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B12 Deficiency Neuropathy

VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Approved


DIAGNOSIS: B12 Deficiency Neuropathy

ICD-10: E53.8 (Other specified vitamin B deficiencies); G63.4 (Polyneuropathy in nutritional deficiency); G32.0 (Subacute combined degeneration of spinal cord in diseases classified elsewhere); D51.0 (Vitamin B12 deficiency anemia due to intrinsic factor deficiency); D51.9 (Vitamin B12 deficiency anemia, unspecified); E53.8+G63 (Vitamin B12 deficiency with polyneuropathy)

CPT CODES: 82607 (Serum vitamin B12), 83921 (Methylmalonic acid (MMA)), 83090 (Homocysteine), 85025 (CBC with differential), 85060 (Peripheral blood smear), 85044 (Reticulocyte count), 80053 (CMP (BMP + LFTs)), 83615 (LDH), 84443 (TSH), 86340 (Intrinsic factor antibodies), 86255 (Anti-parietal cell antibodies), 82941 (Gastrin level (fasting)), 86364 (Tissue transglutaminase IgA (tTG-IgA)), 82784 (Total IgA), 84146 (Serum pepsinogen I and II), 87389 (HIV antibody), 82390 (Copper level), 84630 (Zinc level), 82136 (Methylmalonic acid (urine)), 86334 (SPEP/immunofixation), 70553 (MRI brain), 95925 (Somatosensory evoked potentials (SSEP)), 95930 (Visual evoked potentials (VEP)), 43239 (EGD with gastric biopsy), 11104 (Skin punch biopsy for IENFD)

SYNONYMS: B12 deficiency neuropathy, cobalamin deficiency neuropathy, vitamin B12 neuropathy, subacute combined degeneration, SCD, megaloblastic neuropathy, pernicious anemia neuropathy, cobalamin-responsive neuropathy, B12-related myeloneuropathy, cyanocobalamin deficiency, methylcobalamin deficiency, posterior column disease, funicular myelosis

SCOPE: Evaluation and management of neurological manifestations of vitamin B12 deficiency including peripheral neuropathy, subacute combined degeneration of the spinal cord, and cognitive changes. Includes diagnosis, treatment, monitoring of neurological recovery, and identification of underlying etiology (pernicious anemia, malabsorption, dietary deficiency). Excludes pure hematologic B12 deficiency without neurological involvement. For general peripheral neuropathy workup, see the Peripheral Neuropathy template.


DEFINITIONS: - Subacute Combined Degeneration (SCD): Demyelination of posterior columns and lateral corticospinal tracts of the spinal cord due to B12 deficiency; presents with sensory ataxia, spasticity, and proprioceptive loss - Pernicious Anemia: Autoimmune destruction of gastric parietal cells causing intrinsic factor deficiency and B12 malabsorption; most common cause of severe B12 deficiency - Methylmalonic Acid (MMA): Metabolite elevated in B12 deficiency; more sensitive than serum B12 alone; specific for B12 (not elevated in folate deficiency) - Homocysteine: Elevated in both B12 and folate deficiency; less specific than MMA for B12 deficiency alone - Intrinsic Factor (IF): Glycoprotein produced by parietal cells; required for B12 absorption in terminal ileum - Holotranscobalamin (Active B12): The biologically active fraction of circulating B12; may be more sensitive than total B12


PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting


1. LABORATORY WORKUP

1A. Essential/Core Labs

Test Rationale Target Finding ED HOSP OPD ICU
Serum vitamin B12 (CPT 82607) Confirm deficiency; <200 pg/mL diagnostic; 200-400 pg/mL borderline >400 pg/mL (normal) STAT STAT ROUTINE STAT
Methylmalonic acid (MMA) (CPT 83921) Elevated in B12 deficiency; more sensitive than serum B12; essential if B12 200-400 pg/mL Normal (<0.4 umol/L) URGENT ROUTINE ROUTINE URGENT
Homocysteine (CPT 83090) Elevated in B12 and folate deficiency; helps confirm metabolic B12 deficiency Normal (<15 umol/L) URGENT ROUTINE ROUTINE URGENT
CBC with differential (CPT 85025) Macrocytic anemia (MCV >100); hypersegmented neutrophils; pancytopenia possible Normal; no macrocytosis STAT STAT ROUTINE STAT
Peripheral blood smear (CPT 85060) Macro-ovalocytes, hypersegmented neutrophils (>=5 lobes); megaloblastic changes Normal morphology URGENT ROUTINE ROUTINE URGENT
Reticulocyte count (CPT 85044) Low in megaloblastic anemia; rises within 5-7 days of treatment (reticulocyte crisis) Normal; monitor for treatment response URGENT ROUTINE ROUTINE URGENT
CMP (BMP + LFTs) (CPT 80053) Renal dysfunction affects MMA interpretation; LDH elevated in megaloblastic anemia; electrolytes Normal STAT STAT ROUTINE STAT
Folate (serum and RBC) (CPT 82746, 82747) Rule out concurrent folate deficiency; folate replacement alone may worsen neurological B12 deficiency Normal (serum >4 ng/mL; RBC folate >280 ng/mL) URGENT ROUTINE ROUTINE URGENT
LDH (CPT 83615) Markedly elevated in megaloblastic anemia due to intramedullary hemolysis Normal URGENT ROUTINE ROUTINE URGENT
TSH (CPT 84443) Autoimmune thyroid disease co-occurs with pernicious anemia Normal (0.4-4.0 mIU/L) - ROUTINE ROUTINE -
Iron studies (ferritin, TIBC) (CPT 82728, 83540) Co-existing iron deficiency may mask macrocytosis; combined deficiency common Normal - ROUTINE ROUTINE -

1B. Extended Workup (Etiology)

Test Rationale Target Finding ED HOSP OPD ICU
Intrinsic factor antibodies (CPT 86340) Highly specific (>95%) for pernicious anemia; sensitivity ~50-70% Negative - ROUTINE ROUTINE -
Anti-parietal cell antibodies (CPT 86255) Sensitive (~80-90%) but less specific for pernicious anemia; positive in other autoimmune conditions Negative - ROUTINE ROUTINE -
Gastrin level (fasting) (CPT 82941) Elevated in pernicious anemia due to achlorhydria; helps confirm autoimmune gastritis Normal - ROUTINE ROUTINE -
Tissue transglutaminase IgA (tTG-IgA) (CPT 86364) Celiac disease screening; celiac causes B12 malabsorption at terminal ileum Negative - ROUTINE ROUTINE -
Total IgA (CPT 82784) IgA deficiency causes false-negative celiac serologies Normal - ROUTINE ROUTINE -
Holotranscobalamin (active B12) (CPT 82607) Biologically active B12 fraction; may detect early deficiency before total B12 falls Normal (>35 pmol/L) - ROUTINE ROUTINE -
Serum pepsinogen I and II (CPT 84146) Low pepsinogen I in autoimmune atrophic gastritis; pepsinogen I/II ratio <3 suggests atrophic gastritis Normal ratio - - ROUTINE -
Helicobacter pylori testing H. pylori can cause B12 malabsorption; may coexist with pernicious anemia Negative - ROUTINE ROUTINE -
HIV antibody (CPT 87389) HIV causes B12 malabsorption and neuropathy Negative - ROUTINE EXT -
Copper level (CPT 82390) Copper deficiency mimics B12 deficiency myeloneuropathy; concurrent deficiency possible post-bariatric surgery Normal (70-155 mcg/dL) - ROUTINE ROUTINE -
Zinc level (CPT 84630) Excess zinc supplementation causes copper deficiency; common etiology of copper-deficient myelopathy Normal - ROUTINE ROUTINE -

1C. Rare/Specialized (Refractory or Atypical)

Test Rationale Target Finding ED HOSP OPD ICU
Schilling test (historical) Classic test for pernicious anemia; rarely performed; replaced by IF antibodies and MMA Normal absorption - - EXT -
Methylmalonic acid (urine) (CPT 82136) Urine MMA may be more reliable in renal insufficiency than serum MMA Normal - - EXT -
Transcobalamin II level Rare genetic deficiency causing functional B12 deficiency with normal serum B12 Normal - - EXT -
Genetic testing (TCN2, MMACHC, MTHFR) Inborn errors of cobalamin metabolism; young patients with B12-resistant neuropathy No pathogenic variant - - EXT -
Anti-ganglioside antibodies (CPT 86255) If concurrent autoimmune neuropathy suspected (CIDP, MMN); may coexist Negative - EXT EXT -
Paraneoplastic panel (CPT 86255) If subacute onset, weight loss, smoking; paraneoplastic myelopathy mimics SCD Negative (Anti-Hu, CV2) - EXT EXT -
SPEP/immunofixation (CPT 86334) Monoclonal gammopathy can cause neuropathy mimicking B12 deficiency No M-spike - EXT EXT -

2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study Timing Target Finding Contraindications ED HOSP OPD ICU
MRI spine (cervical and thoracic) with and without contrast (CPT 72141, 72146) URGENT if myelopathy symptoms; ROUTINE if neuropathy only Subacute combined degeneration: bilateral symmetric T2 hyperintensity in posterior columns ("inverted V sign" on axial); may involve lateral columns GFR <30 for gadolinium; pacemaker; metal implants URGENT URGENT ROUTINE URGENT
Nerve conduction studies (NCS) and EMG (CPT 95907-95913, 95886) Baseline; 3-4 weeks after symptom onset optimal for Wallerian degeneration detection Axonal sensorimotor polyneuropathy; reduced sensory amplitudes more than motor; sural nerve often affected early Pacemaker (relative); anticoagulation for needle EMG (relative) - ROUTINE ROUTINE -

2B. Extended

Study Timing Target Finding Contraindications ED HOSP OPD ICU
MRI brain (CPT 70553) If cognitive impairment or encephalopathy White matter changes; cerebral atrophy (chronic); exclude other causes of cognitive decline GFR <30; pacemaker; metal - ROUTINE ROUTINE -
Somatosensory evoked potentials (SSEP) (CPT 95925) If clinical myelopathy suspected but MRI equivocal Prolonged central conduction time confirming posterior column dysfunction None significant - ROUTINE ROUTINE -
Visual evoked potentials (VEP) (CPT 95930) If visual symptoms or optic neuropathy suspected Prolonged P100 latency None significant - EXT EXT -
Autonomic function testing (QSART, tilt table) If orthostatic symptoms, sudomotor dysfunction Abnormal autonomic function None significant - - ROUTINE -
EGD with gastric biopsy (CPT 43239) If pernicious anemia confirmed; screen for atrophic gastritis and gastric carcinoid Atrophic gastritis; intestinal metaplasia; rule out gastric carcinoid/adenocarcinoma Coagulopathy; recent MI - ROUTINE ROUTINE -

2C. Rare/Specialized

Study Timing Target Finding Contraindications ED HOSP OPD ICU
CT enterography or capsule endoscopy If small bowel malabsorption suspected (celiac, Crohn, bacterial overgrowth) Small bowel pathology Bowel obstruction (capsule); contrast allergy (CT) - EXT EXT -
Hydrogen breath test (lactulose or glucose) If small intestinal bacterial overgrowth (SIBO) suspected as cause of malabsorption Positive for SIBO None significant - - EXT -
Skin punch biopsy for IENFD (CPT 11104) If small fiber neuropathy component suspected; normal NCS with ongoing pain Reduced intraepidermal nerve fiber density Anticoagulation (relative) - - EXT -

3. TREATMENT

3A. Acute/Emergent - B12 Replacement

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Cyanocobalamin IM IM Confirmed or suspected B12 deficiency with neurological symptoms; preferred parenteral route 1000 mcg :: IM :: daily x 7 days :: 1000 mcg IM daily x 7 days, then 1000 mcg IM weekly x 4 weeks, then 1000 mcg IM monthly indefinitely Cobalt or cobalamin hypersensitivity (rare); Leber hereditary optic neuropathy (relative) Reticulocyte count at day 5-7 (reticulocyte crisis confirms response); B12 and MMA at 1-2 months; CBC at 1-2 months; potassium during first 48 hours (hypokalemia from erythropoiesis) STAT STAT ROUTINE STAT
Hydroxocobalamin IM IM Alternative to cyanocobalamin; longer-acting; preferred in some countries; better for cyanide toxicity 1000 mcg :: IM :: daily x 7 days :: 1000 mcg IM daily x 7 days, then 1000 mcg IM every other day x 2 weeks, then 1000 mcg IM monthly indefinitely Cobalt or cobalamin hypersensitivity (rare); Leber hereditary optic neuropathy (relative) Reticulocyte count at day 5-7; B12 and MMA at 1-2 months; CBC at 1-2 months; potassium during first 48 hours (hypokalemia from erythropoiesis) STAT STAT ROUTINE STAT
Cyanocobalamin SC SC If IM injection contraindicated (anticoagulation, thrombocytopenia) or patient preference 1000 mcg :: SC :: daily x 7 days :: 1000 mcg SC daily x 7 days, then 1000 mcg SC weekly x 4 weeks, then 1000 mcg SC monthly indefinitely Cobalt or cobalamin hypersensitivity (rare); Leber hereditary optic neuropathy (relative) Reticulocyte count at day 5-7; B12 and MMA at 1-2 months; CBC at 1-2 months; potassium during first 48 hours (hypokalemia from erythropoiesis) URGENT URGENT ROUTINE URGENT
Potassium supplementation IV/PO Prevent hypokalemia during B12 replacement; erythropoiesis consumes potassium 20 mEq :: PO :: daily PRN :: 20-40 mEq PO daily; monitor potassium q12-24h during first 48 hours of B12 replacement; supplement if K <3.5 mEq/L Hyperkalemia; renal failure (use cautiously) Potassium levels q12-24h during initial treatment URGENT URGENT - URGENT
Magnesium sulfate IV IV Correct hypomagnesemia; magnesium required for enzymatic reactions involving B12 2 g :: IV :: once PRN :: 2 g IV over 2 hours if Mg <1.5 mg/dL; then oral magnesium oxide 400 mg PO daily Renal failure; heart block Magnesium levels; cardiac monitoring during IV infusion URGENT URGENT - URGENT
Folic acid PO Correct concurrent folate deficiency; MUST give with B12 to avoid masking B12 deficiency 1 mg :: PO :: daily :: 1 mg PO daily; NEVER give folate without B12 in suspected B12 deficiency (may worsen neurological damage) None significant Ensure B12 is being co-administered; reticulocyte count URGENT URGENT ROUTINE URGENT

3B. Symptomatic Treatments - Neuropathic Pain

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Gabapentin PO Neuropathic pain (first-line); burning, tingling, shooting pain 300 mg :: PO :: qHS :: Start 300 mg qHS; titrate by 300 mg every 1-3 days to TID dosing; target 900-1800 mg/day divided TID; max 3600 mg/day; adjust for renal function (CrCl 30-59: max 1400 mg/day; CrCl 15-29: max 700 mg/day; CrCl <15: max 300 mg/day) Severe renal impairment (dose adjust required); respiratory depression with opioids Sedation, dizziness, peripheral edema; taper to discontinue (do not stop abruptly) - ROUTINE ROUTINE -
Pregabalin PO Neuropathic pain (first-line alternative) 75 mg :: PO :: BID :: Start 75 mg BID; may increase to 150 mg BID after 1 week; max 300 mg BID (600 mg/day); adjust for renal function (CrCl <60: reduce dose); Schedule V controlled substance Severe renal impairment (dose adjust required); history of substance abuse (relative) Sedation, weight gain, peripheral edema; dizziness; taper to discontinue - ROUTINE ROUTINE -
Duloxetine PO Neuropathic pain (first-line); especially effective for painful neuropathy with comorbid depression 30 mg :: PO :: daily :: Start 30 mg daily x 1 week; increase to 60 mg daily; max 120 mg/day Hepatic impairment; CrCl <30; concurrent MAOIs; uncontrolled narrow-angle glaucoma Nausea (usually transient); BP monitoring; discontinuation syndrome (taper over 2+ weeks) - ROUTINE ROUTINE -
Venlafaxine XR PO Neuropathic pain (second-line SNRI) 37.5 mg :: PO :: daily :: Start 37.5 mg daily; increase by 75 mg every 4-7 days; target 150 mg daily; max 225 mg/day Uncontrolled hypertension; concurrent MAOIs BP monitoring; serotonin syndrome; discontinuation syndrome (taper over 2+ weeks) - ROUTINE ROUTINE -
Amitriptyline PO Neuropathic pain (second-line); useful for concurrent insomnia 10 mg :: PO :: qHS :: Start 10-25 mg qHS; increase by 10-25 mg weekly; max 150 mg qHS Cardiac conduction abnormality; recent MI; urinary retention; narrow-angle glaucoma; elderly (anticholinergic burden) ECG if dose >100 mg/day; anticholinergic effects; sedation; weight gain - ROUTINE ROUTINE -
Nortriptyline PO Neuropathic pain (second-line); fewer anticholinergic effects than amitriptyline 10 mg :: PO :: qHS :: Start 10-25 mg qHS; increase by 10-25 mg weekly; max 150 mg qHS Cardiac conduction abnormality; recent MI; urinary retention; narrow-angle glaucoma; elderly ECG if dose >100 mg/day; anticholinergic effects (fewer than amitriptyline); sedation - ROUTINE ROUTINE -
Capsaicin cream 0.075% TOP Localized neuropathic pain in feet or hands 0.075% cream :: TOP :: TID-QID :: Apply thin layer TID-QID to affected area; takes 2-4 weeks for full effect; wash hands thoroughly after application Open wounds; avoid eyes and mucous membranes Initial burning sensation (decreases with continued use); do not apply to broken skin - - ROUTINE -
Lidocaine 5% patch TOP Localized neuropathic pain; adjunct therapy 1-3 patches :: TOP :: daily :: Apply 1-3 patches to painful area for 12 hours on, 12 hours off; max 3 patches simultaneously Severe hepatic impairment; application to broken skin Minimal systemic absorption; local skin irritation - ROUTINE ROUTINE -

3C. Second-line/Refractory

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Tramadol PO Moderate neuropathic pain refractory to first-line agents 50 mg :: PO :: q6h PRN :: Start 50 mg q6h PRN; may increase to 100 mg q6h; max 400 mg/day; ER formulation 100-300 mg daily Seizure disorder; concurrent MAOIs; concurrent SSRIs/SNRIs (serotonin syndrome risk) Seizure risk; serotonin syndrome; dependence (Schedule IV); constipation - ROUTINE ROUTINE -
Capsaicin 8% patch (Qutenza) TOP Localized neuropathic pain refractory to standard topical therapy 8% patch :: TOP :: q3 months :: Applied by healthcare provider for 30-60 minutes; may repeat every 3 months; pretreat area with topical lidocaine Open wounds; capsaicin allergy BP during application; pain during and after application; must be applied in clinical setting - - ROUTINE -
High-dose oral B12 (if parenteral not tolerated) PO B12 replacement when injections refused or contraindicated; compliance concerns 1000 mcg :: PO :: daily :: 1000-2000 mcg PO daily; ~1% absorbed passively independent of intrinsic factor; may be adequate for mild deficiency; monitor closely None significant B12 and MMA levels at 2-3 months to confirm adequate absorption; if MMA remains elevated, switch to parenteral - - ROUTINE -
Methylcobalamin SL SL Alternative oral B12 formulation; may have improved bioavailability 1000 mcg :: SL :: daily :: 1000-5000 mcg sublingual daily; dissolve under tongue; efficacy data limited compared to IM None significant B12 and MMA levels at 2-3 months; switch to parenteral if inadequate response - - ROUTINE -

Combination Therapy Note: For refractory neuropathic pain, combining agents from different classes (e.g., gabapentinoid + SNRI, or gabapentinoid + TCA) is often more effective than maximizing monotherapy. Avoid combining TCAs with SNRIs (serotonin syndrome risk). Neuropathic pain from B12 deficiency often improves or resolves with adequate B12 replacement alone; allow 3-6 months of treatment before concluding pain is refractory.


4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation ED HOSP OPD ICU
Neurology consultation for confirmation of B12 deficiency neuropathy and monitoring of neurological recovery URGENT URGENT ROUTINE URGENT
Hematology referral for evaluation of persistent macrocytic anemia or pancytopenia not responding to B12 replacement - ROUTINE ROUTINE -
Gastroenterology referral for EGD and evaluation of pernicious anemia, atrophic gastritis, or malabsorption etiology - ROUTINE ROUTINE -
Physical therapy for gait training, balance exercises, and fall prevention given proprioceptive loss and sensory ataxia - ROUTINE ROUTINE ROUTINE
Occupational therapy for hand function optimization and adaptive equipment if fine motor impairment from neuropathy - ROUTINE ROUTINE -
Endocrinology referral for evaluation of concurrent autoimmune thyroid disease (autoimmune polyglandular syndrome) - - ROUTINE -
Nutrition/Dietitian referral for dietary counseling regarding B12-rich foods, especially for vegans, vegetarians, and post-bariatric patients - ROUTINE ROUTINE -
Pain management referral for refractory neuropathic pain not responding to first- and second-line agents after adequate B12 replacement - - ROUTINE -
Neuropsychological testing for cognitive assessment if persistent cognitive impairment despite B12 normalization - - ROUTINE -
Social work consult for assistance with self-injection training, medication access, and disability resources - ROUTINE ROUTINE -

4B. Patient Instructions

Recommendation ED HOSP OPD ICU
B12 injections are lifelong if pernicious anemia is the cause; stopping injections will cause neuropathy to recur and worsen - ROUTINE ROUTINE -
Neurological symptoms may take 3-12 months to improve after starting B12 replacement; improvement depends on duration and severity of deficiency before treatment - ROUTINE ROUTINE -
Return immediately if worsening weakness, difficulty walking, or new bladder/bowel dysfunction develops (may indicate progressive myelopathy requiring urgent evaluation) ROUTINE ROUTINE ROUTINE -
If self-administering B12 injections, use proper IM technique and rotate injection sites (outer thigh or deltoid); attend injection training with nursing - ROUTINE ROUTINE -
Do not take folate supplements without B12 as folate alone may mask B12 deficiency while neurological damage continues to progress ROUTINE ROUTINE ROUTINE -
Inspect feet daily for cuts, blisters, or wounds using a mirror for soles; impaired sensation increases injury risk - ROUTINE ROUTINE -
Use night lights, handrails, and remove throw rugs to prevent falls from impaired balance and proprioception - ROUTINE ROUTINE -
Test bath water temperature with elbow before entering as impaired sensation increases burn risk - ROUTINE ROUTINE -
Neuropathic pain medications take 2-4 weeks to reach full effect; do not stop gabapentin or pregabalin abruptly - ROUTINE ROUTINE -
Report new numbness, tingling, or weakness to your neurologist as this may indicate inadequate treatment or alternative diagnosis - ROUTINE ROUTINE -
If vegan or vegetarian, lifelong B12 supplementation is required as plant-based diets contain no natural B12 - ROUTINE ROUTINE -

4C. Lifestyle & Prevention

Recommendation ED HOSP OPD ICU
Complete alcohol cessation as alcohol independently causes neuropathy and worsens B12 malabsorption ROUTINE ROUTINE ROUTINE -
Smoking cessation to improve vascular health and support nerve recovery - ROUTINE ROUTINE -
Dietary sources of B12: meat, fish, eggs, dairy, fortified cereals; supplement if dietary intake insufficient - ROUTINE ROUTINE -
Fall prevention: remove throw rugs, ensure adequate lighting, install grab bars, use assistive devices for sensory ataxia and proprioceptive loss - ROUTINE ROUTINE -
Regular exercise as tolerated (walking, swimming, stationary bike) to maintain strength and cardiovascular health; avoid exercises requiring intact proprioception without supervision - ROUTINE ROUTINE -
Avoid excessive vitamin B6 supplementation (>100 mg/day) which independently causes peripheral neuropathy - ROUTINE ROUTINE -
Annual screening for gastric carcinoid/adenocarcinoma if pernicious anemia confirmed (3-fold increased risk of gastric cancer) - - ROUTINE -
Metformin users: annual B12 screening as metformin reduces B12 absorption by 10-30% - ROUTINE ROUTINE -
Review medications for B12-lowering agents: proton pump inhibitors, H2 blockers, metformin, colchicine, nitrous oxide exposure - ROUTINE ROUTINE -
Nitrous oxide avoidance: inform anesthesia team of B12 deficiency before any surgical procedures as N2O irreversibly oxidizes B12 and precipitates acute neurological deterioration ROUTINE ROUTINE ROUTINE ROUTINE

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis Key Distinguishing Features Tests to Differentiate
Copper deficiency myeloneuropathy Nearly identical to B12 SCD clinically; often post-bariatric surgery or zinc excess; may co-occur with B12 deficiency Serum copper, ceruloplasmin; zinc level; may have neutropenia/anemia without macrocytosis
Diabetic polyneuropathy Length-dependent symmetric sensory neuropathy; no myelopathy; burning pain common HbA1c, fasting glucose, OGTT; NCS shows axonal polyneuropathy; no posterior column findings on MRI
Multiple sclerosis Demyelinating lesions; relapsing-remitting course; dissemination in time and space; young females MRI brain/spine shows periventricular lesions; CSF oligoclonal bands; normal B12 and MMA
Cervical spondylotic myelopathy Compressive myelopathy; neck pain; upper motor neuron signs in lower extremities MRI cervical spine shows structural compression; B12 and MMA normal
HIV-associated myelopathy (vacuolar myelopathy) Similar posterior column involvement; immunocompromised; often with concurrent neuropathy HIV testing; CD4 count; may coexist with B12 deficiency
Neurosyphilis (tabes dorsalis) Posterior column dysfunction; lightning pains; Argyll Robertson pupils; may have concurrent neuropathy RPR/VDRL; FTA-ABS; CSF VDRL
CIDP Progressive or relapsing proximal and distal weakness; areflexia; demyelinating pattern on NCS NCS shows demyelination (not axonal); CSF elevated protein; nerve enlargement on ultrasound
Folate deficiency neuropathy Similar megaloblastic anemia; neuropathy less prominent; no SCD typically Normal MMA; elevated homocysteine; low serum/RBC folate; B12 normal
Friedreich ataxia Progressive sensory ataxia; cardiomyopathy; onset in youth; autosomal recessive Genetic testing (GAA trinucleotide repeat); normal B12
Hereditary spastic paraplegia Slowly progressive spastic paraparesis; family history; no sensory loss typically Genetic testing; no posterior column involvement; B12 normal
Nitrous oxide toxicity Acute/subacute SCD-like syndrome; often in B12-deficient patients; recreational N2O use History of N2O exposure; B12 may be normal or low; MMA elevated; rapid onset
Paraneoplastic myelopathy/neuropathy Subacute onset; weight loss; smoking history; may affect posterior columns Paraneoplastic antibodies (anti-Hu, CV2); CT chest/abdomen/pelvis
Vitamin E deficiency Spinocerebellar ataxia; proprioceptive loss; may mimic SCD; fat malabsorption Serum vitamin E level; fat-soluble vitamin panel

6. MONITORING PARAMETERS

Venue column indicates where monitoring is typically ordered/initiated. Most monitoring continues in outpatient setting.

Parameter Frequency Target/Threshold Action if Abnormal ED HOSP OPD ICU
Serum B12 level 1-2 months after starting treatment, then every 6-12 months >400 pg/mL If persistently low on oral, switch to parenteral; increase dose - ROUTINE ROUTINE -
Methylmalonic acid (MMA) 2-3 months after starting treatment, then annually Normal (<0.4 umol/L) If elevated despite supplementation, evaluate compliance and absorption; switch to parenteral if on oral - ROUTINE ROUTINE -
Homocysteine 2-3 months after starting treatment Normal (<15 umol/L) If elevated, check folate; assess compliance - ROUTINE ROUTINE -
CBC with reticulocyte count Day 5-7 (reticulocyte crisis); 1-2 months; then every 6-12 months Reticulocyte rise by day 5-7; normalizing MCV and Hgb by 8 weeks If no reticulocyte response, reconsider diagnosis; check folate, iron ROUTINE ROUTINE ROUTINE ROUTINE
Potassium Q12-24h during first 48 hours of treatment >3.5 mEq/L Supplement potassium; severe hypokalemia can cause arrhythmia STAT STAT - STAT
Neurological examination (sensory, motor, proprioception, Romberg, gait) Each visit; formal assessment at 3, 6, and 12 months Progressive improvement; stable or improved strength and sensation If worsening, re-evaluate diagnosis; check B12/MMA; consider additional causes - ROUTINE ROUTINE -
Pain scores (NRS 0-10) Each visit Reduction >=30-50% from baseline Titrate pain medications; consider combination therapy or referral - ROUTINE ROUTINE -
Gait and fall risk assessment Each visit Stable or improving gait; no falls PT referral; assistive devices; home safety evaluation - ROUTINE ROUTINE -
MRI spine (if SCD at baseline) 6-12 months after treatment initiation Resolution or improvement of posterior column signal changes If worsening or new lesions, reconsider diagnosis; check compliance - - ROUTINE -
NCS/EMG follow-up 6-12 months after treatment; then PRN for symptom change Stable or improved nerve conduction parameters If progressive despite treatment, reconsider diagnosis or look for additional etiology - - ROUTINE -
Iron studies 1-2 months after treatment initiation Normal hemoglobin; adequate iron stores Iron supplementation if deficient (combined deficiency common in pernicious anemia) - ROUTINE ROUTINE -
Gastric surveillance (if pernicious anemia) EGD with biopsy every 3-5 years No dysplasia, carcinoid, or adenocarcinoma Gastroenterology referral for management of premalignant lesions - - ROUTINE -

7. DISPOSITION CRITERIA

Disposition Criteria
Discharge home Stable neurological examination; able to ambulate safely (with assistance if needed); reliable follow-up arranged; B12 injection initiated or prescription provided; caregiver available for injection administration or self-injection training completed; no severe hypokalemia or electrolyte abnormality
Admit to floor Acute or subacute myelopathy (gait ataxia, spasticity, weakness); inability to ambulate safely; severe pancytopenia requiring monitoring; need for frequent electrolyte monitoring during initial B12 replacement; concurrent acute illness complicating management; falls requiring inpatient rehabilitation assessment
Admit to ICU Severe symptomatic anemia requiring transfusion with hemodynamic instability; high-output cardiac failure from severe anemia; severe hypokalemia with cardiac monitoring need during B12 replacement; respiratory compromise from severe weakness
Transfer to higher level Neurology consultation not available; EMG/NCS not available for diagnostic workup; MRI not available for myelopathy evaluation; hematology evaluation required but not available locally

8. EVIDENCE & REFERENCES

Recommendation Evidence Level Source
Serum B12 <200 pg/mL diagnostic; MMA and homocysteine for borderline levels Class II, Level B Stabler SP. NEJM 2013
Parenteral B12 replacement for neurological B12 deficiency Class II, Level B Devalia V et al. Br J Haematol 2014
High-dose oral B12 (1000-2000 mcg/day) may be as effective as IM for maintenance in selected patients Class I, Level B Vidal-Alaball J et al. Cochrane Database Syst Rev 2005
Intrinsic factor antibodies highly specific (>95%) for pernicious anemia Class II, Level B Toh BH et al. NEJM 1997
MRI posterior column T2 hyperintensity in subacute combined degeneration Class III, Level C Timms SR et al. Neuroradiology 1993
Neurological damage may be irreversible if treatment delayed >6 months Class II, Level B Healton EB et al. Medicine (Baltimore) 1991
Gabapentin, pregabalin, duloxetine first-line for neuropathic pain Class I, Level A Finnerup NB et al. Lancet Neurol 2015
Folate supplementation without B12 may worsen neurological manifestations Class II, Level B Reynolds EH. Lancet Neurol 2006
Metformin-associated B12 deficiency in 10-30% of users Class I, Level B Aroda VR et al. J Clin Endocrinol Metab 2016
Nitrous oxide precipitates acute neurological deterioration in B12-deficient patients Class III, Level C Flippo TS, Holder WD Jr. South Med J 1993
Pernicious anemia associated with 3-fold increased risk of gastric carcinoid and adenocarcinoma Class II, Level B Hsing AW et al. JNCI 1993
Hypokalemia during B12 replacement from rapid erythropoiesis can be life-threatening Class III, Level C Expert consensus; case reports
Celiac disease as cause of B12 malabsorption Class II, Level B Dahele A, Ghosh S. Eur J Gastroenterol Hepatol 2001
NCS/EMG shows axonal sensorimotor polyneuropathy in B12 deficiency neuropathy Class II, Level B Saperstein DS et al. Neurology 2003
Copper deficiency mimics B12 deficiency myeloneuropathy; should be excluded Class III, Level C Kumar N et al. Mayo Clin Proc 2006

CHANGE LOG

v1.1 (January 30, 2026) - Eliminated all cross-references ("Same as cyanocobalamin") in Section 3A; hydroxocobalamin IM and cyanocobalamin SC rows now self-contained with full contraindications and monitoring - Standardized structured dosing format across all treatment sections (3A, 3B, 3C) to [dose] :: [route] :: [frequency] :: [full_instructions] - Added ICU column to Section 4B (Patient Instructions) and Section 4C (Lifestyle & Prevention) for consistent 4-venue coverage - Cleaned gabapentin contraindications: moved renal dose adjustments to dosing field, added respiratory depression warning with opioids - Added taper instructions to pregabalin and venlafaxine monitoring - Corrected nortriptyline monitoring to be self-contained (removed comparative reference to amitriptyline) - Improved magnesium sulfate dosing: added threshold and oral maintenance step-down - Added nitrous oxide avoidance to ICU setting (Section 4C) for pre-surgical safety communication

v1.0 (January 30, 2026) - Initial template creation - Comprehensive laboratory workup including B12, MMA, homocysteine, IF antibodies, anti-parietal cell antibodies, and etiology-directed testing - MRI spine for subacute combined degeneration with characteristic imaging findings - EMG/NCS for peripheral neuropathy characterization - B12 replacement protocols: cyanocobalamin IM, hydroxocobalamin IM, SC route, high-dose oral, sublingual - Neuropathic pain management with gabapentinoids, SNRIs, TCAs, and topical agents - Pernicious anemia workup including intrinsic factor antibodies, anti-parietal cell antibodies, gastrin - Celiac disease screening with tTG-IgA and total IgA - Comprehensive differential diagnosis including copper deficiency, MS, cervical myelopathy, nitrous oxide toxicity - Monitoring parameters for treatment response (reticulocyte crisis, B12/MMA normalization, neurological recovery) - Gastric surveillance recommendations for pernicious anemia - Patient education on lifelong supplementation, nitrous oxide avoidance, and fall prevention


APPENDIX A: B12 Replacement Dosing Quick Reference

Scenario Route Induction Maintenance Notes
Neurological symptoms (any cause) IM 1000 mcg IM daily x 7 days 1000 mcg IM weekly x 4 weeks, then monthly indefinitely Preferred initial route for neurological disease
Pernicious anemia IM 1000 mcg IM daily x 7 days 1000 mcg IM monthly indefinitely Lifelong; cannot absorb oral B12 via IF pathway
Dietary deficiency (vegan/vegetarian) PO 1000-2000 mcg PO daily x 8 weeks 1000 mcg PO daily indefinitely Monitor MMA at 2-3 months to confirm response
Malabsorption (celiac, SIBO, Crohn) IM 1000 mcg IM daily x 7 days 1000 mcg IM monthly until malabsorption corrected May switch to oral once underlying cause treated
Metformin-induced PO 1000 mcg PO daily x 8 weeks 1000 mcg PO daily while on metformin Annual B12 monitoring recommended
Injection-refused or anticoagulated PO/SL 2000 mcg PO daily x 8 weeks 1000-2000 mcg PO daily indefinitely Monitor MMA closely; switch to IM if inadequate

APPENDIX B: Neurological Recovery Timeline

Domain Expected Recovery Notes
Peripheral neuropathy (sensory) Begins 1-3 months; maximum improvement by 6-12 months Paresthesias often first to improve; numbness may persist
Peripheral neuropathy (motor) Begins 1-3 months; maximum improvement by 6-12 months Distal weakness recovers before proximal
Proprioceptive loss / sensory ataxia Begins 3-6 months; may take 12+ months Incomplete recovery common if treatment delayed
Myelopathy (SCD) Variable; begins 3-6 months Spasticity and posterior column signs may be permanent if treatment >6 months delayed
Cognitive impairment Begins 1-3 months; may take 12+ months Dementia component may be partially irreversible
Optic neuropathy Variable; may improve within weeks Rare; bilateral vision loss
Hematologic (anemia) Reticulocyte crisis day 5-7; Hgb normalizes 6-8 weeks First sign of treatment response

Key principle: Earlier treatment initiation correlates with better neurological outcomes. Neurological symptoms present for >6 months before treatment have significantly lower chance of full recovery.