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Identifying at-risk populations is the cornerstone of prevention: Older adults gastric atrophy and reduced intrinsic factor production increase with age Patients with pernicious anaemia require lifelong monitoring and treatment Post-gastrectomy or bariatric surgery patients lack intrinsic factor or adequate absorption sites Individuals with malabsorption disorders Crohn's disease, coeliac disease, chronic pancreatitis Long-term metformin users the MHRA advises considering periodic B12 monitoring in at-risk patients and testing if deficiency is suspected [2] Proton pump inhibitor (PPI) users prolonged use may reduce B12 absorption, though the clinical significance remains debated Strict vegans and vegetarians dietary B12 comes almost exclusively from animal products People exposed to nitrous oxide recreational use or occupational exposure can rapidly deplete B12 stores Monitoring strategies in UK primary care should include: Risk-based periodic monitoring rather than routine annual testing for all Following specific protocols for post-bariatric surgery patients (per British Obesity and Metabolic Surgery Society guidance) Consideration of B12 testing in patients presenting with unexplained neurological symptoms, cognitive decline, or macrocytic anaemia Patient education plays a vital role in prevention: Vegans should be advised about B12-fortified foods or supplements (consult the British Dietetic Association or The Vegan Society for specific guidance) Patients on long-term metformin or PPIs should be aware of potential B12 depletion Individuals receiving B12 replacement must understand the importance of adherence to treatment, particularly those requiring lifelong therapy Education about the risks of nitrous oxide exposure, especially recreational use When to seek medical attention patients should contact their GP if they experience: Persistent tingling, numbness, or 'pins and needles' in hands or feet Unexplained difficulty walking or balance problems Memory problems or confusion Persistent fatigue with mood changes Urgent medical attention (same-day GP, NHS 111, or A&E) is required for: Rapidly progressive weakness or numbness New bladder or bowel problems Sudden visual changes Significant difficulty walking or falls Early intervention, before significant neurological damage occurs, offers the best prospect for complete recovery

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doi: 10.1111/nyas.12410

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