Evaluation of Vitamin B12 Monitoring in a Veteran Population on Long-Term, High-Dose Metformin Therapy

2012 ◽  
Vol 46 (11) ◽  
pp. 1470-1476 ◽  
Author(s):  
Sarah A Pierce ◽  
Amy H Chung ◽  
Karen Korch Black
Keyword(s):  
Medical Records ◽  
Current Practice ◽  
Megaloblastic Anemia ◽  
Veterans Affairs ◽  
Deficiency Anemia ◽  
Vitamin B ◽  
High Dose ◽  
Duration Of Treatment ◽  
Secondary Objective

BACKGROUND: Metformin can result in vitamin B12 deficiency, potentially leading to complications such as neuropathy. Annual monitoring of vitamin B12 has been suggested; however, it is unknown whether current practice reflects this recommendation. OBJECTIVE: To identify vitamin B12 monitoring patterns in patients on long-term, high-dose metformin. Secondary objective was to determine the frequency of new vitamin B12 deficiency, anemia, and neuropathy documented after initiation of high-dose metformin. METHODS: Electronic medical records of veterans treated at the Veterans Affairs Maryland Healthcare System with high-dose metformin (≥2000 mg/day) as of November 1, 2010, were reviewed. Data regarding metformin treatment, vitamin B12 measurements, and documentation of vitamin B12 deficiency, cyanocobalamin supplementation, anemia, and neuropathy were collected. Subjects treated with metformin for less than 1 year or those with documented peripheral neuropathy, megaloblastic anemia, vitamin B12 deficiency, or a condition associated with vitamin B12 malabsorption prior to metformin initiation were excluded. RESULTS: Subjects (N = 235) had a mean metformin dose of 2050 mg/day and mean duration of treatment of 5.2 years. Sixty percent did not have vitamin B12 measured. Of subjects receiving metformin for 10 years or more, nearly half (46%) never had vitamin B12 measured. New documentation of vitamin B12 deficiency or cyanocobalamin supplementation was found in 5.5% of the population, and anemia was found in 12%. Of the 14% with new neuropathy, 42% did not have vitamin B12 measured. CONCLUSIONS: Vitamin B12 was not routinely monitored in patients on high-dose metformin, even in those at highest risk (≥10 years of therapy), or in those with potential manifestations of vitamin B12 deficiency (neuropathy). Cases of vitamin B12 deficiency and resulting anemia or neuropathy may be undiagnosed and untreated because of lack of monitoring. Prospective studies examining the effect of increased vitamin B12 monitoring on identification and treatment of vitamin B12 deficiency in patients on metformin are warranted.

scholarly journals Trombocytosis in childhood relapsing nephrotic syndrome

2007 ◽  
Vol 47 (3) ◽  
pp. 100
Author(s):  
Ade Hafni ◽  
Danny Hilmanto ◽  
Dedi Rachmadi ◽  
Nanan Sekarwana
Keyword(s):  
Nephrotic Syndrome ◽  
Iron Deficiency ◽  
Medical Records ◽  
Steroid Treatment ◽  
Deficiency Anemia ◽  
High Dose ◽  
Number Of Patients ◽  
Frequent Relapses ◽  
Acute Haemorrhage

Background Thrombosis is a serious complication of nephroticsyndrome (NS). Long-term steroid treatment may inducethrombocytosis in relapsing NS that may predispose to thrombosis.Most children with idiopathic NS respond to steroids; however, asubstantial number of patients will relapse frequently and requirerepeated high dose steroid therapy, thus increase the risk ofthrombocytosis.Objective To compare the occurrence of thrombocytosis betweenchildren with frequent relapses of NS (FRNS) and those withinfrequent relapses (IFRNS).Methods We reviewed the medical records of children aged 1-14years diagnosed as FRNS and IFRNS at the Department of ChildHealth, Hasan Sadikin General Hospital Bandung from 2000-2005. We excluded children with iron deficiency anemia,hemolytic anemia, acute haemorrhage, malignancy, and those whoreceived cyclophosphamide.Results There were 33 children (26 males, 7 females) with FRNSand 33 children (27 males, 6 females) with IFRNS. The meanplatelet level of children with FRNS (517,909+165,670/ml) washigher than that of children with IFRNS (416,272+145,763/ml)(P=0.005). The occurrence of thrombocytosis in children withFRNS (18) was higher than that of children with IFRNS (7)(P=0.005).Conclusion This study shows that thrombocytosis is morecommon in FRNS than IFRNS, therefore we should take moreprecaution to the occurrence of thrombosis in FRNS.

Vitamin B-6 Vitamer Levels in Plasma and Related Symptoms in Hemodialysis Subjects Taking low- and High-Dose Renal Multivitamin Supplements

2012 ◽  
Vol 82 (2) ◽  
pp. 130-136 ◽  
Author(s):  
Clement ◽  
Boylan ◽  
Miller ◽  
Driskell ◽  
Giraud ◽  
...  
Keyword(s):  
Medical Records ◽  
Low Dose ◽  
Vitamin B ◽  
High Dose ◽  
Vitamin Supplement ◽  
Pyridoxine Hydrochloride ◽  
Cluster Group ◽  
The Mean ◽  
Multivitamin Supplements ◽  
High Dose Vitamin

Introduction: The purpose of this study was to evaluate the B-6 vitamers in plasma and related symptoms in hemodialysis subjects taking high- or low-dose vitamins. Methods: A total of 24 hemodialysis (HD) subjects were divided into two groups. Twelve subjects received a high-dose vitamin supplement [50 mg pyridoxine hydrochloride (PN-HCl) /tablet] and 12 received a low-dose vitamin supplements containing (10 mg PN-HCl/tablet) for 6+ months. Plasma B-6 vitamers were analyzed using HPLC. Other data were obtained from subjects’ medical records. Subjects were assessed for vitamin B-6 related symptoms. Cluster analysis was used to form symptom groups. Student t-tests and analysis of variance were used to determine differences (p < 0.05) in group means. Results: The mean ±SD plasma B-6 vitamer and 4-pyridoxic acid concentrations (nmol/L) were as follows in the 10-mg and 50-mg PN-HCl groups, respectively: pyridoxal- 5’-phosphate (PLP) 10 ± 3 and 16 ± 8 (p = 0.04); pyridoxal (PL) 50 ± 96 and 68 ± 06; pyridoxine (PN) 26 ± 50 and 191 ± 107; and 4-pyridoxic acid (4-PA) 43 ± 64 and 99 ± 361. The cluster group with a significantly higher (p = 0.04) plasma 4-PA concentration of 167 ± 697 nmol/L reported more tingling hands, tachycardia, and diarrhea. Conclusion: Plasma PLP levels and symptoms related to B-6 in HD subjects are impacted by dose of PN-HCl.

scholarly journals Audit of pharmacological management of borderline personality disorder as per NICE clinical guidelines CG78

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S319-S319
Author(s):  
Bethany Dudley ◽  
Shakina Bellam ◽  
Andrew Lawrie
Keyword(s):  
Borderline Personality Disorder ◽  
Personality Disorder ◽  
Current Practice ◽  
Term Treatment ◽  
Borderline Personality ◽  
Duration Of Treatment ◽  
Pharmacological Management ◽  
Single Drug ◽  
Written Information

AimsTo audit the current practice of pharmacological management of Borderline Personality Disorder with NICE Clinical guideline [CG78]: Borderline personality disorder:Objectives:23 patient records were analysed in the last 18months with a diagnosis of EUPD to compare current practice against NICE clinical guidance. (2009)Standards:When prescribing 1)Use a single drug.2)Use the minimum effective dose.3)Agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment. Antipsychotic drugs should not be used for medium, long term treatment.Indication:4)Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated. (Repeated self-harm, marked emotional instability, risk taking behaviour and transient psychotic symptoms).5)Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan in a crisis. The duration of treatment should be no longer than 1 week.6)When considering drug treatment, provide the person with written material about the drug. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm.Review:7)Review the effectiveness and tolerability of previous and current treatments.8)Discontinue ineffective treatments.BackgroundBorderline Personality Disorder is common in psychiatric settings with a reported prevalence of 20%.As per NICE Guidance (CG 78), no medications have been found effective for the longer term treatment of personality difficulties.This audit was carried out to review if patients were offered psychiatric reviews to discuss the medications they are using, the effectiveness of these, and any potential side effects.ResultGood practice compliance of 90-100% was noted where >90% compliance was seen in areas where the effectiveness and tolerability of current and previous medication was reviewed by the clinicians under Structured Clinical Management. Also was noted that antipsychotics were not used for medium to long term in patients with Borderline Personality Disorder in the cohort.The following areas were non-compliant with the NICE recommendations where a compliance <79% has been achieved.When prescribing, use a single drug (avoid polypharmacy), agree target symptoms, monitoring and duration, provide written information, discuss evidence for effectiveness in treatment of borderline personality disorder.Partial compliance was achieved (80-89%) with use of sedatives for less than 1 week and discontinuation of ineffective treatment.ConclusionDistribute key cards to clinicians.Provide written information to patients.Re-audit in 6 months.

scholarly journals Effect of long-term supplementation with folic acid and B vitamins on risk of depression in older women

2015 ◽  
Vol 206 (4) ◽  
pp. 324-331 ◽  
Author(s):  
Olivia I. Okereke ◽  
Nancy R. Cook ◽  
Christine M. Albert ◽  
Martin Van Denburgh ◽  
Julie E. Buring ◽  
...  
Keyword(s):  
Folic Acid ◽  
Older Women ◽  
Controlled Trial ◽  
Vitamin B ◽  
High Dose ◽  
Adjusted Relative Risk ◽  
Folate Supplementation ◽  
Depression Risk ◽  
Incident Cases

BackgroundHomocysteine-lowering nutrients may have preventive/ameliorative roles in depression.AimsTo test whether long-term B-vitamin/folate supplementation reduces depression risk.MethodParticipants were 4331 women (mean age 63.6 years), without prior depression, from the Women's Antioxidant and Folic Acid Cardiovascular Study – a randomised controlled trial of cardiovascular disease prevention among 5442 women. Participants were randomly assigned to receive a combination of folic acid (2.5mg/d), vitamin B6 (50mg/d) and vitamin B12 (1 mg/d) or a matching placebo. Average treatment duration was 7 years. The outcome was incident depression, defined as self-reported physician/clinician-diagnosed depression or clinically significant depressive symptoms.ResultsThere were 524 incident cases. There was no difference between active v. placebo groups in depression risk (adjusted relative risk 1.02, 95% CI 0.86–1.21, P = 0.81), despite significant homocysteine level reduction.ConclusionsLong-term, high-dose, daily supplementation with folic acid and vitamins B6 and B12 did not reduce overall depression risk in mid-life and older women.

Requirements for operational cure in multiple myeloma

Blood ◽  
2021 ◽  
Author(s):  
Mohamad Mohty ◽  
Hervé Avet-Loiseau ◽  
Jean-Luc Harousseau
Keyword(s):  
Multiple Myeloma ◽  
Residual Disease ◽  
Limit Of Detection ◽  
Autologous Transplantation ◽  
Significant Proportion ◽  
Response To Treatment ◽  
High Dose ◽  
Duration Of Treatment ◽  
The Impact

Multiple myeloma is usually considered as an incurable disease. However, with the therapeutic improvement observed in the last few years, achievement of an "operational" cure is increasingly becoming a realistic goal. The advent of novel agents, with or without high-dose chemotherapy and autologous transplantation, uncovered a correlation between the depth of response to treatment and the outcome. Of note, minimal residual disease (MRD) negativity is increasingly shown to be associated with improved progression-free survival (PFS), and MRD status is becoming a well-established and strong prognostic factor. Here, we discuss the impact of MRD negativity on PFS and long-term disease control, as a surrogate for a potential cure in a significant proportion of patients. The MRD value and impact should be examined by focusing on different parameters: (i) sensitivity or lower limit of detection level (method used); (ii) timing of assessment and sustainability (iii) type and duration of treatment; (iv) initial prognostic factors (most importantly, cytogenetics) and (v) patient age. Currently, the highest probability of an operational cure is in younger patients receiving the most active drugs, in combination with autologous transplantation followed by maintenance therapy. Older patients are also likely to achieve operational cure, especially if they are treated upfront with an anti-CD38 antibody-based therapy, but also with novel immunotherapies in future protocols. The incorporation of MRD as a surrogate endpoint in clinical trials, would allow the shortening of these, leading to more personalised management, and achievement of long-term cure.

Nutritional B12 Deficiency in Infants of Vitamin B12-Deficient Mothers

2011 ◽  
Vol 81 (5) ◽  
pp. 328-334 ◽  
Author(s):  
Oya Halicioglu ◽  
Sezin Asik Akman ◽  
Sumer Sutcuoglu ◽  
Berna Atabay ◽  
Meral Turker ◽  
...  
Keyword(s):  
Megaloblastic Anemia ◽  
Maternal Diet ◽  
Clinical Manifestations ◽  
Serum Vitamin ◽  
Failure To Thrive ◽  
Clinical Findings ◽  
Vitamin B ◽  
Animal Products ◽  
Hematological Evaluation ◽  
Nutritional Vitamin

Aim: Nutritional vitamin B12 deficiency in infants may occur because the maternal diet contains inadequate animal products. Clinical presentations of the infants who had nutritional vitamin B12 deficiency were analyzed in this study. Subjects and Methods: Patients with nutritional vitamin B12 deficiency were enrolled in the study between 2003 and 2010. The diagnosis was based on a nutritional history of mothers and infants, clinical findings, hematological evaluation, and low level of serum vitamin B12. Results: Thirty children aged 1 - 21 months constituted the study group. Poverty was the main cause of inadequate consumption of animal products of the mothers. All infants had predominantly breastfed. The most common symptoms were developmental delay, paleness, apathy, lethargy, anorexia, and failure to thrive. Hematological findings were megaloblastic anemia (83.3 %), thrombocytopenia (30 %), and severe anemia (13.3 %). All of the mothers had low serum B12 levels; eight of them had megaloblastic anemia. Conclusion: The unusual clinical manifestations of vitamin B12 deficiency may also be seen apart from neurological and hematological findings. Nutritional vitamin B12 deficiency due to maternal deficiency might be a serious health problem in infants. Therefore, screening and supplementation of pregnant and lactating women to prevent infantile vitamin B12 deficiency should be considered.

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