Cyanocobalamin Injection (Vitamin B12)
OFFICE ADMINISTRATION / SELF ADMINISTRATION
Indications for Prior Authorization:
- Vitamin B12 deficiencies due to malabsorption which may be associated with the following conditions:
- Addisonian (pernicious) anemia
- Gastrointestinal pathology, dysfunction, or surgery, including gluten enteropathy or sprue, small bowel bacteria overgrowth, total or partial gastrectomy
- Fish tapeworm infestation
- Malignancy of pancreas or bowel
- Folic acid deficiency
- Requirements of vitamin B12 in excess of normal (due to pregnancy, thyrotoxicosis, hemolytic anemia, hemorrhage, malignancy, hepatic and renal disease) can usually be met with oral supplementation.
Prior authorization criteria:
- Diagnosed vitamin B12 deficiency, AND
- Has tried and failed oral cyanocobalamin as evidenced by medical record documentation (does not apply to pernicious anemia)
- Pernicious anemia: parenteral vitamin B12 is the recommended treatment and will be required for the remainder of the patient's life.
- 100 mcg IM daily for 6 or 7 days; with clinical improvement and reticulocyte response, the same dose may be given on alternate days for seven doses, then every 3 to 4 days for another 2 to 3 weeks.
- Maintenance: 100 mcg monthly
- Patients with normal intestinal absorption: when the oral route is not adequate, initial treatment similar to that for patients with pernicious anemia may be indicated depending on deficiency severity.
- One year