#Hematology_21 #Anemia #Macrocytic_anemia_6 Treatment of VitB | "لعلي أفيدك" Clinical discussion

#Hematology_21 #Anemia #Macrocytic_anemia_6
Treatment of VitB12 deficiency

لو المريض اتشخص ك B12 deficiency سواء كان b12 level اقل من 200pg/ml او كانت قيمته borderline من 200-300 وعملنا تحليل لل MMA وال homocysteine وكانو elevated
بهلحاله هنعطيه replacement therapy by B12
بروتوكول العلاج هيكون على حسب هل في Sever anemia او neurological symptom او لأ

واشهر Formulation هنستخدمها لل replacement

Hydroxycoblamin
موجود ك I.M

Cyanocoblamin
موجود ك I.M و SC و orally و Intranasal

الفرق الجوهري بينهم ان ال Cyano لو هيتاخد ك maintenance بيتاخد مرة شهريا
أما ال Hydroxy فإله frequency اقل وبينعطى مره كل 2-3 شهور ك maintenance

السيناريو الأول هو مريض بدون neuro symptoms :
patient without significant Neurologic symptoms

حسب ال BCSH
British Committee for Standards in Haematology (BCSH)
ال recommendation كانت اعطاء 1000mcg of vitB12
ويكون I.M ثلاث مرات في الاسبوع لمدة أسبوعين

اما حسب ال British Columbia (Canada) Medical Association فبيفضلو ال oral method
cyanocobalamin orally as treatment of choice

1,000 mcg/day in patients with pernicious anemia or food-bound cobalamin malabsorption

250 mcg/day in patients with vitamin B12 deficiency due to other causes
في برتوكول تالت
cyanocobalamin or hydroxocobalamin 1,000 mcg intramuscularly per day or every other day for 1 week, followed by weekly injections up to 8 weeks, followed by every 3-4 weeks

وبعدها يكمل Maintenance وال duration هتعتمد على حسب هل المسبب لل b12 deficiency اتصلح
ولا irreversible
duration of treatment depends on underlying cause

for temporary causes (for example, pregnancy), review need for continued treatment once patient is fully replete and causative agent removed

suggested maintenance therapy in patients without neurologic involvement

if caused by dietary deficiency, consider high-dose oral vitamin B12 (50-150 mcg/day) over 3-4 months to replace stores, followed by ≥ 6 mcg/day orally (life-long treatment for vegans or vegetarians where diet is unlikely to change

if caused by food-bound vitamin B12 malabsorption, consider a lower minimum dose of daily oral cyanocobalamin and increasing dose as necessary (BCSH Grade 2C);
suggested dose 500-1,000 mcg/day.

for irreversible cases (such as pernicious anemia, or after gastric surgery), continue treatment for life typically with vitamin B12 1,000-2,000 mcg/day orally or monthly parenteral cyanocobalamin 1,000 mcg (or hydroxocobalamin 1,000 mcg every 3 months)


السيناريو التاني :

Patient with Significant neurologic symptom
حسب ال BCSH
(BCSH) suggest hydroxocobalamin 1,000 mcg intramuscularly on alternate days until no further improvement (review need to continue treatment after 3 weeks)
وبعدها يكمل maintenance بال Hydroxy بجرعة 1000mcg كل شهرين

British Columbia (Canada) Medical Association guidelines suggest crystalline cyanocobalamin 1,000 mcg intramuscularly or subcutaneously daily for 1-5 days, then switch to 1,000-2,000 mcg/day orally

وفي بروتوكول تالت
هياخد 1000mcg كل يوم لمدة 2week
ثم مرة واحدة في الأسبوع لحد ما ال Hb يصير نورمال
وبعدها يمشي maintenance كل اسبوعين ياخد 1000mcg لمدة 6 شهور
وبعدها يكمل monthly لمدى الحياة

or cyanocobalamin is administered at 1,000 mcg/day intramuscularly or subcutaneously for the first week, then twice a week for the next two weeks, followed by 1,000 mcg every month for life
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