Behind the fetish of vitamin B12 shots

Behind the fetish of vitamin B12 shots

Medicines and other treatments need to be tested. We want reliable proof that something works and is safe before we recommend it. We don’t like the false dichotomy of “alternative medicine”. If there is good evidence that it works, it’s medicine. If it doesn’t work, it’s quackery.

It doesn’t matter who’s doing the quacking. A quack is a quack, even if there’s a medical diploma on the wall.

The story: a woman brings in her teenage daughter, complaining that the girl is tired a lot. It turns out that mom herself has had some blood tests that showed a low vitamin B12 level, so her doctor is giving her regular B12 injections. Can her daughter get some, too?

I realize that B12 injections are common. Many docs administer these, and many adults get these—probably some of you reading this. So what’s the science behind this practice?

Vitamin B12 deficiency is a real thing. It can occur because of a poor diet, or because some medications (like acid blockers) interfere with absorption. Or it can occur because of a specific autoimmune disorder called “Pernicious Anemia.” Whatever the cause, the health consequences of vitamin B12 deficiency can include anemia, neuropathy, irritability, and depression.

There is a simple blood test to measure vitamin B12 levels, though the levels in the blood don’t always correlate with whether there is enough B12 levels in the cells themselves. We can test for this, too, indirectly, through other blood tests including methylmalonic acid and homocysteine levels. So we can, in fact, know if a person is truly deficient. These confirmatory tests are rarely done.

Instead, many adults are told that their vague symptoms of tiredness or fatigue are caused by B12 deficiency, instead of actually trying to address genuine issues like insufficient sleep, sleep apnea, overreliance on caffeine, and depression (to name a few of the many genuine causes of fatigue.)

It gets worse. The treatment of B12 deficiency, as has been established from studies done in the 1960s, is ORAL B12. That’s right. Pills. Injections of B12 are not necessary—oral supplements work well, even in pernicious anemia. They’re cheap and they work. I suppose a very rare patient, say one who has surgically lost most of their gut, could require injections. But the vast majority of people with genuine B12 deficiency can get all of the B12 they need through eating foods or swallowing supplements. No needles needed.

So why this fetish with injections? From the patient’s point of view, shots feel more like something important is going on. Placebos need rituals—with acupuncture, for instance, the elaborate ritual creates an illusion of effectiveness. And from the doctor’s point of view, injections reinforce dependence on the physician, creating visits and cash flow.

So: people seem to think they feel better with injections, and the doctor makes a little cash, and everyone’s happy. So what’s the harm in that?

I think it’s wrong to knowingly dispense placebos, even harmless ones. We doctors like to criticize the chiropractors and homeopaths. We point fingers. They’re the quacks. We’d better take a close look at what we’re doing, first. Our placebos are sometimes far more dangerous than theirs.

More importantly, people should be able to expect more from physicians. Patients come to us for genuine answers—if they wanted a witch doctor, they would have found one. I think we need to hold ourselves to a higher standard than a huckster at the carnival. We’re not here to promise that we’ve got all the answers. We are here to be honest, and to use the best knowledge that science has to offer, using  genuine compassion and thought. Let’s leave the quacking to the quacks. We’ll stick with real medicine.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

Image credit: Shutterstock.com

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  • http://www.vegventures.com Maija Haavisto

    What an incredibly ignorant article (more like a crappy troll), including the ridiculous use of the word “fetish” and claiming acupuncture is based on placebo just because you don’t know anything about myofascial trigger points. It’s embarrassing that stuff like this actually gets published here.

    “Real medicine”, yeah right. Clearly you have no idea about the properties of the different forms of vitamin B12, which are far from limited to treating a deficiency. Maybe next time do your research first?

  • http://www.facebook.com/glen.harness Glen E Harness Jr.

    What about those of us who’ve had our ileum removed due to Crohn’s disease? If the ileum is where B12 is absorbed, and you no longer have one, then the ORAL B12 isn’t going to help much.

    • http://twitter.com/martin_hofmann_ Martin Hofmann

      He specifically mentions that patient’s who have had portions of their gut removed are likely candidates for B12 injections.

      • http://twitter.com/bostongal1641 bostonmeg

        Which the author referred to as “a very rare patient who surgically lost most of their gut”. All you need to develop a true Vitamin B12 deficiency is have part of your ileum removed (not even all of it needs to be removed to cause this deficiency) – not “large portions of your gut”. I am no longer able to absorb any B12 from dietary or pill forms because of this surgery. Believe I would rather get it from dietary sources.

        • http://twitter.com/PedInsider Roy Benaroch MD

          OK, I apologize for the word “most.” People who have lost their ileum, or some of their ileum, for medical for functional reasons will not be able to absorb oral B12. These people should be working with a specialist for nutritional advice regarding B12 and other micronutrients. They are not the people who this article was about.

          The vast majority of those receiving B12 injections have normal GI tracts. They are not missing ileum, and they don’t have pernicious anemia. If they’re B12 deficient, or are suspected of being B12 deficient, or if they just wish to get extra B12, oral supplements will do fine.

          Note: nowhere am I criticizing the patients. They’re doing what they’ve been told, and they’re believing what their doctors have told them. It’s the doctors pushing quackery– actively pushing B12 injections for people who don’t need them– those are the people I am calling out.

          • pennyyg

            Roy – if only you could see it from the patient’s side. Doctors are certainly not pushing injections – quite the reverse – they are giving oral tablets to people who can’t absorb them, often for unknown reasons. Their GI tract may look perfect but it’s not getting through in the same way as injections are. We don’t know why – but it’s happening very frequently. We are now beginning to see definite methylation cycle defects in those who can afford to pay for testing. I am one such person and the significant defects revealed perfectly explain why I need daily injections. I have one of the few doctors who actually believed me and allowed me as much B12 as keeps me stable. I was only months from death at the time. I know many more people in the same situation but who can’t get what they need to get their life back.There is probably no other doctor in the UK who would have treated me at all on the test results I had. There are more reasons for not absorbing nutrients than the GI tract. A major one is damage done to the stomach lining from acid-suppressant drugs which leave the patient producing little or no acid. Look at the following article: http://chriskresser.com/what-everybody-ought-to-know-but-doesnt-about-heartburn-gerd

  • Yul Ejnes, MD, MACP

    I normally don’t post comments on blogs (even though I publish monthly on this one), but I just wanted to thank you and commend you for calling out this emperor with no clothes.

    • Suzi Q 38

      Yay.
      My neurologist gave me one injection.
      I have spinal stenosis in m Cspine and hav neuropathies.

      I now just take vitamin B-12 in tablet form.

  • doc99

    Is the object to have the patient feel better or to follow the latest evidence-based protocol? Just asking.

    • southerndoc1

      Neither. The object is good Press-Ganey scores.

      • http://twitter.com/PedInsider Roy Benaroch MD

        Zing!

  • NormRx

    When I started pharmaceutical sales in the early seventies I knew quite a number of physicians that did B12 injections. Most of the patients that received these injections were elderly female patients. The doctors told me that most of these injections were not necessary, they did them for the placebo effect. What is the alternative, send the patients to a psychiatrist?

    I had another doctor tell me that he had a patient that was convinced her husband was trying to kill her, the doctor knew the husband and family for years, and there was no evidence of abuse. What the doctor did was start asking the woman about her bowel habits and stressing the importance of regular bowel movements. It didn’t take long for the woman to be obsessed with her bowel movements and was no longer concerned about her husband killing her. Today the doctor would probably call the police, refer her to a psychiatrist or start her on numerous psychotropics.

    • pennyyg

      How does “I’m feeling better” equate to “the placebo effect”? Can’t you just consider for a moment that maybe the reason the patient is feeling better is that the injection has delivered B12 into their system which couldn’t be achieved any other way? As someone who has lost their bladder and bowel function, and is disabled from major nerve damage resulting from a prolonged B12 deficiency (despite normal results Mr. Benaroch), these injections keep me alive. Very few people willingly subject themselves to repeated injections so they must be doing something very beneficial to justify them. Just because you don’t understand their effect doesn’t mean there isn’t one.

      • NormRx

        pennyyg–Where did I say some people could not benefit? Where did I say your personally could not benefit? Boy, you sure got defensive right away. I really don’t care whether you or any one else gets a B 12 shot every day. I do stand by what I said, and that is many of these patients were elderly female and a little bit nuts and the doctors felt it was mostly a placebo effect.

        • pennyyg

          Maybe the reason why they were “a little bit nuts” is because they were not getting enough B12 for their own particular need and were in the early stages of dementia. I think the clue in your post is “in pharmaceutical sales”. Pharma companies can’t make any money out of B12 since it is a vitamin and want instead to sell medicines which only gloss over the worsening symptoms instead of actually addressing them. Yes, I am defensive – every day I speak to all the victims of doctor’s ignorance on this condition – all the ones given antidepressants instead of what they actually need – more B12.

          • NormRx

            I got news for you, I sold B12, my company had a full line of injectables and I don’t think they were in it for philanthropic
            reasons.

  • http://twitter.com/sarasteinmd Sara Stein MD

    Oh dear. So the 40% of the population who have an MTHFR DNA mutation that impacts their methylation ability to convert the common form of B12 – cyanocobalamin – into the useable mitochondrial form of methylcobalamin (and folic acid into methyl-folate, and pyridoxine into pyridoxal-5-phosphate) are having placebo response because you measured their cyanocobalamin level and it was normal. But you didn’t measure other measures of B12 metabolism such as homocysteine or MMA or their MTHFR DNA looking for either or both 677 and 1298 mutations, and you are simply disregarding their complaints of low energy, anxiety, ADHD, depression.

    Go ahead, keep writing Adderall and Zoloft prescriptions for an MTHFR mutation – you will have a patient for life.

    I’ll give you props for one piece of this – you’re right that cyanocobalamin injections are indicated for pernicious anemia or small bowel/malabsorption problems in patients who are normal methylaters. So yes, they are overused, but only because it’s the wrong kind of B12.

    You can learn more at the Institute for Functional Medicine. Not alternative, all evidence based.

    • http://twitter.com/PedInsider Roy Benaroch MD

      I think you’re confusing the terms “mutation” and “polymorphism.” MTHFR polymorphisms do affect B12 metabolism (as do other polymorphisms at other domains), but it doesn’t result in zero ability to metabolize the vitamin. There may be a role for an altered “RDA” for such individuals, but there’s no particular reason to suspect they would need injections of B12– which is the point of the article.

    • B12d

      40% of the population have one polymorphism or another, I don’t think the evidence supports that 40% have a damaging MTHFR mutation? I could be wrong here.
      What this means, IMHO, is that these people are more likely to suffer from B12 stress (resulting in B12 deficiency).
      I have a theory (and I’m out on a limb here):- caucasians generally live further from the equator and are more likely to be carnovores and omnivores than, for example, Indians (many of whom have been vegetarians for thousands of years). Therefore there simply wasn’t the evolutionary pressure in caucasians to be efficient at recycling B12 – if we were short of B12, we were also short of calories! As a result, evolution favoured genes more directly important to daily life. Whereas of course races subsisting on very little meat would have more evolutionary pressure to favour the B12 recycling and efficient use genes.
      Is this useful? Well it might explain the rash of B12d (B12 deficient) patients in modern developed countries. We now have beef grown over 13 months instead of 36 months – far less time for the B12 to be laid down. 90% of the world’s industrial production of B12 is injected into farm animals, and if you were a farmer, would you inject enough to make the eaters healthy, or just enough to ensure the animal grows? We microwave the carcass to destroy microorganisms (and B12 as it happens) on its way to the supermarket so it lasts longer. So there’s less in the diet, and supplements become necessary.
      Just a thought.

      • ninguem

        All of this may well be true. But if the only issue is B12 deficiency from whatever mechanism, then the treatment is to deliver B12 to the body. Diet, sublingual tablets, oral tablets, injection. Those are your choices.

        It is abundantly clear it can be delivered orally or parenterally. Why the big deal over the injection? Is there a question of hepatic uptake in the oral route? I would tend to agree if there’s a need to deliver a large amount of the vitamin, quickly, it’s hard to beat an injection.

      • http://twitter.com/sarasteinmd Sara Stein MD

        Good thought, made worse by medications such as PPI’s and metformin that block B12 absorption- which brings us back to … guess what… injections!

  • aelephant

    What’s with the attack on acupuncture? Is the author aware of the Cochrane Library reviews that show it is effective?

    • http://twitter.com/PedInsider Roy Benaroch MD

      The acupuncture comment wasn’t really the thesis of the article, but since you asked: the best, genuinely blinded acupuncture studies (using sham needles that fool both patient and acupuncturist) show that sham acupuncture is as effective (or ineffective) as “real” acupuncture. It’s an elaborate hoax, as are B12 injections for the majority of people— thus the comparison.

      • http://twitter.com/B12DinPEI B12DinPEI

        I would love to see the study that says B12 injections are an elaborate hoax for the majority of people. Evidence?

      • ninguem

        Roy, I seem to recall reading….I think in the 1960′s or thereabouts, oral B12 was not commercially available, the injection was. Everyone was injecting, and the supply problem left people thinking the vitamin could not be taken orally, even when the supply problem was fixed. The “oral B12 doesn’t work” meme came out of that.

        I could be wrong on that, something I dimly remember reading once.

  • pennyyg

    Well – it’s due to opinions like this that so many patients are having their quality of life reduced to zero. It must be wonderful to know it all and decide that patients are having a placebo effect and are tolerating injections just because they actually like them! Get real Roy! You really don’t have all the answers or even a smidgeon of understanding about this condition. Maybe one day you’ll suffer it from yourself and you’ll find out the hard way how ignorant and arrogant many in the medical profession are on this subject. You better read up now though on how to treat yourself – you might just be at the mercy of another medic like yourself who, in reality, hasn’t a clue about how to recognise what’s wrong with you and will simply tell you you are depressed, a hypochondriac or that your reported improvement on B12 injections is only a ‘placebo effect.’ I’m glad you’re not my doctor.

  • http://twitter.com/PedInsider Roy Benaroch MD

    Why would the pharmaceutical industry want me to write an article criticizing the use of their product? This comment doesn’t make any sense.

    For the record, I have no financial relationship with any pharmaceutical company.

    • http://twitter.com/B12DinPEI B12DinPEI

      B12 is not a pharmaceutical, it is a vitamin. In Canada and many other countries, a prescription is not required for injectable B12. I can buy 10 doses of cyanocobalamin for $6.45 so it isn’t making the manufacturer a billion dollars a year as some drugs are. B12 Deficiency symptoms such as peripheral neuropathy, fatigue, tinnitus, ataxia, dementia, depression, anxiety, vertigo, vision problems, hair loss, gastritis, incontinence and palpitations are being medicalized when B12 injections would provide a cure.

      • http://twitter.com/PedInsider Roy Benaroch MD

        Riiiiight…. and I’m pointing out that current guidelines and science support treating B12 deficiency, with oral B12. I’m not questioning whether B12 is essential, or whether it should be treated. I’m saying that most of the time, it doesn’t need to be injected. I’m criticizing doctors for using unnecessary injections– for medicalizing (to use your word) an ordinary vitamin. This “diminishes the importance of vitamins and minerals”, as you say, how, exactly?

        • ninguem

          For all the namecalling, the articles cited support what Dr. Benaroch is saying. Most people, I’d say the vast majority of people, can absorb vitamin B12 orally just fine. There is no need to inject.

          The first article:

          A number of patients with senile dementia, with normal B12 levels, were given oral B12 (how long, not clear from the abstract) The serum and CSF-VB12 levels of the demented patients (who already had normal B12
          levels) did not show any significant elevation after oral B12. Patients given oral B12 AND IM B12 did show a marked rise in B12 levels. So the conclusion is, if you have a patient with normal B12 levels, and you want to get that number much higher, give the B12 parenterally.

          Fine. That’s hardly Earth-shattering news.

          The second article:
          “Daily oral cyanocobalamin at doses of 1000-2000 microg can be used for treatment in most cobalamin-deficient patients who can tolerate oral supplementation. There are inadequate data at the present time to support the use of oral cyanocobalamin replacement in patients with severe neurologic involvement.”

          Yeah, sounds about right to me.

          If I had a B12 deficient patient with neurologic findings, I suspect I’d load the patient by B12 injections, but when B12 is normalized, I’d maintain orally.

          Dr. Benaroch, what do you think? A symptomatic B-12 deficient patient in front of you, would you give parenteral B12 until normalized? Would you switch to oral when levels normalized, and/or symptoms improved?

          B12is not a pharmaceutical, it is a vitamin. In Canada and many othercountries, a prescription is not required for injectable B12.

          Wow. thanks for informing us that B12 is a vitamin.

          InjectableB12 is nonprescription in the USA as well. You can inject B12 without aprescription. Many pharmacies inject B12 without a prescription. Freestanding laboratories offer the injections without a prescription.

          What you need a prescription for, is for insurance coverage of the injection.

          Meaningthe patient wants the injection for “free”. The reality of that, to getthe insurance coverage, is to get the physician to SAY that theinjection is needed. That’s fine if it’s medically indicated. If not,and most of the time it is NOT needed by injection, what the patient is
          doing is asking for the doctor to say the injection is medicallynecessary, when it is not.

          In other words, the patient wants thedoctor to lie, in order to save a few dollars on the vitamin. If asked
          by the insurance company to provide documentation to support theinjection, it’s the doctor who pays the price.

          • ninguem

            Whether “fetish” is the right choice of words, heck I don’t know.

            I do know I get a fair number of elderly who want the injections. Most I can convince to take the oral B12. I think those cherry-flavored lozenges are rather tasty.

            A few, insist on continuing the injections, because some other doc did it 20 years ago. Generally I humor them.

          • pennyyg

            What do you consider “adequate absorption of oral B12″? Raised serum level? Does the patient actually feel better? Don’t you think there are many people who are trying to survive on tablets because they can’t access the injections? There will be some who do just fine on them, but there are many others who won’t yet their serum level will be normal to high. There are very few patients who would rather have an injection over tablets, especially if they need them very frequently. However, if through trial and error, they find this is the only way that keeps them stable and lets them have some semblance of a life, then it is a necessary evil.

          • ninguem

            Sheesh, all this is about if how to get a molecule inside the body. For a generation or more, physicians were told the only way to get B12 in the body was by injection. We were told, I know I was, that you **had** to give the vitamin by injection.

            Who can’t access the B12 injections? For Pity’s sake, you can order B12 online. Amazon.com, and any of a number of other sites, some USA-based, some Canadian.

            It may be state-specific, and some of these places may be “prescribing” the vitamin on paper, though the person with prescriptive authority (doctor, PS, nurse-practitioner) has never seen you, to skirt any “prescription only” laws.

          • pennyyg

            In the UK, you can’t purchase any injectable B12 without a prescription or from a UK sourced website. Add to that the fact that a lot of people are not confident to start injecting themselves without proper guidance and monitoring – and who can blame them? Would you be prepared to buy an injectable substance from an unverifiable source in another country and inject it into yourself?

          • ninguem

            You can’t win for losing with this crowd. One person attacks physicians and “western medicine” because B-12 is restricted to prescription use, you’re attacking because it is not.

            Actually, strictly speaking, in the USA it **does** require a prescription, as described above, but there are many ways around that. So as a practical matter, you can get the B12 if you want. Or if you want someone to inject for you but don’t want to see your physician for any reason, you can just walk into any of a number of pharmacies, freestanding blood draw stations for labs, depending on the state, and any number of naturopaths and such who would be more than happy to do the injection and try to upsell you on any of a number of other potions that they just happen to carry. The “prescription” was taken care of behind the scenes..

          • pennyyg

            Perhaps if you read my reply properly you would better understand what I actually said. The reason why people are having to take risks buying it online is because their doctors won’t given them what they need and the option is not available to buy it themselves from pharmacies (in the UK). If people could buy it safely from a trustworthy source, they would leave their doctors in their ignorance and just treat themselves. That option is not available to them.

          • ninguem

            I looked in Amazon.co.uk,

            Of interest, they offer transdermal B12, that I did not realize was available. I don’t know if they have it in the USA.

            Transdermal (through the skin) with a reservoir and a chemical vehicle may not be good enough for you, Seems you need a needle.

            Your own UK pernicious anemia sites and B12 sites discuss various ways to get the injectable vitamin if you have your heart set on it. Although many contributors on those sites point out the same thing, crystalline B12 tablets are absorbed orally just fine.

            Or pay privately. I find it hard to believe you can’t pay a UK doctor privately for the injection.

            The NHS GP’s, or specialists seeing NHS patients, as opposed to private, won’t give B12, when they system you love so much won’t allow it. And I don’t blame the NHS, they don’t want to pay for things that are not medically necessary. Same here, I’ll give the shot, but don’t expect me to lie to insurance companies or Medicare and say it’s medically necessary.

          • Selina B

            The statements made about US law are wrong. Injectable B12 is not available without a prescription. Title 21 of the Federal Food Drug and Cosmetics Act, Section 250.201 Paragraph B and subsection 1 reads:
            “(b) On the basis of the scientific evidence and conclusions summarized in the
            statement of the U.S.P. Anti-anemia Preparations Advisory Board as well as
            pertinent information from other sources, the Commissioner of Food and Drugs
            finds it is the consensus of well informed medical opinion that:

            (1) The parenteral administration of cyanocobalamin or vitamin B12 is
            generally recognized as a fully effective treatment of pernicious anemia.
            Parenteral cyanocobalamin preparations have not been and are not authorized for
            use except by or on the prescription of a duly licensed medical practitioner.”

            This law also underscores the fact that research suggests injectable B12 is the most effective and only recommended treatment. Unfortunately this law is based on the faulty presumption that doctors are knowledgeable about this condition and are willing to treat it correctly. Dr. Roy seems to be an exemplary example of how this law fails patients.

        • frances egan

          Definition of Pernicious, as in Pernicious anemia; Highly destructive, fatal. Now that is serious. As pernicious anemia results from the lack of the ability to absorb, within the stomach, B12 from food stuffs, oral B12 must, surely, be totally inadequate.As I recall a particular client, who, would present with ashen pallor and extreme fatique, would be given 5 inj of B12 1000 mcg to be had over 10 days. This was an effective treatment, as the results were remarkable.It had to be repeated approx. 6 monthly. Bye the way, ask a hemorrhagic menopausal client, how she would value, for her well being, oral B12 as opposed to parental B12.

          • ninguem

            This is like talking to the wall.

            Active transport to extract B12 from food, and passive absorption of crystalline B12 from a tablet, are two completely different things. The literature on this is abundant, and clearly not read by you.

            Even in the presence of pernicious anemia, passive absorption of B12 might be 1% but the B12 tablets contain 1000-2000 mcg each. 1% of that is 10-20 mcg, and daily requirement is 2 mg.

            There’s lots of literature on it.

            Hey, if someone walks in my office, asks for B12 injections, I’ll try to talk sense to them. If they insist anyway, I’ll just shrug my shoulders and say fine, here’s the shot.

            Just don’t expect me to lie to the insurance company and say its medically necessary.

          • pennyyg

            Ninguem – if you, or someone in your family, ever find themselves in the same position as many others of us, come to us and we will still try to help you. We promise not to cast it up to you and will nod sympathetically when you say, “But all the books said . . but I always thought that tablets worked just as well . . but I was always told that all those needing injections were “a bit nuts”.

          • ninguem

            ….all those needing injections were “a bit nuts”……

            I never said that.

            Just you.

            You say you’re in the UK. There’s a nice place in Rampton that can help you.

            ….backing away slowly….

          • frances egan

            Thank you for sharing that information. I will certainly read it up.

          • http://twitter.com/PedInsider Roy Benaroch MD

            It was named pernicious when treatment was unavailable. Whipple figured out that it could be effectively treated with oral raw liver. B12 hadn’t yet been isolated, but there’s tons of it in liver. Oral treatment, even before the role of B12 was understood, was effective.

            Warning: this paragraph is disgusting and you probably shouldn’t read it: There’s a story of an earlier researcher who had discovered that his own vomit– after eating meat– could also cure pernicious anemia when patients ate it. I have no idea how he got them to ingest vomit, but it probably contained enough of his own intrinsic factor to facilitate B12 absorption. Science is cool. And gross, sometimes. But always cool.

  • Docbart

    Glad to see quackery called out. I have quite a few patients with low B12 levels because they take metformin. Most docs don’t screen those patients, in spite of recommendations to do so. Just about all those deficiencies are easily corrected with oral B12.

    While on the subject, how about hugely overpriced B vitamins, which failed as treatment for hyperhomocysteinemia, which have now been repurposed as treatments for neuropathy?

  • Jennifer Owen

    I’m always amazed at how mean we are to each other in the comments. As a medical student, I love this site because it is a place for physicians, nurses, other medical personnel, patients, etc to come together and share experiences, ideas, opinions and advice on the real world of medicine and primary care – topics that aren’t always discussed in the academic world. But then we attack the people who take the time to post here just because we don’t agree. I realize this is a common theme on any internet blog, but I’m still idealistic enough to expect more from my future colleagues and patients. And I suppose I’m joining the status quo by posting this… I graduate in four months and already becoming jaded. Sigh.

    • frances egan

      Please take heart and stand by your ideals, which are to be commended. The future is yours! You and those many, who I believe ,are of the same opinion as yours, can change this and be the light at the end of the tunnel that is a fallout of Individualism.In my humble opinion, the generation influenced by Individualism is less tolerant and more sarcastic. The old saying ‘ Sarcasm is the lowest form of wit’ is sadly missed.Enjoy your graduation!

  • traumadoc

    i am the old school. ben using b-12 injections for my patients. most of them are cancer survivors, the elderly,herpes carriers,anemics and much more.
    my patients come 1st and if it makes them feel better and they ask for it, i will administer it. the more someone does research, the more they dig themselves a whole to no where..the old saying—”why fix something that works’!

  • http://twitter.com/DinoDocLucy Lucy Hornstein

    The Alties are coming, the Alties are coming!

    Thanks for calling them out, Roy. Behind you 100%.

    • ninguem

      Indeed. I don’t know why they get so heated up about this. Can’t speak for anyone else, all I’m saying is oral is as good as injectable. Don’t know about your training, but I know dogma where I trained, B12 had to be given by injection, oral did not work. If someone insists on injections and will pay cash if insurance denies coverage, fine, I’ll indulge them.

      Like that Lederle article in 1991, it seems the efficacy of oral B12 was being kept secret.

      The B12 with or without a prescription thing is strange. On paper, a prescription is required. In reality…..at least in my area……you can walk into blood draw stations at a laboratory chain, and into a few pharmacies, and just get it. There may be a prescription written behind the scenes.

      • pennyyg

        Surely the best way to know if oral tablets are working is to ask the people who take them. Most of them are saying “No”. Fact.

        • ninguem

          Wow. A fact. Because you say so.

          Thank you for that piece of………a piece of something all right.

          • pennyyg

            No, not because I say so – because they are saying so on a daily basis.

          • ninguem

            Who’s “they”, the voices in your head?

            This is useless, believe what you want, I don’t care.

          • pennyyg

            “I don’t care” Yes – that is quite obvious.

  • ninguem

    Another way the “prescription” B12 might be getting through as nonprescripton, looking at the injectable B12 on Amazon.

    It might be officially for veterinary use, despite the use by humans as alluded to in the reviews.

  • f. lusu

    wrong to knowingly dispense placebos. wrong? how about unethical.
    it can Ruin the dr.-patient relationship, and isn’t a physician the biggest placebo of all ? what’s the harm of a dr. making a “little cash” by giving the B12 shots?? if a dr. knows that a patient can get cheap oral supplements but gives the injections anyway, just to make money and to “reinforce dependence on the physician,creating visits and cash flow” ,he’s on very shaky moral ground. at best it’s pseudo-medicine,at worst it’s deception for financial gain.

  • tcascade

    As a vegan, I am very concerned with my own intake of B-12. I supplement my diet with a little bit of nutritional yeast everyday. It’s easy, effortless and far safer than injections.

    I think it is important for healthcare providers to recognize that B-12 injections are a global issue. I was working at a remote medical clinic in Iraq in 2006. We had employees leave the camp to retrieve B-12 ampules, dodging roadside bombs and deadly checkpoints the whole way. It was heartbreaking to see their response when I refused to provide the injection. I view this supplement as a placebo for the vast majority of meat-eaters. And, who knows what was actually inside the ampules or the sterility or purity with which it was manufactured? I tried, often in vain, to educate my patients that the risk they were taking was too high. But, placebos and medical mythology have enormous influence over patients’ behaviors.

  • http://twitter.com/MomMilkshake Milkshakes Anytime

    Dr. Carr was our children’s pediatrician for many years and I observed with my own eyes his decline. It was startling and so very sad as he is a wonderful, kind, Doctor. After his case, I get B12 injections frequently. I’ve seen changes in both my energy level and my “regularity”. Thrilled that someone was able to see what was really wrong with our beloved pediatrician and that he was able to be saved.