Gemini 3 Pro Preview

🏁 TL;DR Practice Changers
1️⃣ Active B12 in pregnancy
2️⃣ Don't delay tx for neuro sx
3️⃣ "Indeterminate" zone (180-350) needs clinical judgement
4️⃣ Oral ≥1mg is 1st line for unknown/dietary causes
5️⃣ Stop routine re-testing on IM

🔄 Follow-up
❌ On IM: Do not re-test B12 levels. They will be high & unhelpful. Monitor symptoms only.
✅ On Oral: Review sx at 3mo (1mo if pregnant).
🤕 Sx persist/worsen? Check adherence, consider MMA, or switch to IM.

💊 Treatment Strategy
💉 IM (Lifelong): AIG, Total Gastrectomy, Ileal resection.
💊 Oral (≥1mg daily): Dietary causes OR unknown cause (if malabsorption not suspected).
Note: Consider IM if adherence issues or severe neuro sx.

🦠 Autoimmune Gastritis (AIG)
(Replaces term "Pernicious Anaemia")
🔍 Suspect AIG? Check Anti-Intrinsic Factor (Anti-IF).
⚠️ Neg Anti-IF does not rule out AIG.
🦀 Cancer Risk: AIG = ↑ risk of gastric ca.
🚩 New/worsening upper GI sx (dyspepsia/nausea)? ➡️ Urgent endoscopy.

📊 Interpretation (Total B12)
📉 <180 ng/L: Confirmed deficiency.
🤔 180-350 ng/L: Indeterminate.
👉 Action: Check serum MMA or trial tx if symptomatic/pregnant/irreversible cause.
📈 >350 ng/L: Deficiency unlikely.

🧪 Diagnosis
Initial: Total B12 or Active B12 (HoloTC).
🤰 Pregnancy: Use Active B12.
🎈 N₂O use: B12 levels unreliable. Check MMA or Homocysteine (secondary care).
⚠️ Red Flag: Suspect SACD/neuro symptoms? Treat immediately (IM), do not wait for labs! 💉