This protocol addresses the next clinical step in patients with neurological manifestations of vitamin B12 deficiency caused by recreational nitrous oxide use, whose initial treatment has not produced sufficient improvement in symptoms.
Recreational nitrous oxide use can cause vitamin B12 deficiency leading to neurological manifestations. First-line management involves offering vitamin B12 replacement — either intramuscular or oral — alongside advising the person to stop recreational nitrous oxide use.
The initial approach of vitamin B12 replacement (intramuscular or oral, with advice to stop nitrous oxide use) aimed to increase vitamin B12 concentrations, with symptom improvement expected within weeks to months. When symptoms continue to interfere with normal daily activities despite this treatment, escalation to this next-line protocol is indicated.
The next step centres on adjusting the oral treatment regimen. The full protocol details which specific adjustment to the oral approach to consider, and under what circumstances an alternative route of administration becomes appropriate.
Offer either intramuscular or oral vitamin B12 replacement to people with a vitamin B12 deficiency caused by recreational nitrous oxide use, based on clinical judgement and the person's preference.
If the person's symptoms have not sufficiently improved so they are still interfering with their normal daily activities, take into account their treatment preferences and either: increase the oral dosage to the maximum licensed dosage or if they are already taking the maximum licensed dosage for oral treatment, switch to intramuscular vitamin B12 injections.
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