BLOGS Ask the Pharmacist ASK THE PHARMACIST: November 2017


Are you 50 years or older? Are you a vegan? Do you take medications, particularly proton pump inhibitors for acid reflux, metformin, antibiotics, birth control, asthma drugs or BHRT? Do you eat the SAD (Standard American Diet)? Do you consume excessive alcohol or coffee? Have you had exposure to nitrous oxide at the dentist office, gastric bypass surgery? Do you suffer from Crohn’s or colitis? Are you celiac? Do you often feel shortness of breath?

If you answered yes to any of those questions and are experiencing fatigue, anxiety or depression, tingly hands or feet, swollen tongue, blurry vision, yellowish skin or memory loss with no other potential causes, you may have a Vitamin B-12 deficiency.

Because Vitamin B-12 is not found in any plant foods unless they are fortified, and only found in abundance in animal products, nutritional yeast, some cheeses and eggs, vegans must supplement their diets. Anyone taking prescription drugs that deplete B-12 should be tested and supplemented when appropriate. If your diet is lacking in free range/grass-fed, wild caught animal sources or eggs, you may be lacking this essential vitamin and notice symptoms.

Vitamin B-12 is a cobalamin. Its water soluble and essential for red blood cell production, which explains the fluctuating symptoms expressed when it is absent. If you can handle it, search for images of tongue inflammation common to B-12 deficiency. Now, take a good look at your tongue in the mirror. Is it red, swollen, shiny, “beefy”, geographic and lacking the usual bumpy texture? Are the corners of your mouth cracked and sore? It definitely is time to ask for simple blood tests to measure your levels.

One other sneaky problem that can lead to low B-12 levels cannot be avoided. Aging is a fact of life that can lead to lowered stomach acid levels and therefore decreased intrinsic factor (IF). IF is needed to absorb B-12 from food and transport it to the cells that use it. If you are missing a portion of your stomach or have constant gastritis, IF will be compromised.

Once your primary care practitioner tests your B-12 levels and hopefully your, MCV, MCH, and folate levels as well, you may be prescribed supplemental forms of these important nutrients. If the deficiency is severe, an injection may be necessary.

Malabsorption is the most common reason for low B-12, so it makes sense that B-12 shots would be the best method for replacement therapy. The most common injection is cyanocobalamin, as it is an inexpensive synthetic form, but naturally occurring hydroxocobalamin may have some advantages. While your body must break down both to form methylcobalamin to be usedful, the cyano form requires more steps and the hydroxo form is active considerably longer. Injections are especially important if B-12 needs to be quickly restored, intestinal parasites are suspected, and if portions of the digestive tract have been surgically removed. The dosage range varies considerably and can be 100mcg to 1000mcg daily, weekly, monthly or four times a year. While most injections are given IM and in the physician’s office, it can be given subcutaneously (like insulin) and at home once you are trained.

While oral forms of B-12 are abundant as capsules and tablets, sublingual tablets and liquids are better absorbed. Look for methylcobolamin or hydroxocobalamin, but only adenosylcobalamin if urine is tested for methylmalonic acid. There are products that are combinations of all forms. According to Ben Lynch “methyl supports methylation, adenosyl supports energy and hydroxo supports the reduction of nitric oxide. Avoid the cyano form if possible. The dosage can range from 100 mcg to 5000 mcg.

Whoa, so much information here…just remember methylated B-12 and the other forms support production of health DNA, keep your brain cells sharp, your nervous system healthy, your red blood cells abundant and may be more bioactive than other forms of Vitamin B-12 like cyanocobalamin. Because B-12 and folate work together, if you are low in one, your body may try to compensate for a while, but one without the other in adequate amounts can have deleterious effects. Correcting only folate levels without additional B-12 can lead to irreversible central and peripheral nerve damage.

Vitamin B-12 deficiency may take a long time to correct with supplementation. If you suspect that you may have a deficiency, do not delay in contacting you physician to request lab testing. Taking supplements can play a vital role in your overall healthcare.

Deidre (Dee) Kohley, Rph, works at Watkins Pharmacy, is a graduate of Ferris University and has lived all her life in Muskegon. She continues to find ways to reach women who genuinely want to get well or live an optimal life. Dee loves digging into research to find new ways to help people. She is married and has seven children and nine grandchildren who keep her busy. She loves the beach and spending time outside enjoying the seasons. You can contact her by going to her website or

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