Cobalamin (Vitamin B12) deficiency: is it a problem for our aging population and is the problem compounded by drugs that inhibit gastric acid secretion?

Proton pump inhibitor use and its effect on vitamin B12 and homocysteine levels among men and women: A large cross-sectional study

BACKGROUND

Previous studies have demonstrated an association between proton pump inhibitors (PPI) use and vitamin B12 deficiency. However, data regarding PPI use and elevated serum homocysteine level, an important marker of vitamin B12 deficiency, are scant.

METHODS

Data were collected from medical records of subjects examined at a screening center in Israel. Cross sectional analysis was conducted on 25,953 subjects. Levels of vitamin B12 and homocysteine were compared between subjects who consumed PPI medications and those who did not.

RESULTS

The mean age of the study population was 45 years and 33% were females. Subjects who received PPI medications had a minor higher vitamin B12 levels (320 pmol/L vs 300 pmol/L, p=0.024). Levels of vitamin B12 remained higher in females receiving PPI medications after performing a stratified analysis according to subjects' gender. Homocysteine levels were higher in subjects receiving PPI medications as compared to those who did not (12.0 μmol/L vs 11.6 0 μmol/L, p<0.001). Levels remained higher in female subjects after performing a stratified analysis according to subjects' sex. There was no statistically significant difference in the prevalence of vitamin B12 deficiency (according to two cutoffs: vitamin B12≤200 or ≤140 pmol/L) as well as the prevalence of hyperhomocysteinemia (defined as homocysteine >15.0 μmol/L) between the two groups.

CONCLUSIONS

According to our study, no association was found between PPI medication use and vitamin B12 deficiency or hyperhomocysteinemia. Patients receiving PPI medications had slightly higher levels of vitamin B12 and homocysteine, however these differences were too small to have any clinical relevance.

Depression, Hematologic Parameters, and Blood Levels of Vitamin B12 in Patients With Laryngopharyngeal Reflux Under Use of Proton Pump Inhibitors

Objective

The objective of this study was to evaluate and correlate hematologic indices, vitamin B₁₂ levels, and depression in patients with suspected laryngopharyngeal reflux (LPR) treated with proton pump inhibitor (PPI).

Methods

This was a prospective study with a population (n = 23) consisted of patients with suspected LPR and treated with 2 daily doses of Omeprazole 40 mg (80 mg or full dose). The study volunteers performed a complete blood count and vitamin B₁₂ dosage before and after 3 and 6 months of treatment, as well as depression screening using the Center of Epidemiologic Studies-Depression (CES-D) questionnaire before and after 6 months of treatment. Scores greater than 16 were considered as suggestive of depression.

Results

The mean score on the CES-D scale of study participants at baseline significantly decreased after 6 months of treatment. A significant decrease was observed in the red blood cells count (RBC) after 6 months in relation to 3 months. Significant increases in mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) were observed from 3 months to 6 months in this study. Vitamin B₁₂ levels increased significantly between baseline and after 6 months of treatment.

Conclusion

Decreased scores on the CES-D scale were associated with increased MCV values, with no association with vitamin B₁₂ levels. However, vitamin B₁₂ levels also increased significantly after 6 months of treatment with PPI.

Vitamin B(12) deficiency is linked with long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial?

The purpose of this study was to determine whether institutionalized older individuals taking proton pump inhibitors (PPI) for more than 12 months were more likely to have vitamin B(12) deficiency than individuals not taking PPI, and whether cyanocobalamin nasal spray would improve their vitamin B(12) status. Participants were long-term care residents aged 60-89 years. PPI users (n = 17) were treated with cyanocobalamin nasal spray for 8 weeks; non-PPI users (n = 19) were not treated but were followed for the same time duration. Serum samples from all subjects were analyzed for vitamin B(12) and serum methylmalonic acid (sMMA) at baseline and the end of the 8-week treatment. There was a significant difference in mean vitamin B(12), sMMA, and frequency of deficiency between control and intervention groups at baseline. After treatment, there was an increase (p = 0.012) in serum vitamin B(12) concentration, and a decrease (p = 0.004) in frequency of deficiency in PPI users. Thus, we found that institutionalized older individuals on PPI for more than 12 months may be more likely to be vitamin B(12) deficient than non-PPI users. Additionally, treatment of PPI users with cyanocobalamin nasal spray for 8 weeks could improve vitamin B(12) status.

Safety of the long-term use of proton pump inhibitors

The proton pump inhibitors (PPIs) as a class are remarkably safe and effective for persons with peptic ulcer disorders. Serious adverse events are extremely rare for PPIs, with case reports of interstitial nephritis with omeprazole, hepatitis with omeprazole and lansoprazole, and disputed visual disturbances with pantoprazole and omeprazole. PPI use is associated with the development of fundic gland polyps (FGP); stopping PPIs is associated with regression of FGP. In the absence of Helicobacter pylori infection, the long-term use of PPIs has not been convincingly proven to cause or be associated with the progression of pre-existing chronic gastritis or gastric atrophy or intestinal metaplasia. Mild/modest hypergastrinemia is a physiological response to the reduction in gastric acid secretion due to any cause. The long-term use of PPIs has not been convincingly proven to cause enterochromaffin-like cell hyperplasia or carcinoid tumors. PPIs increase the risk of community acquired pneumonia, but not of hospital acquired (nosocomial) pneumonia. There is no data to support particular care in prescribing PPI therapy due to concerns about risk of hip fracture with the long-term use of PPIs. Long-term use of PPIs does not lead to vitamin B12 deficiencies, except possibly in the elderly, or in persons with Zollinger-Ellison Syndrome who are on high doses of PPI for prolonged periods of time. There is no convincingly proven data that PPIs increase the risk of Clostridium difficile-associated diarrhea in persons in the community. The discontinuation of PPIs may result in rebound symptoms requiring further and even continuous PPI use for suppression of symptoms. As with all medications, the key is to use PPIs only when clearly indicated, and to reassess continued use so that long-term therapy is used judiciously. Thus, in summary, the PPIs are a safe class of medications to use long-term in persons in whom there is a clear need for the maintenance of extensive acid inhibition.

Is low-dose oral cobalamin enough to normalize cobalamin function in older people?

OBJECTIVES

To investigate whether the use of low-dose oral cobalamin (Cbl) supplements by older persons, as frequently found in multivitamin preparations, affects their Cbl serum concentrations and function, determined by measurements of the serum Cbl-related metabolites methylmalonic acid (MMA), homocysteine (HCYS), and methylcitric acid (MCTR).

DESIGN

Cross-sectional study.

SETTING

Community.

PARTICIPANTS

Two hundred forty-two independent, active, community-living, older adult volunteers recruited from community events and activities for seniors.

MEASUREMENTS

We systematically collected data on vitamin supplement intake, diet, medications, and medical and surgical history. Serum was obtained for Cbl, MMA, HCYS, and MCTR, and creatinine and hematological parameters.

RESULTS

Serum levels of Cbl were significantly higher in subjects on oral Cbl supplements (2-37.5 microg/day). Similarly, serum levels of the metabolites MMA, HCYS, and MCTR were also lower in subjects on Cbl supplementation. Intake of low-dose oral supplements of Cbl significantly reduced the odds of low Cbl levels or high MMA. The relationship between Cbl supplement dosage and the biochemical parameters was dose dependent.

CONCLUSION

Oral Cbl (2-37.5 microg/day) intake by community-dwelling healthy older adults is associated with higher serum levels of Cbl and improved or normalized Cbl function, as indicated by lower concentrations of the metabolites MMA, HCYS, and MCTR. Use of low-dose oral Cbl replacement therapy might be sufficient to prevent Cbl deficiency in a large proportion of this population.