Role of Pernicious Anemia in Patients Admitted to Internal Medicine with Vitamin B12 Deficiency and Oral Replacement Therapy as a Treatment Option

BACKGROUND

To determine the role of vitamin B12 deficiency in pernicious anemia and the efficacy of oral vitamin B12 replacement therapy given regardless of the etiology, and to compare the endoscopic and pathological findings in patients diagnosed with vitamin B12 deficiency.

METHODS

The study included 216 patients, aged 18 - 65 years, diagnosed with vitamin B12 level < 200 pg/mL between May 2015 and May 2016. Evaluation was made of the demographic characteristics of the patients, diseases, drugs used, dietary habits, previous use of vitamin B12 replacement therapy, family history of vitamin B12 deficiency, laboratory test values, and neurological symptoms present at the time of presentation. Endoscopy was applied to all the patients included in the study. Anti-parietal cell antibody (APCA) and anti-intrinsic factor antibody (AIFA) analyses were applied to all patients.

RESULTS

Evaluation was made of a total of 216 patients diagnosed with vitamin B12 deficiency, comprising 145 (67.1%) females and 71 (32.9%) males. The mean vitamin B12 level of the patients was determined as 127 pg/mL at the time of presentation and 334 pg/mL after treatment. APCA positivity was determined in 40 (18.5%) patients, and AIFA positivity in 5 (2.3%) patients. Atrophy was determined endoscopically in 53 (24.5%) patients and pathologically in 90 (41.7%). Helicobacter pylori positivity was determined in 196 (90.7%) patients. A diagnosis of pernicious anemia (PA) was made in 4 (1.9%) patients (patients with AIFA positivity or APCA accompanied by corpus atrophy). APCA positivity was determined but not corpus atrophy in 36 (16.7%) patients and these cases were accepted as suspected pernicious anemia. In this study of 216 patients with vitamin B12 deficiency, stomach pathologies which could cause vitamin B12 deficiency (atrophic gastritis, HP, PA) and the responses to oral replacement therapy were investigated. As vitamin B12 absorption plays a role in the pathogenesis. Vitamin B12 deficiency can lead to atrophic gastritis, and this was determined with biopsy in 41.7% of the patients. APCA positivity was determined in 18.5% of the patients investigated with respect to autoimmune atrophic gastritis (pernicious anemia) and AIFA positivity in 2.3%. A diagnosis of PA was made in 4 (1.9%) patients from autoimmune marker positivity and the presence of corpus atrophic gastritis. HP was determined in 90.7% of the patients with vitamin B12 deficiency, and although no correlation was determined between HP and atrophy, HP positivity was determined in 84 (93.3%) of the patients with pathological atrophy. From the time of diagnosis, the patients in the study were prescribed 1,000 µg/day vitamin B12. At the 40-day follow-up examination, a significant increase was observed in the vitamin B12 levels of 92.5% of the patients. At the end of the study, as oral replacement therapy was seen to be effective to a great extent, even in patients with PA, it was concluded that for patients not responding to oral replacement therapy, it would be appropriate to apply parenteral vitamin B12 treatment.

CONCLUSIONS

In developing countries such as Turkey, the role of HP infection in vitamin B12 deficiency must be kept in mind. The incidence of atrophic gastritis and pernicious anemia is higher than expected in vitamin B12 deficiency. Thus, it can be concluded that it is appropriate to investigate patients with vitamin B12 deficiency with respect to atrophic gastritis and PA, and oral replacement therapy should be the first stage in the treatment of vitamin B12 deficiency.

Pre-Diabetics with Hypovitaminosis D Have Higher Risk for Insulin Resistance

BACKGROUND

Various studies have been reported on the relationship between vitamin D, whose deficiency has been identified in a pandemic way, and metabolic-endocrine diseases, including insulin resistance. Insulin resistance is an important public health issue since it is a common cause of death as it transforms into metabolic syndrome and type 2 diabetes mellitus (DM). In this study, the aim is to investigate the relationship between the level of serum 25 hydroxy vitamin D (25(OH)D) and insulin resistance.

METHODS

A retrospective study was carried out including 2,008 patients aged between 18 - 67 chosen from among the patients who had applied to Saglik Bilimleri University Antalya Training and Research Hospital. Patients were divided into three groups as non-diabetic, pre-diabetic, and diabetic according to their blood glucose profile and into three categories according to their 25(OH)D levels. The relationship between serum vitamin D levels and insulin resistance was compared between the groups. Individuals with homeostasis model assessment of insulin re-sistance (HOMA-IR) > 2.5 were considered to have insulin resistance.

RESULTS

The study was composed of 2,008 patients, 1,614 were female (80.4%). Of the participants, 216 (10.6%) were diabetics, 849 (42.3%) were pre-diabetics, and 943 (47.1%) were non-diabetics. It was identified that age, fasting blood glucose, HbA1c, triglyceride (Tg), very-low-density lipoprotein cholesterol (VLDL-C), fasting insulin, and HOMA-IR levels were significantly higher in diabetic patients than in pre-diabetic patients (all p < 0.001) and similarly higher in pre-diabetics than in non-diabetics. Tg, VLDL, fasting insulin, and HOMA-IR levels were significantly lower in the group with 25(OH)D ≥ 30 ng/mL. Especially in pre-diabetic individuals, a significant negative correlation was observed between the 25(OH)D level and HbA1c (p = 0.020), Tg (p = 0.001), VLDL-C (p = 0.001), fasting insulin (p < 0.001) and HOMA-IR (p < 0.001). While high HOMA-IR was positively associated with fasting blood glucose and total cholesterol values (all p < 0.001), it was negatively associated with age (p < 0.001), LDL-cholesterol (p < 0.001), HDL-cholesterol (p < 0.001) and 25(OH)D (p = 0.001).

CONCLUSIONS

Diabetic subjects have lower plasma 25(OH)D levels and pre-diabetics with hypovitaminosis D have higher risk for insulin resistance. Thus, HOMA-IR must be well evaluated in pre-diabetic individuals with vitamin D deficiency/insufficiency, if there is associating abdominal obesity.

Management of hypertriglyceridemia induced acute pancreatitis and therapeutic plasmapheresis : Report of nine cases and review of literature

Hypertriglyceridemia is one of the rare causes of the acute pancreatitis. The prevalance of hypertriglyceridemia has increased recently due to the changing eating habits, sedentary lifestyle, alcohol consumption, obesity and concomitant diabetes mellitus. Therefore, the frequency of the acute pancreatitis due to hypertriglyceridemia may increase in coming years. Diagnosis of the acute pancreatitis by hypertriglyceridemia can be overlooked easily and may be very severe if untreated accurately on time. In addition to the standard management of pancreatitis, specific treatment for hypertriglyceridemia that is insulin, heparin and anti-hypertriglyceridemic drugs are used. Therapeutic plasmapheresis is the last treatment option and seems the most effective one in this subject through developing device and membrane technologies when we review the current literature. Not only triglycerides but also proinflammatory cytokines and adhesion molecules that play an active role in pathogenesis are removed by plasmapheresis. So, the effectiveness of treatment appears promising. However, the exact pathophysiology of hypertriglyceridemia-induced pancreatitis could not be fully understood and the majority of published experience comes from the case reports and the benefit of randomized clinical trials is not available. Therefore, there are no data about what are the exact indications and when we start therapeutic plasmapheresis in literature. This manuscript describes our hospital experience with treatment options and analyzes reports published recently about plasmapheresis as a treatment modality for hypertriglyceridemia induced acute pancreatitis.