vitamin B12 deficiency with acid suppressive therapy

Although gastric acid is required to cleave vitamin B12 from ingested dietary proteins, and the same parietal cells that produce acid also produce intrinsic factor, studies have been mixed as to whether acid suppressive therapy leads to low vitamin B-12 levels. a large community-based case-controlled study was done by Kaiser Permanente North California comparing 26,000 patients with an incident diagnosis of vitamin B12 deficiency with 185,000 without (see PPI and B12 deficiency jama 2013 in dropbox, or doi:10.1001/jama.2013.280490).  Results:

--Vitamin B12 deficiency was more commonly diagnosed in patients with at least a 2 year supply of PPIs compared to nonusers (OR, 1.65).
--among people taking PPIs for at least 2 years, those on a higher dose (greater than 1.5 pills per day) had a higher OR of 1.95, as compared to those who were on lower doses of less than 0.75 pills per day, with OR of 1.63, and a statistically significant trend.
--a similar trend was found with people on H2 blockers, though there was no increased risk in those taking less than 0.75 pills per day.  The odds ratios were also significantly less than with PPIs.
--In addition, there was an increasing trend of vitamin B12 deficiency with longer duration of use of PPIs, but no trend with H2 blockers
--The strength of the association between PPI use and B12 deficiency decreased with discontinuation of the PPI
--The association between PPIs and B12 deficiency was strongest among those who were younger, especially those younger than 30 years of age.  The association was also stronger for women than men.  No differences by race/ethnicity.  No difference if diagnosis of GERD or not.

so, although the study was not a randomized controlled trial, it has the benefit of being very large, did find that the likelihood of B12 deficiency increased with higher potency of acid suppression (PPI>H2 blocker) and higher doses of the PPI, more likely with longer duration of taking the PPI, decreased on stopping PPI,  and was more profound than with other conditions known to be associated with B12 deficiency such as thyroid disease.  There there also is a reasonably plausible mechanism. This again reinforces that PPI's are very strong drugs and should be used only when necessary -- prior studies have shown that it is pretty uncommon for patients initially put on PPIs to be "stepped-down" to less aggressive therapies (H2 blockers or calcium tablets), reinforcing the "step-up" approach of starting with less potent and increasing potency as clinically needed (though i also do find that even in this case, over time some patients can be down-titrated)

Comments

Post a Comment

if you would like to receive the near-daily emails regularly, please email me at gmodest@uphams.org

Popular posts from this blog

cystatin c: better predictor of bad outcomes than creatinine

  another article found significant discordance between creatinine and cystatin C in assessing renal function,  finding that the latter correlated most strongly with both renal and non-renal adverse clinical outcomes (see   ckd cystatin c better than creat AJKD2023  in  dropbox or doi: 10.1053/ j.ajkd.2023.04.002)   Details: -- 158,601 adults who were in the Stockholm Creatinine Measurements (SCREAM) project and had testing of creatinine and cystatin C on the same day during a healthcare encounter, from 2010-2018     -- >400,000 outpatient tests were done for both creatinine and cystatin C levels -- mean age 62, 48% female -- mean eGFR by creatinine (   eGFR cr ) 80; mean eGFR by cystatin C ( eGFR cys  ) 73 -- mean stage of renal insufficiency: 39%  eGFR cr   90+; 38%  eGFR cr  60-89; 12%  eGFR cr  45-59; 7.1%  eGFR cr  30-44; 3.2%  eGFR cr  15-29, 0.7%  eGFR cr ...
Read more

diabetes DPP-4 inhibitors and the risk of heart failure

the FDA just came out with a safety alert about 2 DPP-4 inhibitors and the increased risk of heart failure (released 04/05/2016)(see  http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494252.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery ​ ). details: --saxagliptin and alogliptin were singled out because of 2 clinical trials in diabetic patients with heart disease. in each trial more patients taking these meds were hospitalized for heart failure vs those on placebo     --in the saxagliptin trial: 3.5% were hospitalized for heart failure (vs 2.8% on placebo). risk factors included prior heart failure or kidney disease     --in the alogliptin trial: 3.9% were hospitalized for heart failure (vs 3.3% on placebo) --recommendation by the FDA:     -- we should consider stopping these drugs if the patient develops heart failure ...
Read more

UPDATE: ASCVD risk factor critique

I decided to do an extensive update of my prior ASCVD (atherosclerotic cardiovascular disease) risk analysis and critique of risk calculators, with much more information about the “non-traditional” risk factors. I felt that there should be more data/clarification, since I think we are really undertreating/not preventing the most common cause of death by relying on the current ASCVD risk calculators   -- Cardiovascular risk models:      -- many of us rely on the various cardiovascular risk models to determine the appropriate approach to patients, and these are often integrated into the electronic medical records      -- these risk models have several very important limitations:          -- they are typically based on community data, eg from the Framingham study etc. But, in clinical practice, we are dealing with the individual and not the community:          ...
Read more