eMedicine Specialties > Hematology > Red Blood Cells and Disorders

Pernicious Anemia: Follow-up

Author: Marcel E Conrad, MD, (Retired) Distinguished Professor of Medicine, University of South Alabama
Contributor Information and Disclosures

Updated: Aug 26, 2009

Follow-up

Further Inpatient Care

  • Once therapy is started, hospitalization is only required for patients with severe life-threatening anemia. This may be required until patients develop an adequate hematological response. Patients whose Cbl deficiency is due to underlying diseases involving the intestine or pancreas may require additional therapy. Examples of additional therapy are surgical correction of anatomic abnormalities of the gut, producing small bowel bacterial overgrowth, or the treatment of fish tapeworm anemia or pancreatitis.

Further Outpatient Care

  • Outpatient follow-up of patients with pernicious anemia is required to ensure that they have responded to therapy with Cbl and that they continue to receive Cbl on a regular basis for the remainder of their life. Most patients can be taught to self-administer Cbl subcutaneously so that visits to the physician can be minimized.

Inpatient & Outpatient Medications

  • Cbl at a dose of 100 mcg/mo by subcutaneous or intramuscular injection is provided as maintenance therapy after the patient has experienced an initial response to treatment. Lifetime compliance is necessary.

Deterrence/Prevention

  • Because an increased familial incidence of pernicious anemia exists, family members should be aware that they are at greater risk of developing this disease and should seek medical attention promptly if they develop anemia or mental and neurological symptoms.
  • Determine whether Cbl deficiency is the etiology in patients who recently developed evidence of mental deterioration.
  • Periodically perform studies for Cbl deficiency or prophylactically treat patients with Cbl when they have undergone total gastrectomy, bypass procedures for weight reduction, ileectomy, pancreatectomy, or when they have atrophic gastritis or chronic inflammatory disease of the ileum.
  • Strict vegetarians should continue supplementary Cbl, particularly during pregnancy and while nursing a newborn infant.
  • Monitor siblings and children of patients with a hereditary abnormality of Cbl deficiency for evidence of the specific defect in Cbl transport or metabolism.

Complications

  • If patients are not treated early in the disease, neurological complications can become permanent.
  • Severe anemia can cause congestive heart failure or precipitate coronary insufficiency.
  • The incidence of gastric adenocarcinoma is 2- to 3-fold greater in patients with pernicious anemia than in the general population of the same age. Presently, periodic gastroscopy and/or barium roentgenographic studies are not advocated in patients who are asymptomatic with treated pernicious anemia because they have not been demonstrated to prolong lifespan.

Prognosis

  • Early recognition and treatment of pernicious anemia provides a normal, and usually uncomplicated, lifespan. Delayed treatment permits progression of the anemia and neurological complications. The mental and neurological damage can become irreversible without therapy.

Patient Education

  • Compliance in obtaining adequate vitamin B-12 for a lifetime by injection (or possibly orally) is necessary to avoid relapse of pernicious anemia.
  • For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Anemia.

Miscellaneous

Medicolegal Pitfalls

  • Failure or significant delay in establishing a diagnosis of Cbl deficiency and in initiating appropriate therapy
  • Administration of folic acid rather than vitamin B-12 in patients with Cbl deficiency, which can correct the hematological abnormalities while accelerating the neurological deficits
  • Failure to advise patients with pernicious anemia of the importance of continuing Cbl therapy for lifetime
 


More on Pernicious Anemia

Overview: Pernicious Anemia
Differential Diagnoses & Workup: Pernicious Anemia
Treatment & Medication: Pernicious Anemia
Follow-up: Pernicious Anemia
Multimedia: Pernicious Anemia
References
Further Reading
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References

  1. Elmadfa I, Singer I. Vitamin B-12 and homocysteine status among vegetarians: a global perspective. Am J Clin Nutr. May 2009;89(5):1693S-1698S. [Medline].

  2. Chan JC, Liu HS, Kho BC, Lau TK, Li VL, Chan FH, et al. Longitudinal study of Chinese patients with pernicious anaemia. Postgrad Med J. Dec 2008;84(998):644-50. [Medline].

  3. Andrès E, Vogel T, Federici L, Zimmer J, Ciobanu E, Kaltenbach G. Cobalamin deficiency in elderly patients: a personal view. Curr Gerontol Geriatr Res. 2008;848267. [Medline].

  4. Erkurt MA, Aydogdu I, Dikilitas M, Kuku I, Kaya E, Bayraktar N, et al. Effects of cyanocobalamin on immunity in patients with pernicious anemia. Med Princ Pract. 2008;17(2):131-5. [Medline].

  5. Beutler E, Lichtman MA, Coller BS. Williams Hematology. 6th ed. New York, NY:. McGraw-Hill;2001:425-446.

  6. Hoffman R, Benz EJ Jr, Shattil SJ. Hematology: Basic Principles and Practice. 3rd ed. New York, NY:. Churchill Livingstone;2000:446-484.

  7. Jandl JH. Blood: Textbook of Hematology. 2nd ed. Boston, Mass:. Little, Brown and Co;1996:251-288.

  8. Lee GR, Foerster J, Lukens J. Wintrobe's Clinical Hematology. 10th ed. Baltimore, Md:. Williams & Wilkins;1999:941-978.

  9. Scriver CR, Beaudet AL, Sly WS. The Metabolic and Molecular Bases of Inherited Disease. 2nd ed. New York, NY:. McGraw-Hill;1995:3129-3149.

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Keywords

pernicious anemia, vitamin B-12 deficiency, megaloblastic anemia, cobalamin deficiency, Cbl deficiency, iron deficiency anemia, addisonian anemia, Biermer anemia, Hunter-Addison anemia, Lederer anemia, Biermer-Ehrlich anemia, Addison-Biermer disease, macrocytic achylic anemia, malignant anemia,

adenosylcobalamin, methylcobalamin, intrinsic factor, IF, macrocytic anemia, neurological complications, severe gastric atrophy, achlorhydria, gastrectomy, gastric stapling, bypass procedures for obesity, extensive infiltrative disease of the gastric mucosa, Zollinger-Ellison syndrome,

tropical sprue, regional enteritis, ulcerative colitis, ileal lymphoma, Imerslünd-Grasbeck syndrome, chronic pancreatitis, sore tongue, smooth tongue with loss of papillae, paresthesias, megaloblastic madness, tapeworm infestation, Diphyllobothrium latum, congenital pernicious anemia, hereditary transcobalamin I deficiency, homocystinuria, homocystinemia

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Contributor Information and Disclosures

Author

Marcel E Conrad, MD, (Retired) Distinguished Professor of Medicine, University of South Alabama
Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, and Southwest Oncology Group
Disclosure: No financial interests None None

Medical Editor

David Aboulafia, MD, Medical Director, Bailey-Boushay House; Clinical Professor, Department of Medicine, Division of Hematology, University of Washington
David Aboulafia, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Medical Directors Association, American Society of Hematology, Infectious Diseases Society of America, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Troy H Guthrie, Jr, MD, Director of Cancer Institute, Baptist Medical Center
Troy H Guthrie, Jr, MD is a member of the following medical societies: American Federation for Medical Research, American Medical Association, American Society of Hematology, Florida Medical Association, Medical Association of Georgia, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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