On B12, fatigue, malaise, and clinical experience.

For patients feeling malaise,

B12 is a blood test that pays.

      Don’t look at the blood cells

      Just check on the B12

And treatment’s a penny a day.

A patient came in with vague symptoms a week ago and gave me permission to give some information.  Having had a gastric bypass a number of years ago, about a month ago the patient noted fatigue and malaise, just an overall lousy feeling, gradually getting worse.  I ordered the usual panel of tests: CBC, sed rate or ESR, Chemistry 14, B12, folic acid, thyroid stimulating hormone or TSH, mono spot, 25 OH vitamin D, and for men, a testosterone level. 

Our reference lab says that levels of 20 to 30 are vitamin D insufficiency, above 30 is normal(some literature supports 40).  This patient’s level came back at 8. 

We didn’t learn much about Vitamin B12 in med school.  It’s important, we were told, because of pernicious anemia, but chances are you won’t see any problems with it.  And don’t even bother to check if the patient is under 40 and has normally shaped red blood cells.

In residency I diagnosed an elderly patient who had tingling of the hands and feet with B12 deficiency; her level was 199 and the lower limit of normal was 200.   She felt much better the day after the first injection, some of the other docs felt because of the placebo effect.

Years later, in private practice, and I saw a 38-year old who didn’t feel good with large red blood cells.  Her B12 level was low, and the patient felt much better after the first injection.  Over the next three months I lowered the age bar on the basis of experience, and when the 19-year-old artist came up with a lower level, I abandoned age as a decider.  The youngest one I’ve found so far was 11.

In the days before online physician communities, I sought out the hematologist,   someone who should know more than me.  When it came to B12, he didn’t. 

I’d been  pondering for a month, getting what I could from books, when I ran into a neurologist in the hospital parking lot.  No age limit, he said, and don’t both with further testing after a low level.  If they give their own shot, it costs $3.50 for ten months treatment.  And if the person is over the age of 60, has symptoms and a level under 400, treat them.

Which sounded a little radical, but within three months the reference lab started sticking on a caveat that said 10% of those with a level under 400 benefit from injections.

A patient, who did not do well, came to the hospital with a B12 level of “undetectable.”  The red and white blood cells were perfectly normal.  An extreme case which I will never forget; a CBC is a lousy way to decide to check for the problem.

B12 only comes from animals (seaweed is close enough).  Strict vegetarians eventually have B12 problems.  Most people who lack the vitamin eat plenty of meat, but have lost their ability to absorb it.  And with the growing number of people on acid reducers (think purple pills), more and more people can’t absorb B12 at all.

The patient with the gastric bypass has fingertip tingling and a level of 357.  If not for the previous medical history, and my previous clinical experience, I’d be willing to give her vitamin B12 pills in large doses with a recheck of the level in 6 months.

Ninety percent of the patients I started on B12 injections in the last 20 years gave their own injections; I never wanted to have a reputation of being a “shot doctor.”  Nor did I want my motivations questioned.

I have found three cases of B12 deficiency and three cases of B12 insufficiency in my four weeks in Barrow.


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12 Responses to “On B12, fatigue, malaise, and clinical experience.”

  1. bill feiges Says:

    does b-12 work orally bill

    • walkaboutdoc Says:

      B12 will work for some people, but its usefulness is time limited. I never had anyone on B12 oral supplements that kept a good level more than three years. Which certainly doesn’t mean I won’t see one tomorrow.

  2. bill feiges Says:

    what do you mean time limited? over a space of time or intenally whithin your systems.

    • walkaboutdoc Says:

      Some vitamin B12 deficient patients do well on oral supplements, but of those who do, few are still doing well after three years. did that answer your question?

  3. Mike Says:

    I’m 33, have a B12 of 348 and Folic Acid of 24. I have been having burning in the shoulders and arms and pain in the hands for about 4 months. Dr. said my results for B12 are normal. I was taking a multivitimun when I had the test done. Would you consider this normal?

    • walkaboutdoc Says:

      I started B12 injections when mine was 376, but I was in my fifties at the time.

      The algorithm of how to deal with borderline b12 levels, between 200 and 400, is not clear. An article this month in American Family Physician recommended started oral supplements aat 1000 micrograms daily and rechecking a level in 3-6 months if the patient’s signs or symptoms justify it and the level is equivocal.

      In my patients who are as young as you are, who have had borderline B12 levels, some have elected for further testing now (methylmalonic acid and homocysteine), some have chosen oral supplementation, many have chosen injections, and many more have chosen reevaluation in 3-6 months.. If the level is under 400 I always recommend followup.

      All that being said, please see your doctor again because the problem isn’t getting better.

      • Mike Says:

        Thanks for the information. I started taking the 2000 microgram B12 Strips found at GNC in August. I had my B12 levels taken again in December and they are now at 844. Burning in the arms has basically left and I’m not tired anymore.

      • walkaboutdoc Says:

        Good to hear you’re doing well on the strips! I would bet the burning in the arms and the fatigue were from a deficiency.

  4. Leana Says:

    Great article! I am inching up on 40, a vegetarian, and have reflux. I have been taking an OTC PPI for over a decade and B12 for a year. I have been feeling malaise and difficulty concentrating, which is something I can’t afford as a doctoral student. You noted the PPI may prevent absorption of B12. It sounds as though I can choose to suffer malaise or pain from reflux. It also sounds as if B12 supplements will only last a certain amount of time. Any suggestions?

    • walkaboutdoc Says:

      If you have taken a PPI for that long, you need to ask your doc to check a level. I also like to get VitaminD levels, tsh, and folate. Injection vit b12 is so cheap it’s hardly worth. Buying pills.

  5. Tiffany Says:

    I’m 33 and my b12 levels are constantly low for at least two years that I know of. Before the injections, my levels stayed around 120. After almost a year of shots my level shot up to over 1,000 so my Dr. switched to pills but even with those my level immediately dropped to 200. Now I’m back on the shots. But two weeks after an injection, my level is still only 370. Is it normal to have your levels still below 400 even after the shot? Also I’ve been having tingling in hands, feet and face. dizziness, fatigue and now musle weakness in my left arm.

    • walkaboutdoc Says:

      Most experts would agree that there’s a gray area in B12 levels between 200 and 400; further testing (methyl malonic acid and homocysteine levels) can be done, especially in the face of symptoms of B12 deficiency, such as fatigue, malaise, weakenss and tingling. Of course, such symptoms can come from other causes, and just because you have one diagnosis doesn’t mean you can’t have two (for example, folic acid deficiency). A level of 370, 2 weeks after an injection, might indicate increased utilization such as might come from a blind loop syndrome or a parasite infestation.

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