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CPE-009 · synthetic case B12-FX-05

Neuropathy, B12 220 and metformin for five years

Neurologic features with a borderline level.

Synthetic · no real patientAuthored by Biod · reviewed by Dr. AmaralB12 engine v1.0.0

Purpose: Neurologic features with a borderline level.

Inputs the engine received

Laboratory

Serum vitamin B12
220 pg/mL
MCV
92 fL
Hemoglobin
13.8 g/dL

Patient

Age
63 years
Sex
Male

Neurologic features

Peripheral neuropathy symptoms
Yes

Drugs, diet and risk groups

Months on metformin
60 months

What the engine reports

Priority

Neurologic features and B12

B12-05

Neurologic involvement can occur without anemia and raises the urgency of finding vitamin B12 deficiency. BSH advises that treatment should not wait for confirmation when neurologic involvement is present.

Detected clinical pattern

Borderline B12 — Confirmatory Test Needed

A serum B12 between 200 and 300 pg/mL does not settle the question. Methylmalonic acid and homocysteine can.

  • B12 level: B12 220 pg/mL · borderline

Recommended next steps

For physician consideration. Urgent review always comes first.

  1. 1Measure B12 (with MMA) promptly.BSH 2014.
  2. 2Consider methylmalonic acid (with homocysteine) when deficiency is suspected.
  3. 3Consider intrinsic-factor antibodies.
  4. 4The ADA standards say periodic B12 measurement should be considered in people on metformin, especially with anemia or neuropathy.

Missing information

  • Methylmalonic acid (and homocysteine) to settle a borderline B12.
Evidence and rule trace · 4 rules

B12-03Borderline B12, confirmatory test not done

Inputs: serum B12 220 pg/mL (200–300) · MMA and homocysteine not entered

Borderline: a serum B12 in this range does not settle the question.

B12-05Neurologic or psychiatric features with unmeasured or low B12

Inputs: neuropathy symptoms · B12 220 pg/mL

Neurologic involvement raises the urgency of finding B12 deficiency.

B12-08Pernicious anemia evaluation

Inputs: age 63 · anti-intrinsic factor not done

Pernicious anemia evaluation.

B12-10Drug exposure that lowers B12

Inputs: metformin 60 months

Drug-associated risk of B12 deficiency.

Evidence

  • EV-BSH-2014 · Devalia V, Hamilton MS, Molloy AM; British Committee for Standards in Haematology. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol. 2014;166(4):496-513.
  • EV-STABLER-2013 · Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-160.
  • EV-GREEN-2017 · Green R, Allen LH, Bjørke-Monsen AL, et al. Vitamin B12 deficiency. Nat Rev Dis Primers. 2017;3:17040.
  • EV-ADA-STANDARDS · American Diabetes Association Professional Practice Committee. Standards of Care in Diabetes, section on pharmacologic approaches to glycemic treatment (current edition). Diabetes Care.

Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety considerations. It does not diagnose, find the cause, or select a vitamin product, dose or route. Physician adjudication is required.

Change the values

The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.

Serum B12 level

  1. ✓ Below 200 pg/mL

    Deficiency pattern

  2. ● 200 to 300 pg/mL

    Borderline: MMA and homocysteine settle it

  3. ○ Above 300 pg/mL

    Deficiency unlikely, not excluded

Laboratory
  • <200
  • 200–300
  • >300
Patient
Sex
Neurologic features
Drugs, diet and risk groups

Live result · computed in your browser

Priority

Neurologic features and B12

B12-05

Neurologic involvement can occur without anemia and raises the urgency of finding vitamin B12 deficiency. BSH advises that treatment should not wait for confirmation when neurologic involvement is present.

Detected clinical pattern

Borderline B12 — Confirmatory Test Needed

A serum B12 between 200 and 300 pg/mL does not settle the question. Methylmalonic acid and homocysteine can.

  • B12 level: B12 220 pg/mL · borderline

Recommended next steps

For physician consideration. Urgent review always comes first.

  1. 1Measure B12 (with MMA) promptly.BSH 2014.
  2. 2Consider methylmalonic acid (with homocysteine) when deficiency is suspected.
  3. 3Consider intrinsic-factor antibodies.
  4. 4The ADA standards say periodic B12 measurement should be considered in people on metformin, especially with anemia or neuropathy.

Missing information

  • Methylmalonic acid (and homocysteine) to settle a borderline B12.
Evidence and rule trace · 4 rules

B12-03Borderline B12, confirmatory test not done

Inputs: serum B12 220 pg/mL (200–300) · MMA and homocysteine not entered

Borderline: a serum B12 in this range does not settle the question.

B12-05Neurologic or psychiatric features with unmeasured or low B12

Inputs: neuropathy symptoms · B12 220 pg/mL

Neurologic involvement raises the urgency of finding B12 deficiency.

B12-08Pernicious anemia evaluation

Inputs: age 63 · anti-intrinsic factor not done

Pernicious anemia evaluation.

B12-10Drug exposure that lowers B12

Inputs: metformin 60 months

Drug-associated risk of B12 deficiency.

Evidence

  • EV-BSH-2014 · Devalia V, Hamilton MS, Molloy AM; British Committee for Standards in Haematology. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol. 2014;166(4):496-513.
  • EV-STABLER-2013 · Stabler SP. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-160.
  • EV-GREEN-2017 · Green R, Allen LH, Bjørke-Monsen AL, et al. Vitamin B12 deficiency. Nat Rev Dis Primers. 2017;3:17040.
  • EV-ADA-STANDARDS · American Diabetes Association Professional Practice Committee. Standards of Care in Diabetes, section on pharmacologic approaches to glycemic treatment (current edition). Diabetes Care.

Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety considerations. It does not diagnose, find the cause, or select a vitamin product, dose or route. Physician adjudication is required.

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