by Tyler J. Arsenault B.Sc (Nutrition)

Naturopathic doctors, including our very own Dr. Shelly LInehan ND have been using vitamin B12 therapy for years. In patients with extreme deficiencies, common symptoms include anemia, gastrointestinal disorders, and neurological symptoms such as absent or impaired reflexes, loss of touch, seizures and even dementia. These serious symptoms are typically more likely to be found in people with blood levels below 148pml/L. Anything above this number is considered “sufficient” by Health Canada, so if you’ve ever been told by your doctor that your B12 levels are “normal”, it means that your B12 level could have been 300pml/L. It could have been 900pml/L, heck it could have even been 149pml/L, just one tiny speck away from abnormal. As a patient you have no idea, and you might also have no idea that the “sufficient” level does not guarantee freedom from B12 deficiency symptoms and disease.

“Inter-individual variation” is a term used by pharmacists, naturopathic doctors, and medical doctors to describe the effects of higher than “sufficient” levels of B12 used therapeutically to not only reverse deficiency symptoms, but to manage anxiety, depression, insomnia and chronic fatigue (among others). In clinical practice, amounts up to 900pml/L have continued to show subjectively reported benefit; that’s a quantity of B12 over 6 times the level deemed as “sufficient”. These observations are consistent with the evidence used in intramuscular injection studies which have demonstrated improved energy, mood and stress; though a detailed rationale likely requires some degree of assumption. Double-blind placebo-controlled studies would be incredibly useful in solidifying or dispelling these observations and improving the baseline minimal standard established by Health Canada.

In Canada, there are three types of commercially available B12 used for injection; methylcobalamin, hydroxocobalmin and cyanocobalamin. The first 2 are naturally occurring vitamers; which is to say that they both qualify as vitamin B12 and your body will use them as though they are B12; which is (obviously) fantastic. Typically at our clinic, we have our vitamin B12 compounded as methylcobalamin without preservatives, as methylcobalamin is the active co-enzyme form of B12 and is ready and able to donate a methyl group in biological processes that require methylation (it’s a long story).

For years, this was the common practice, and for our patients with insurance coverage, they often were able to get their vitamin B12 injections covered. Recently and perhaps shockingly however, insurance companies have only been covering vitamin B12 injections with a drug identification number (DIN). The insurance companies want to make sure (of course) that they are covering a legitimate product. However, the problem that has arisen is that both hydroxocobalamin and methylcobalamin don’t have a DIN number in Canada, because they are classed as natural health products as opposed to drugs, and as such they have a natural product number (NPN) assigned to them by Health Canada. Assuming that insurance companies are aware of this, that effectively means just one thing; they will only cover injectable cyanocobalamin with a DIN number. Is that such a big deal though? Can’t we simply switch to cyanocobalamin?

The interesting thing about cyanocobalamin is that it isn’t a natural form of vitamin B12. It’s a synthetic version of vitamin B12 that does not exist in nature and as such is synthesized by pharmaceutical companies. This fact alone is enough to unsettle patients, but that’s not the end of the story.

Cyanocobalmin is a vitamer that consists of cobalamin and cyanide bound together. Cyanide you say?! The stuff that super spies would use to commit suicide in James Bond movies? The stuff that was used deliberately to kill people in gas chambers? The same stuff historically used by terrorists as a means of causing mass casualties? Yes – that stuff. Good ol cyanide.

But wait? Is it really a problem? Manufacturers of cyanide dismiss the concern, stating that cyanide is excreted and everything is fine. But toxicity with cyanocobalamin is possible, and HAS happened unlike the two natural vitamers of B12. Oral use of cyanocobalamin can cause skin problems and has led to anaphylactic shock. Hives, difficulty breathing, swelling, diarrhea, rash, headache and dizziness are all possible side-effects. In the event of full-on cyanide poisoning, patients are treated with hydroxocobalamin; one of the natural forms of vitamin B12 that scavenges the cyanide and excretes it in urine.

At this point, one has to wonder why we wouldn’t simply use methylcobalamin or hydroxocobalamin considering they don’t contain cyanide, don’t necessarily require conversion and don’t lead to a host of possible side effects that require treatment with hydroxocobalamin. It’s for these reasons that we DON’T use cyanocobalamin as our choice of injectable. However, now that we have patients whose insurance will only cover a DIN-ed cyanocobalmin, we (as well as our patients) feel like our backs are up against the wall and we have to play by the game that favours synthetic drug manufacturers yet again. Our patients are forced to choose between a synthetic form of B12 that they don’t necessarily want (for reasons already stated), or to forgo their insurance coverage for the kind of B12 that they would prefer. We’re hoping that this is a glitch that will eventually fix itself, but with many NDs preferring to use the natural B12 vitamers we would hope that the change occurs sooner rather than later.

We’re working with our patients to do our best to explain this unique situation to them, but for those of you who aren’t patients, and are curious as to what the differences between vitamin B12 injections are; and the politics that go along with it please feel free to share this article with friends and help spread the word; it might lead to more rapid change.

As always, thanks for reading. Come back and visit us again anytime!