New statement letter from the NHS Cornwall for the cut down of B12 injections from GP Practice's.

Message for GPs
As you may be aware the Pharmacists have been looking at B12 for some time. When the CV-19
started, although some felt this was hype, we thought otherwise and looked stopping all B12
injections. We put it to the partners and they gave us the green light to proceed.
We identified 1,300 patients. A short message was created and approved, This was sent out: Those
with mobile phones by iPlato those without were sent a message. A list was created and sorted by
date of last injection. All pharmacies were notified of our plans and that they needed to source stock
ASAP. We created a report that showed, last injection, last B12 and if IF had been done as well as
FBC, MCV and haemocrit. By exporting to Excel we could flag who needed to be reviewed before
proceeding. Kay, Michael and myself have worked through the weekend to ensure all were reviewed
and scripts issued for oral B12 (see FAQs below for reasoning).
Having done all this work, we need your support. Be aware of why we did it. We spent a long time
reviewing and considering each to avoid work for the GPs. If you do have patients who are directed
to you please blame us, refer to us, say that it was all our doing – time is soon going to be precious
and doing this we feel has mitigated clinical risk as much as possible, protected staff and patients
and freed nurse time. Please do not restart anyone without discussing with us. It may well be correct
but the criteria you use to restart must be fair and equally applied or we have just created a major
and significant event.
At the end of this time we fully intend to review all patients and have their bloods done. Having
looked at published papers it will be the biggest and longest study of oral B12 ever conducted.
Thank you for your support
B12: Q&A on BMG Switch from injections to Oral medication
The following information was sent to all patient facing staff to inform them of why this was done
and to hopefully answer questions at the first contact rather than trigger multiple contacts and take
up precious time.
As prescribers it is important that you are aware of this work and also say there will be considerable
pressure on you to prescribe
As you are aware BMG have made a decision to switch all patients who are currently prescribed B12
injections to oral. Currently there are 1,300 such patients who come to the practice every 2 or 3
months to have this done. Coronavirus has made it necessary for us to take the decision that ALL
patients will be moved during the challenging months ahead to oral tablets. Clear reason: Risk
reduction:
 Patients do not come to surgery – especially when most will fall under the ‘At Risk’ category
and should self-isolate
 Do not put our staff at risk as all would require full protection gear to do this.
 It will free up valuable nurse time: Staff health will become an issue and the staff who do
this activity will soon be required for other tasks.
It is important that we deal with priority tasks and this means staff being able to answer questions to
protect other staff time.
Frequently asked questions on B12 injections:
Q: I must have my B12 injection as I have a medical condition.
A: Whilst many people DID have a medical condition, such as pernicious anaemia, ALL patients start
B12 by having 5 or 6 loading doses. 50% of this goes into the liver and is stored for when the levels
start to go down again. All patients have a 3 month ‘top up’. All patients who are currently
prescribed B12 will have levels sufficient to carry them through these challenging months ahead
Q: I’m at risk if I don’t get them!
A: Looking at happened in China and now in Italy it is without doubt the biggest global threat we
have faced since Spanish Flu of 1918. Whilst many fear not having their B12, it is clear that the threat
of CV-19 far exceeds any benefit a patient may feel they obtain from their injections.
Q: I need the injection as I HAVE BEEN TOLD that I CANNOT absorb B12.
A: B12 is the largest of the vitamin molecules. We don’t make it – it has to be obtained from the diet.
Patients are almost all aware that B12 mainly gets into our body because of a ‘carrier’ called intrinsic
factor (IF). This IF binds to B12 and takes it into the blood. HOWEVER: there is another 5% which is
absorbed without IF. The problem is that modern diet is so low in B12 that deficiency rates are
spiking. This is not due to lacking IF – it is due to low amounts in the diet.
Advise patients that: A good diet contains 2 – 5 mcg of B12 and we will absorb this. Few intake this
amount and so deficiency is inevitable.
Q: I cannot absorb B12: Again this links to patients believing this having been told and for most this
has been endorsed by the Internet. We have prescribed 1,000mcg tablets daily – That is 400 times
that normal recommended amount. Even in patients who DO NOT HAVE IF they will absorb their
daily recommended amount.
Q: I have pernicious anaemia?
A: For some – they did, but they don’t now as has been treated because they have had their loading
dose. The loading doses which everyone has had has treated the pernicious anaemia. The 3 monthly
injections are simply a precaution to stop it coming back. As stated, they have sufficient levels and
stores to take us though this difficult time.
Q: Only B12 injection has been proven to work.
A: Again: untrue. Whilst historically we use injection this is to get quick and speedy resolution if a
problem exists. There is no evidence that oral B12 is inferior or puts patients at risk.
Bottom line: ALL patients who have been switched to oral have been informed. Nationally, all NHS
organisations will be stopping B12 injections. Some will offer oral on a script, other areas have
stopped and asked patients to purchase it.
Q: I was sent a text/letter telling me about this. I went to my nominated pharmacy and it’s not there.
What’s going on?
A: There are 1,300 people that the pharmacy team have to individually check before starting this
new oral B12. The majority have been done, with only a few hundred left to change and issue.
Q: I’ve just had my injection. Do I go to get and start these oral B12 meds now?
A; If you have just had your injection we have issued a post-dated script to start one month before
your next injection was due.