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Nearly two-thirds of vitamin B12 injections in older adults may be unnecessary
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Approximately 64% of vitamin B12 injections in adults aged 65 and older may be inappropriate, resulting in millions in unnecessary health care costs, according to findings published in JAMA Internal Medicine.
“Randomized clinical trials demonstrate that treating vitamin B12 ... deficiency with oral supplementation substantially increases serum B12 levels compared with intramuscular injections, with no difference in hematologic or neuropsychiatric outcomes,” William K. Silverstein, MD, of the department of medicine at the University of Toronto, and colleagues wrote. “Despite this, some primary care physicians still inappropriately administer B12 injections to elderly patients.”
Researchers conducted a population-based retrospective cohort study with information collected from health system administrative databases to determine the prevalence of inappropriate B12 supplementation. Those aged 65 years and older who received at least one intramuscular B12 prescription between Jan. 1, 2011, and Sept. 30, 2015, were included in the study.
B12 supplementation was considered inappropriate for patients with normal serum B12 levels (221 pmol/L) or in those who did not have a documented B12 level in the year leading up to the first B12 intramuscular prescription.
Within the study period, 405,469 intramuscular B12 prescriptions were made to 146,850 people, 63.7% (n = 93,615) of whom did were deemed inappropriate. In the year prior to first B12 injection, 25.5% (n = 37,487) had normal B12 levels and 38.2% (n = 56,128) did not have a documented B12 level.
Among those without a B12 level documented within a year of injection, 43.1% (n = 24,175) had ever had their B12 level measured, which occurred a mean 1,033.5 days prior to first B12 prescription. Researchers found that only 35.3% (n = 8,539) of those who had documented B12 levels and received an injection had marginally deficient levels of B12.
Silverstein and colleagues estimated that inappropriate B12 injection prescribing cost approximately CAD$45 million (approximately US$34.2 million) each year.
“Further studies should examine this issue, to inform quality improvement initiatives aimed at reducing this unnecessary care,” Silverstein and colleagues wrote. – by Erin Michael
Disclosures: Silverstein reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.
Perspective
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Daniel G. Federman, MD
It is well known that vitamin B12 supplementation can be administered to most people with daily pills or parenterally through periodic injections with no difference in hematologic or neuropsychiatric complications. Silverstein et al published a retrospective cohort study utilizing administrative data bases in Ontario, Canada as a research letter attempting to demonstrate the prevalence and impact of inappropriate parenteral B12 injections in those persons 65 and older. Interestingly, they defined inappropriate parenteral supplementation when it was administered to those with a serum B12 level of ≥ 221 pmol/L. Utilizing that methodology, in part utilizing charges for a physician visit and cost of supplies, they estimated that more than CAD$45 million in expenditures could potentially be avoided if these were switched to oral medications.
While I agree that there are many cases where parenteral B12 can be replaced by daily oral supplementation, by the nature of this being published in letter format with limited space to describe methodology in detail, it is not clear, or at least to me, why they chose a level of 221 pmol/L as a cutoff. For one thing, it is well known that many with B12 deficiency at a cellular level can have low-normal vitamin B12 blood levels and testing serum methylmalonic acid levels may be more sensitive to detect B12 deficiency. Furthermore, it is not apparent in forming their economic analysis, whether all patients came in to the office to receive injections as opposed to being taught to administer it to themselves, and if they did report to the clinic, whether they were charged for a physician visit or nursing visit. They additionally did not describe how they were able to document malabsorption, where perhaps parenteral B12 may be indicated, through the methodology employed. They also deemed it inappropriate if no vitamin B12 level was obtained within a year prior to starting vitamin B12. Some patients might have had low vitamin B12 historically more than 1 year prior and for some reason did not return until much later to receive therapy. I could even envision cases wherein patients with certain maladies (dysphagia, dementia, psychiatric disease, etc.) who cannot reliably take daily supplementation might benefit from monthly or every 3 month injections rather than daily oral supplementation. While I find the authors’ attempts laudatory and I do believe oral supplementation is underused, I question the validity, but not the veracity, of their findings.
References:
Chan CQH, et al. Oral Vitamin B12 replacement for the treatment of pernicious anemia. Front Med (Lausanne) 2016;3 (38):38.
Silverstein WK, et al. JAMA Intern Med. published online July 15, 2019.
Scarpa E, et al. Blood Transfus. 2013 Oct; 11(4): 627–629.
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