitamin B12 determination remains the best test for unmasking vitamin B12 deficiency. It should be ordered in conjunction with serum and red cell folate determinations in the course of investigating a macrocytic anemia. When vitamin B12 deficiency has been established, a Schilling test or plasma uptake test is indicated to pinpoint the cause.

Experimental nutritional folate deficiency in the baboon (Papio cynocephalus)

1. Folate deficiency was produced in baboons by feeding them on a diet which was deficient in folic acid.

2. Loss of body-weight, anorexia, asthenia, gingivitis and diarrhoea were common features of the deficiency.

3. Haematologically, the deficiency was characterized by leucopenia with a greater proportional decrease in the polymorphonuclear neutrophils, thrombocytopenia and in some baboons macrocytic anaemia.

4. Deficient baboons had low serum, erythrocyte and liver folate levels and excreted increased amounts of formiminoglutamic acid. The fall in the serum folate level was more rapid than that of the erythrocytes, occurring mainly during the 1st month of deficiency, while erythrocyte levels decreased gradually over a 5-month period.

5. Serum and liver vitamin B12levels and methylmalonic acid excretion were normal in deficient baboons.

Iron, folate, and vitamin B 12 nutrition in pregnancy: a study of 1000 women from southern India

As part of a WHO collaborative programme the prevalence of anaemia was studied and the serum concentrations of iron, folate, and vitamin B(12) were measured in 1 000 pregnant women from southern India. The results of the study show a high prevalence of anaemia, resulting from iron and folate deficiency with iron deficiency predominating. Interrelationships between these nutrients and their effect on pregnancy and the fetus were investigated. The results indicate that, in comparison with populations in developed countries, there was a high prevalence of iron and vitamin B(12) deficiency in the community, but the state of folate nutrition was similar to that found elsewhere.

The present status of vitamin B 12 and folic acid deficiency in psychiatric illness

Vitamin B12 Deficiency

Among the many causes of organic psychoses are a number of processes which may be cured or arrested by the right treatment and by early recognition. This includes deficiency of vitamin B12. There is, therefore, a temptation to carry out sophisticated tests for vitamin B12 deficiency in all psychiatric patients. However, until cheaper and fully-automated techniques become available, routine vitamin B12 assays cannot be justified in psychiatric patients. At the present time a hemoglobin estimation and a careful inspection of the peripheral blood film by an experienced hematologist appear to be the most economic primary screening test for vitamin B12 deficiency. Nevertheless, psychiatrists should be alert to the possibility of vitamin B12 deficiency in patients with unexplained fatigue and in those with confusional states or dementia of unknown origin. Another presentation may be impotence which sometimes precedes other neurological manifestations of the disease. Even in patients who are not anemic or have no blood film abnormalities (which is uncommon) the possibility of missing cases of hypovitamin B12 deficiency can be further diminished by doing serum B12 assays in patients who are clinically at risk. For example, this includes post-gastrectomy patients, those with a familial history of pernicious anemia and those with an associated auto-immune disorder, such as thyroid disease.

Folic Acid Deficiency

The available evidence linking folate deficiency with psychiatric disorders is inconclusive. It is probable that the observed excess of folic acid deficiency in psychiatric patients can be explained on the basis of malnutrition, chronic physical illness, alcoholism or other drug usage. An important exception is brain damage and mental retardation in infants with inborn errors of folic acid metabolism. Further evaluation of folate deficiency is indicated, particularly in the affective disorders and in ambulatory, non-institutionalized, epileptic patients receiving anticonvulsant medication.

A survey of vitamin B-12 deficiency in an elderly psychiatric population

For many years, cases of pernicious anaemia associated with mental symptoms have been described, and interest in these symptoms was renewed following the introduction of liver therapy (Richardson, 1929; Phillips, 1931). Interest later appeared to decline, so that MacDonald Holmes (1956), almost 20 years after the last important clinical review of the subject, could comment with justification that although the cerebral lesions of pernicious anaemia had been recognized for more than a century they were still much less familiar than the lesions which occurred in the spinal cord and peripheral nerves. Since then vitamin B12 deficiency as a cause of mental symptoms has given rise to increasing interest, and this is reflected in recent suggestions that serum vitamin B12 assays should be carried out routinely in psychiatric patients and might be more informative nowadays than the routine Wassermann reaction (Strachan and Henderson, 1965; Hunter and Matthews, 1965).

ACUTE FOLIC ACID DEFICIENCY OF UNKNOWN AETIOLOGY: TEMPERATE SPRUE

The 20 patients described could be included in the group of patients diagnosed as ;idiopathic steatorrhoea'. However, their histories were short and diarrhoea was not a major feature. Since megaloblastic anaemia due to folic acid deficiency was a common feature it is suggested that these patients may form a homogeneous group and the diagnostic label of temperate sprue is suggested.