Iron/ Vitamin B12 (Anti-anaemic preparations)

Recommendations

Type	Recommendation
When to deprescribe
CBR	If haemoglobin and ferritin/B12 levels are within an acceptable range, we suggest deprescribing be offered to older people taking iron and/or vitamin B12: Without an ongoing indication (e.g. underlying cause of iron deficiency has been addressed) For drug-induced indication where the original drug can be suitably reduced, discontinued, or replaced by another drug (e.g. inappropriate prescribing cascade related to metformin or proton pump inhibitors and B12) With no clear or known indication (e.g. no documented history of iron/B12 deficiency or pernicious anaemia)
Ongoing treatment
CBR	We suggest continuing iron or vitamin B12 therapy in older people whose deficiency is due to permanent underlying conditions, such as a history of gastric surgery, pernicious anaemia, or unmodifiable dietary limitations (e.g. vegetarian or vegan diet).
How to deprescribe
CBR	We suggest ceasing iron and/or vitamin B12 therapy without the need for tapering. We suggest before deprescribing, assessing nutritional status and other relevant health factors, as part of a comprehensive care plan to ensure ongoing patient well-being.
Monitoring
CBR	We suggest offering laboratory monitoring of complete blood count, iron studies/B12 periodically to promptly identify any recurrence of iron/B12 deficiency.
CBR	We suggest advising patients to report to their healthcare providers symptoms of iron/B12 deficiency such as unexplained lack of energy, shortness of breath, headache, and heart palpitations, or B12 deficiency symptoms of glossitis (tongue soreness), and neuropathy (numbness involving fingers/toes).

CBR, consensus-based recommendation

Introduction

Anaemia is highly prevalent in older people and is particularly common among the oldest and most frail [271]. The most common causes of anaemia in older people are chronic diseases and nutritional deficiencies (e.g. iron deficiency anaemia, vitamin B12 deficiency) [272]. Anaemia in older people is associated with an increased risk of mortality, morbidity, and all-cause hospitalisation [271].

Narrative summary of evidence on deprescribing

We were unable to identify any direct evidence related to the deprescribing of iron and vitamin B12 in older people from the systematic review and meta-analysis. Recommendations are provided in this section following a Delphi consensus process.

Justification of recommendations

Iron and vitamin B12

Iron supplementation is usually required until iron stores are replenished, and the serum ferritin concentration is within an acceptable range which could take three to six months [273]. Long-term use of iron supplementation may only be required after appropriate investigations have been carried out to determine the underlying cause of iron deficiency and that the cause cannot be corrected [273]. If haemoglobin levels are within an acceptable range, and there is no clear ongoing indication for continued use (i.e. irreversible cause), deprescribing may be appropriate.

Vitamin B12 is indicated for neurological symptoms in addition to anaemia caused by vitamin B12 deficiency [274]. Deficiency can lead to neurological symptoms including peripheral neuropathy, gait abnormalities, and cognitive impairment [275]. Therefore, assessing B12 levels in older people with neurological symptoms may help prevent potentially irreversible neurological complications. Most people with vitamin B12 deficiency caused by permanent underlying conditions (e.g. gastric surgery, pernicious anaemia) often require lifelong maintenance therapy after the initial treatment [274, 275]. Early detection and treatment for the underlying cause is crucial. Those with deficiency caused by the long-term use of other drugs (e.g. metformin, PPIs) that affect B12 absorption may benefit from deprescribing the causative agent where possible. Additionally, in the absence of anaemia or neurological and cognitive signs or symptoms, an RCT found that correcting moderate vitamin B12 deficiency did not provide any neurological or cognitive benefits in later life [276]. In this population, deprescribing may be appropriate.

If considered suitable to deprescribe, iron and/or vitamin B12 therapy generally do not require tapering as they do not cause physiological dependence or withdrawal/rebound syndromes.

Laboratory monitoring, if indicated, may be undertaken periodically to promptly identify any recurrence of iron/B12 deficiency [275]. General symptoms of B12 deficiency include glossitis (tongue soreness), and neuropathy (numbness involving fingers/toes) [277]. In addition, common iron deficiency includes an unexplained lack of energy, shortness of breath, headache, and heart palpitations [278].

It may be helpful to provide examples of common symptoms when encouraging individuals to self-monitor and report symptoms to their healthcare professionals. As some symptoms are non-specific, many individuals may not recognise that they could be indicative of iron and/or vitamin B12 deficiency.