Vitamin B12 prescribing from 2015 to 2024 in English general practice: an observational study to investigate the switch from injections to tablets

Tank, Nikita, Wood, Christopher, Ahankari, Anand ORCID: https://orcid.org/0000-0001-8695-8938, Mackenna, Brian, Walker, Alex ORCID: https://orcid.org/0000-0003-4932-6135 and Lemanska, Agnieszka ORCID: https://orcid.org/0000-0003-4849-2430 (2025) Vitamin B12 prescribing from 2015 to 2024 in English general practice: an observational study to investigate the switch from injections to tablets. BMJ Open, 15 (2). e093748. ISSN 2044-6055

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Abstract

Background Traditionally, intramuscular vitamin B12 injections were considered by patients and clinicians the most effective treatment option for B12 deficiency. The improving understanding of the condition paired with the restricted National Health Service (NHS) resources, resulted in a shift from injections towards tablets. The COVID-19 pandemic accelerated this change, while healthcare services were adapted to reduce COVID-19 transmission. This included new guidelines on vitamin B12 prescribing where injections were substituted by tablets. Objective We investigated changes between 2015 and 2024 in prescribing B12 injections and tablets including the effect of the COVID-19 pandemic. Design, population and setting This was an observational study of general practice in England covering 100% of the population. Methods We used prescribing data published by the NHS Business Service Authority. Monthly prescription counts and rates per 100 000 patients were visualised in longitudinal plots from 1 January 2015 to 30 September 2024. We stratified the analysis by regions in England. Changes in yearly counts and rates were summarised using descriptive statistics. Linear regression and data from before the COVID-19 pandemic were used to model trends from 2020 to 2024 as if the pandemic had not occurred. The predicted values and their 95% CI were used to assess the effect of the pandemic. Results The number of prescriptions for B12 formulations doubled in the last 10 years from 2.5 million to 5 million per year. The prescriptions for tablets increased from half a million in 2015 to 2 million in 2024. While the prescriptions for injections increased from 2 million to 3 million. In 2020, there was a sharp drop in prescriptions for injections and a simultaneous rapid increase in prescriptions for tablets coinciding with the onset of the pandemic. There were 806 031 (27%) less than expected prescriptions for injections (2 171 924 observed vs 2 977 956 predicted, 95% CI 2 905 348 to 3 050 565) and 299 834 (27%) more prescriptions for tablets (1 415 315 observed vs 1 115 481 predicted, 95% CI 1 094 350 to 1 136 612). After the 2020 drop, by 2024, injections returned to the prepandemic levels of 3 million prescriptions per year and tablets doubled from 1 million in 2019 to 2 million prescriptions in 2024. Conclusions In this study, we document important changes to vitamin B12 prescribing in England over the last 10 years. Before the pandemic, injections were the medication of choice for B12 deficiency but there had been an ongoing debate about the benefits and cost of injections over tablets. The pandemic accelerated the switch from injections to tablets. However, these changes in the pandemic were driven by the availability of resources and not necessarily clinical evidence or patient preference. To establish best practices, more evidence is needed comparing the safety and effectiveness of injections and tablets specific to the condition being treated.