British Society for Haematology (BSH) guidance on Vitamin B12 replacement during the COVID-19 pandemic

Non-dietary vitamin B12 deficiency

(e.g. pernicious anaemia, prior gastrectomy, bariatric surgery, achlorhydria, pancreatic insufficiency, short bowel syndrome, bacterial overgrowth, inflammatory bowel disease)

NICE 2019 recommendation: administer hydroxocobalamin 1 mg intramuscularly every 2– 3 months for life

British Society for Haematology advice during the COVID-19 pandemic for patients established on intramuscular hydroxocobalamin:

The need for intramuscular (IM) hydroxocobalamin should be discussed with each patient individually. We recommend that screening questions for COVID-19 infection are asked be- fore patients attend their GP surgeries. Alternatives to attending the GP surgery such as lo- cal pharmacies or home administration by district nurses should be explored.

As an alternative, oral cyanocobalamin can be offered at a dose of 1 mg per day until regular IM hydroxocobalamin can be resumed, i.e. once GP surgeries are able to do so safely, aim- ing to have a shortest possible break from regular injections.

Patients should be advised to monitor their symptoms and should contact their GP if they begin to experience neurological or neuropsychiatric symptoms such as pins and needles, numbness, problem with memory or concentration or irritability.

Patients who are already self-administering IM hydroxocobalamin should continue to do so but we do not recommend a patient switching to self-administration during the COVID-19 pandemic since instruction is likely to be difficult.

Dietary Vitamin B12 deficiency

NICE 2019 recommendation: advise people either to take oral cyanocobalamin tablets 50– 150 micrograms daily between meals or have a twice-yearly hydroxocobalamin 1 mg injec- tion. In vegans, treatment may need to be life-long, whereas in other people with dietary de- ficiency replacement treatment can be stopped once the vitamin B12 levels have been cor- rected and the diet has improved.

British Society for Haematology advice during the COVID-19 pandemic for patients established on intramuscular hydroxocobalamin:

An alternative is to offer oral cyanocobalamin tablets, 50–150 micrograms, daily between meals. We recommend reassessing serum B12 prior to recommencing IM hydroxocobalamin.

However, many of these patients may be vitamin B12 replete with adequate levels within the liver, and therefore may be able to safely stop taking vitamin B12 supplements possibly for up to a year (Hoffbrand 2016).

Dietary advice should be given to all patients. Patients on vegetarian and especially vegan diets should continue taking oral supplements.