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Dr. Damien Downing's Column...expert advice on treating environmental illnesses with ecological and nutritional medicine. |
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Thursday, February 10th, 2011:
Vitamin B12
by Damien Downing MD
We at the British Society for Ecological Medicine (BSEM) have been talking to the Pernicious Anaemia Society (PAS). Martyn Hooper and his colleagues there have achieved a remarkable amount, with 3,500 members after just two years, and a questionnaire that identifies several key symptoms of B12 deficiency about which none of us knew — the “strange tiredness” and “the gulps” for instance. We are looking forward to working with them, both to help sufferers and to prove that B12 deficiency is a real problem for many people. More of that on our website.
Here I want to talk about my own experiences with B12, which I’ve been using for more than 20 years — although we have learnt more all the time since then.
The first thing to say is that B12 is extremely safe. In all that time I have seen one instance of adverse effects, and that was back when we used cyanocobalamin — the original version if you like — and in a complicated case with other problems. Since we have used methylcobalamin and hydroxocobalamin the only adverse effect I have known is one male patient who called me from his car; he was on the way to casualty because just after the injection of B12 that I gave him his urine had turned pink! I was able to reassure him that it was simply overflow of the B12 he had received.
I don’t know why so many doctors are nervous of B12, and reluctant to give more than the official dose, when so many medications have much more severe and more frequent side-effects.
In 1991, in the Journal of Nutritional and Environmental Medicine, we published a “Classic Paper” from 1956, by neurologist Prof J MacDonald Holmes, called “Cerebral Manifestations of Vitamin B12 Deficiency”. The doctor reported that many patients experienced mental or neurological symptoms either before or without blood changes. The main symptoms were:
- Pronounced slowing of mental processes - 100%
- Confusion and memory defect - 100%
- Depression - 50%
- Delusions - 35%
— sound familiar at all? In fact it was not new even then; we referenced a paper in the Lancet in 1929 which linked pernicious anaemia with mental changes, which it said may precede it by “many months”. As a point of interest, vitamin B12 was first isolated in 1946.
I have given over 10,000 injections of vitamin B12, and the effect has been variable. Some people have experienced an immediate benefit; some have felt better later; for some it has done nothing at all. For some it has been life-changing, and this, I gather, is the experience of many in the PAS.
Vitamin B12 is a complicated molecule — I’ll put up a picture if I can manage it. Its absorption is complicated too; it requires a molecule called Intrinsic Factor, secreted by the stomach. Anything that interferes with stomach function — low acid, high acid, antacid medication, surgery — may interfere with Intrinsic Factor.
Forms
There are several forms of vitamin B12 — cyanocobalamin, methylcobalamin and hydroxocobalamin are the ones that are available as injections. There is another form called adenosylcobalamin which is formed in the body as an intermediate stage in metabolism, plus glutathionylcobalamin which is a new molecule to us. Cyanocobalamin is the form that is available on the NHS; our view is that the other two forms are often better.
Methylcobalamin is most indicated in brain disorders, but can be used in most conditions and situations.
The only circumstances in which we think it must be hydroxocobalamin are cancer and poisoning. In cancer this is because methyl- is past the “fork in the road” where the other road leads to adenosyl-, which best guess tells us is the key. In poisoning it’s because the French literature is based on hydroxo-; intensive care units there have long used extremely high doses of hydroxo-, 4-5grams IV daily (remember that some doctors won’t prescribe more than 1 milligram every 3 months; this is 5,000 times that every day) as a safe and effective antidote for cyanide poisoning. we know that works, we don’t know if methyl- would do the same.
Dose
Treatment with B12 needs to be a dose-finding exercise, to figure out how much you need and how often. Some people do respond to 1milligram every 3 months; some need more like 5 milligrams, and some need that dose much more frequently. If you benefit from a small dose there is no reason that you have to take more, but it would be interesting to find out if you get more benefit from a larger dose. The intensive care dose described above tells you that no harm is likely from a large (from 1milligram to 10milligrams) dose.
Route
The normal, accepted route for giving B12 is by injection, either intramuscular or subcutaneous. This route bypasses the stomach, where it is reasonable to assume there is something wrong with absorption of B12. The advantage of subcutaneous injections is that you can learn to do them yourself in time.
That used to be the only route available — well it was that or chopped raw liver! But there are now lozenges of methylcobalamin available; these take advantage of two things. First, they are a big dose — the ones we use are either 5,000 units or 20,000 per lozenge, intended to be taken every day — and second they are meant to be held under the tongue for a while to dissolve. This uses a third route into the body; the rich network of blood vessels under the tongue can carry molecules directly into the system, also bypassing the digestion.
It make sense to use injections of B12 first to see if they work, then to try lozenges to see if they work too; if not you can go back to injections.
Co-factors
I have been doing this sort of medicine for a long time, and learnt a few things. One is this; when you start a new nutritional treatment and feel much better, but it wears off after 3-6 months or so, it’s generally because you’ve missed something — in other words the treatment was necessary but not sufficient.
Of course if the improvement wears off after just 3 weeks it may have been a placebo effect all along.
When treating with a prescription drug, you usually (not always) are intending to block a biochemical process, a chain reaction, and you only need to do that at one point in the chain. When using nutrition you need to get all the links in the chain working properly to get a lasting result. Sorting out one big lack, repairing one link in the chain, will help at first but it won’t last.
So what co-factors go with B12? The straight answer, of course, is all of them, but there are some highlights. The most obvious is folic acid, another member of the B vitamin group — although some evidence suggests that the more natural forms, MTHF (methyltetrahydrofolate) and folinic acid, work better for some people. Certain genes come into play here, and it is possible to do genomic testing to find out more.
B6 is also important, as are minerals such as zinc and magnesium. And then there’s vitamin D - see elsewhere about this. Everybody is individual, and individual assessment is necessary to find out your individual needs. Those who know they need more B12 have already taken a major step in this direction; credit is due. The next steps can get more technical though; we’re happy to help.
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