Scenario

Farrah Begum comes in with a prescription and asks to speak to pharmacy technician Vicky.

“The receptionist at the surgery wasn’t able to give me a reason for this, so I thought I’d come and ask you,” says Farrah. “I went to the doctor a couple of weeks ago because I was feeling really tired, and he did a blood test. It turns out I’m anaemic, but I’m confused as to why I need to have injections and not iron tablets like I did when I was pregnant.”

Vicky looks at the prescription, which is for ‘hydroxocobalamin 1mg im’ three times a week for two weeks then once every three months.

Answer

Farrah has pernicious anaemia, rather than iron deficiency anaemia, which – judging by her prescription – is caused by a lack of vitamin B12.

Hydroxocobalamin is the form of vitamin B12 used in the vast majority of cases because it stays in the body for longer than cyanocobalamin, which is available in tablet form. Therefore hydroxocobalamin only needs to be administered once every few months once the depleted body stores have been replenished by frequent injections.

Farrah can expect to have the injections for life. However, as she has not had any symptoms of neurological involvement such as tingling in her hands, the injections will only need to be every three months and not more frequently.

The bigger picture

Anaemia can have a range of causes, and it is important to establish which is present before starting any treatment. Iron deficiency is often thought of as the culprit, and while this is certainly the case for many people, a proper assessment should be undertaken by means of a blood test as blindly taking iron salts can be harmful and can also mask a more serious reason for the problem, such as gastrointestinal cancer.

Many people think that it is a good idea to take iron-containing products on an ongoing basis. However, this is generally only thought appropriate for certain patient groups, such as women who are pregnant or who have heavy periods (menorrhagia), patients on haemodialysis, and individuals who cannot absorb iron very well – for example, because they have had some or all of their stomach removed.

Another common cause of anaemia is folic acid deficiency. Most cases are self-limiting and so a short course of supplementation is usually sufficient.

Other anaemias are much more serious, but thankfully also either predictable or relatively unusual. They include sickle cell anaemia, which stems from the sufferer having deformed, less flexible red blood cells as a result of their haemoglobin being structurally abnormal, and the anaemia that occurs in chronic renal failure because of a deficiency in erythropoietin or in cancer as a result of chemotherapy.

Extend your learning

• Take a look at your vitamin and mineral supplement shelves: do you have point of sale material or information on product packaging that reflects the recommendations for iron tablets stated in this scenario? Is there anything you could do to improve the care of the customers who browse this fixture?
• Speak to any customers who have regular vitamin B12 injections. What do they say the injection itself feels like? How do they feel immediately afterwards and just before the next one is due?
• The epoetins used for the management of renal anaemia are not interchangeable, yet they have similar names. Check the patient medication records on your dispensary computer for any patients you have on these products (you should be able to search by product names, which can be found in the British National Formulary) to ensure it is not even remotely unambiguous which product each person is on
• If you work in England, refresh your knowledge of the medical exemptions to prescription charges here. Perhaps surprisingly, conditions such as chronic renal failure and organ transplants – which can involve multiple medicines – are not included. So what could you do to help patients manage their healthcare costs?