Megaloblastic Anemia Testing

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INDICATIONS FOR TESTING

Patient presents with megaloblastic anemia and/or neurologic symptoms

ORDER
Vitamin B12
Folate (for patient with known risk factors)

Vitamin B12 >400 pg/mL Vitamin B12 100-400 pg/mL Low folate levels only Low or normal folate
Vitamin B12
levels and high suspicion
<100 pg/mL
for deficiency

Folate deficiency Low

ORDER
Occasionally, clinician may Methylmalonic Acid, Serum
find normal levels of B12 in ORDER
or Plasma (Vitamin B12
symptomatic patients (usually Folate, RBC
Status)
neurologic symptoms) No
B12 deficiency Normal
folate deficiency
MMA and homocysteine may
be appropriate to confirm B12 <0.4 mol/L >0.4 mol/L
deficiency, as homocysteine
may have a role in detecting
folate or B12 deficiency Not
pernicious
anemia

ORDER Optional antibody testing when MMA >0.4 mol/L

Methylmalonic Acid, Serum or
(MMA >0.4 mol/L confirms B12 deficiency )
Plasma (Vitamin B12 Status)
Homocysteine, Total
ORDER
Intrinsic Factor Blocking Antibody

Both elevated
Positive Negative

Pernicious ORDER
Confirmed B12 anemia Gastric Parietal Cell
deficiency Antibody, IgG

Positive Negative

Pernicious ORDER
anemia Gastrin

<100 pg/mL >100 pg/mL

Not pernicious Pernicious anemia

anemia (indirect confirmation)

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