B12 Deficiency - including during COVID

Thanks to apps.nhslothian.scot for summarising and collating this B12 guidance. Please click on their link for more details


The British Society of Haematology previously advised that during the COVID19 pandemic:

"Liver stores last for a year and hence levels of B12 will not be affected if one to two 3 monthly injection is omitted in patients on maintenance parenteral B12 supplements.   BSH supports omitting B12 injections even in this group during COVID19 outbreak at least until the surge has passed"

However, the Society since amended its advice recommending a more individualised approach, and more emphasis on ongoing injections for some and oral supplements for others: BSH Guidance -B12-Replacement Covid 19

We would recommend that clinicians weigh the risks and benefits, and the Lothian GP Sub-Committee advice is to consider injecting into the deltoid (which can be done at the door or through the car window) to minimise COVID19 infection risk.


Primary care investigations

  • FBC and film

  • Serum ferritin

  • Serum folate.

  • Intrinsic factor antibodies.

Please also see macrocytosis/macrocytic anaemia/ cytopenia guidelines, if relevant.


Who to refer

  • Patients not responding haematologically to B12 replacement therapy (where folate and iron stores have been checked and are normal).

  • Patients with suspected malabsorption or disease of the terminal ileum should be referred to Gastroenterology.

  • Patients with neurological symptoms should be discussed with Neurology if advice required.