B12 Injections

[VA Hopeful Dr]

So a question for the group. Like I suspect many of you, I have lots of patients who want B12 injections. I'll check the level and its rarely actually low (rarely actually below 400 even since below that can be a grey zone). I'll offer methylmalonic acid, but that's $40 so I'm rarely taken up on it.

Given that many of my patients don't have insurance, what do y'all think about just letting these patients buy B12 shots at cost to give themselves if they're adamant about it taking it?

It seems wrong to me for some reason, but I'm having trouble thinking of a concrete reason not to let them do it.

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[deleted87716]

The only reason B-12 is given as an IM injection is to bypass the gut in the event the deficiency is caused by lack of intrinsic factor (pernicious anemia). If these patients don't have megaloblastic anemia or low B-12 levels, it's very likely that they have sufficient intrinsic factor to absorb vitamin B-12 orally. Just have them take 1mg/day p.o. It's available OTC, and it'll probably be cheaper than injections. It's just a placebo either way. Anyone giving IM B-12 injections for weight loss or just to make patients feel good is doing it for financial gain. There's no evidence of benefit.

 

[VA Hopeful Dr]

The only reason B-12 is given as an IM injection is to bypass the gut in the event the deficiency is caused by lack of intrinsic factor (pernicious anemia). If these patients don't have megaloblastic anemia or low B-12 levels, it's very likely that they have sufficient intrinsic factor to absorb vitamin B-12 orally. Just have them take 1mg/day p.o. It's available OTC, and it'll probably be cheaper than injections. It's just a placebo either way. Anyone giving IM B-12 injections for weight loss or just to make patients feel good is doing it for financial gain. There's no evidence of benefit.

This is all true, but not what I asked

I guess I'm going for more of an ethical angle. If I'm not making any money off of this (and I won't be, I charge straight cost for stuff like this), and patients want to pay cash to get the B12 shots because of said placebo affect, am I a bad person for indulging them?

 

[deleted87716]

This is all true, but not what I asked

I guess I'm going for more of an ethical angle. If I'm not making any money off of this (and I won't be, I charge straight cost for stuff like this), and patients want to pay cash to get the B12 shots because of said placebo affect, am I a bad person for indulging them?

There are potential side effects with B-12 injections (http://www.webmd.com/drugs/2/drug-6550/vitamin-b-12-injection/details#side-effects). If the benefits don't outweigh the risks, and you can't document any medical indication for them, I think you'd be on shaky ground in the event something went wrong. They may love you now for kowtowing to their demands, but I guarantee you won't be their friend if something bad happens.

Regardless, you should also ask yourself if you really want these kind of patients...

 

[VA Hopeful Dr]

There are potential side effects with B-12 injections (http://www.webmd.com/drugs/2/drug-6550/vitamin-b-12-injection/details#side-effects). If the benefits don't outweigh the risks, and you can't document any medical indication for them, I think you'd be on shaky ground in the event something went wrong. They may love you now for kowtowing to their demands, but I guarantee you won't be their friend if something bad happens.

Regardless, you should also ask yourself if you really want these kind of patients...

Huh, hyperkalemia was a new one for me.

There's lots of patients I don't want, but I feel guilty being too choosey.

 

[SDN]

Huh, hyperkalemia was a new one for me.

There's lots of patients I don't want, but I feel guilty being too choosey.

Don't! If you have the ability to choose your patients, then just choose those who have realistic expectations of medicine.

Trust me, you'll be happier in the long run.


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[surrender903]

Huh, hyperkalemia was a new one for me.

There's lots of patients I don't want, but I feel guilty being too choosey.

why dont you tell them the truth? "this really wont benefit you, i checked your levels and they are normal." you dont have to use those exact words, sell it and offer them something instead. if they are that concerned ask them to drink a 5 hr energy

 

[Mad Jack]

The only reason B-12 is given as an IM injection is to bypass the gut in the event the deficiency is caused by lack of intrinsic factor (pernicious anemia). If these patients don't have megaloblastic anemia or low B-12 levels, it's very likely that they have sufficient intrinsic factor to absorb vitamin B-12 orally. Just have them take 1mg/day p.o. It's available OTC, and it'll probably be cheaper than injections. It's just a placebo either way. Anyone giving IM B-12 injections for weight loss or just to make patients feel good is doing it for financial gain. There's no evidence of benefit.

Hell, even with IF deficiency, high oral doses can be enough to do the trick from what we were taught.

 

[deleted87716]

There's lots of patients I don't want, but I feel guilty being too choosey.

No need to feel guilty. The decision isn't yours, it's theirs. If you attempt to educate them and they don't want to listen, you've done your job. You're a doctor, not a vending machine.

I've actually said that to patients, FWIW. I've also said, "My job is to lead the horses to water. But, it's illegal for me to hold their heads under and make them drink."

 

[cabinbuilder]

I never give those just like I don't give steroids as first line for sinus. I don't let the patient's tell me how to practice and they are welcome to go elsewhere.

 

[JustPlainBill]

I never give those just like I don't give steroids as first line for sinus. I don't let the patient's tell me how to practice and they are welcome to go elsewhere.

And that is why I love our periodic conversations about the things we see/get asked from patients ----

So, being new in practice, how do you deal with the unspoken threat of being reported to "The Board" -- when I was in residency, word was that patients at the county hospital were finding out that they could file a complaint with the board and even if the physician did nothing wrong, it was a good $4K to defend themselves -- lately, the board has been sending out questionnaires to patients who file complaints to try to weed out the spurious ones ---

Just yesterday I had a "I lost my controlled substance script - accidently threw it away" and had to say, "sorry, see you when it's time" --- for the first time....

 

[deleted87716]

So, being new in practice, how do you deal with the unspoken threat of being reported to "The Board"

State Boards of Medicine are charged with protecting the public, and are only going to investigate physicians who may have violated a regulation or law. They don't have any jurisdiction over customer service issues, nor do they investigate them (they don't in my state, anyway).

Just yesterday I had a "I lost my controlled substance script - accidently threw it away" and had to say, "sorry, see you when it's time" --- for the first time....

That's a big red flag for abuse or diversion. In my state, however, I can use our prescription monitoring program to see if they've filled a prescription. On a related note, our EHR now lets us electronically prescribe controlled substances using VIP Access ( https://m.vip.symantec.com/home.v ). I tried it for the first time yesterday. Very cool. No more lost prescriptions. Of course, they can still accidentally dump their pills down the sink...

 

[cabinbuilder]

Most of those are empty threats. I have been known to whip out my phone and start dialing and say, "Lets call them together and tell them how you doctor shop, are non-compliant with your medications, etc....and aren't happy with your care because there is no quick fix and you don't want to help yourself get better?". Love those people. They back down and back peddle very quickly.

Just like the time I was in Southeast Alaska when I had a patient who was medevac by me 4 months earlier for a ruptured bowel and came back into the ER pouring blood into her colostomy bag faster than I could replace it. She was yelling at me, "I hate you CB, I hate you, and I will not be sent to Seattle again." Ok......... I have no problem if people want to die at home and are sick of being sick. However I did tell her that was her right to stay and bleed out and die but there was no way in hell she was going to change her mind at 2am in panic when I'm asleep. I told her to call her family, have a meeting and decide. She had 30 minutes to get on the plane or call the funeral home - her choice.

I will tell you her husband came to me soon after and I called the medevac plane. She was saved - again. Sigh........ all in a day.

 

[VA Hopeful Dr]

Thanks for that all, just needed to hear that. Starting a practice from scratch one tends to accept more at the start when you're worried about paying the bills. I'm starting to do a better job weeding out I just have a few hold overs from the early days.

 

[mommy2three]

Being on the receiving end of these monthly shots I will add one other condition they are used for

Post bariatric surgery patients




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[Doctor4Life1769]

I used to get B12 shots but it did nothing for me except reduce my wallet size

 

[hallowmann]

Have a young (20s-30s) family member that was clearly B12 deficient (like less than 150) without any apparent pernicious anemia or anything, but with major fatigue and progressing memory issues. At the time, she started taking high dose oral B12, with pretty much no change. Never ended up doing a Shillings test or anything, just went straight IM weekly and then monthly and her symptoms significantly improved. Her levels only really got up to 250-300 over more than a year getting the B12. She's still taking monthly 1 cc shots. Her diet is pretty normal, and honestly have no idea why even the shots aren't having a more significant effect.

Anyway, my point is that sometimes people need IM B12, sometimes even if they don't have pernicious anemia contrary to what some on here were implying. Obviously OP's patient isn't deficient and advice already given to OP.

 

[deleted87716]

Anyway, my point is that sometimes people need IM B12, sometimes even if they don't have pernicious anemia contrary to what some on here were implying.

Who said anything like that...?

 

[hallowmann]

Who said anything like that...?

I doubt you meant it strictly that way, but someone could have interpreted the below that way. I was just saying that my relative never had megaloblastic anemia or anything.

The only reason B-12 is given as an IM injection is to bypass the gut in the event the deficiency is caused by lack of intrinsic factor (pernicious anemia)...

 

[deleted87716]

For the record, I don't typically write things requiring interpretation. Read the entire post in context. If you have further questions, I'd be more than happy to answer them.