Home' Australian Pharmacist : Australian Pharmacist August 2013 Contents 60
Australian Pharmacist August 2013 I ©Pharmaceutical Society of Australia Ltd.
1. Choose the CORRECT statement
a) Signs and symptoms include shortness
of breath, chest pain, nocturia and
b) Cigarette smoking is the underlying
cause in up to 90% of cases.
c) Wheezing is the most significant
symptom of COPD due to airflow
d) Disease severity is based on the degree
of limitation on a person’s physical
2. Risk factors for hypothyroidism
a) male gender; a history of autoimmune
b) radiation treatment to the head, neck
or chest; diabetes.
c) lithium therapy; a family history of
d) cigarette smoking; treatment with
3. Iron deficiency anaemia:
a) should be suspected in people
presenting with numbness and
b) impairs immune system function and
myelin synthesis and repair.
c) is most commonly caused by
gastrointestinal bleeding in older
4. Proton pump inhibitors may
contribute to vitamin B12 deficiency
by several different mechanisms
a) changes in the activity of gastric
enzymes due to increased gastric pH.
b) production of vitamin B12 analogues
that compete for absorption.
c) impaired release of protein-bound
vitamin B12 from dietary sources.
d) All of the above.
5. Which of the following factors may
predict a reduction in serum vitamin
B12 levels with PPI therapy?
a) CYP2C9 polymorphism.
b) Gastric carcinoma.
c) High dose regimen.
d) History of GORD.
You recommend that Ted make an
appointment with his doctor to
determine the cause of his tiredness
and breathlessness. You explain that
fatigue can be caused by a range of
medical conditions, and it is important
that he visit his doctor so they can do a
thorough investigation. Causes of fatigue
and dyspnoea can include heart failure,
anaemia, dehydration and electrolyte
imbalances, nutritional deficiencies, pain,
depression and psychosocial factors
such as stress and hot weather. Although
a wide variety of diseases can result in
dyspnoea, approximately two thirds
of patients will have a pulmonary or
Ted returns eight weeks later and explains
that his doctor performed some blood
tests and found he has a type of anaemia.
He hands you a prescription for Neo-B12
Injection. His doctor has told Ted that his
symptoms may have something to do
with him taking omeprazole for a long
time. He is to begin having an injection
every three months and his doctor
explained his fatigue should gradually
improve over the next few weeks.
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Proceedings 1994;69(7):657–63 .
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Medicine, Nursing and Health Professions. 8th edn. Chatswood,
NSW: Elsevier Australia: 2009.
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older adults. Aging Clin Exp Res 2007;19(1):16–25.
4. Mosenifar Z. Chronic Obstructive Pulmonary Disease [revised
Jun 2013]. Medscape Reference [online]. At: http://emedicine.
5. eTG complete [online]. Melbourne: Therapeutic Guidelines.
6. Breslin E, van de Schans C, Breukink S, et al. Perception of
fatigue and quality of life in patients with COPD. CHEST
7. Dumitru I. Heart Failure [revised May 2013]. Medscape
Reference [online]. At: http://emedicine.medscape.com/
8. Orlander PR. Hypothyroidism [revised Mar 2013]. Medscape
Reference [online]. At: http://emedicine.medscape.com/
9. Vanderpump MP, Tunbridge WM, French JM, et al. The
incidence of thyroid disorders in the community: a twenty-
year follow-up of the Whickham Survey. Clin Endocrinol (Oxf )
10. So M, MacIsaac RJ, Grossmann M. Hypothyroidism –
investigation and management. Australian Family Physician
11. Harper JL. Iron deficiency anemia [revised Feb 2013].
Medscape Reference [online]. At: http://emedicine.medscape.
12. Iron deficiency anaemia [revised May 2012]. BMJ Evidence
Centre [online]. At: http://bestpractice.bmj.com/best-practice/
13. Pasricha SS, Flecknoe-Brown SC, Allen KJ, et al. Diagnosis and
management of iron deficiency anaemia: a clinical update.
Med J Aust 2010;193(9):525–32.
14. Hirschowitz BI, Worthington J, Mohnen J. Vitamin B12
deficiency in hypersecretors during long-term acid
suppression with proton pump inhibitors. Alimentary
Pharmacology & Therapeutics 2008;27(11):1110–21
15. Oh S . Proton pump inhibitors – uncommon adverse effects.
Australian Family Physician 2011; 40(9):705–8 .
16. McColl KE. Effect of proton pump inhibitors on vitamins and
iron. Am J Gastroenterol. 2009;104(Suppl 2):S5–9 .
17. Vitamin B12 [revised Dec 2012]. The Merck Manual [online].
2013. At: http://www.merckmanuals.com
18. Singh NN. Vitamin B-12 associated neurological diseases
[revised Nov 2012]. Medscape Reference [online]. At: http://
19. Sagar M, Kanczewska l, ljungdahl A, et al. Effect of CYP2c19
polymorphism on serum levels of vitamin B12 in patients
on long-term omeprazole treatment. Aliment Pharmacol
20. Schenk BE, Ukipers EJ, Jlinkenberg-Knol Ec, et al. Atrophic
gastritis during long-term omeprazole therapy affects serum
vitamin B12 levels. Aliment Pharmacol 1999;13:1343–6 .
21. Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy
causes malabsorption of cyanocobalamin (vitamin B12). Ann
Intern Med 1994;120:211–5.
22. Schenk BE, Festen HP, Kuipers EJ, Klinkenberg-Knol EC,
Meuwissen SG. Effect of short- and long-term treatment with
omeprazole on the absorption and serum levels of cobalamin.
Aliment Pharmacol Ther 1996;10:541–5 .
23. Bradford GS, Taylor CT. Omeprazole and vitamin B12 deficiency.
Ann Pharmacother. 1999;33(5):641–3 .
24. Ali T, Roberts DN, Tierney WM. Long-term safety concerns with
proton pump inhibitors. Am J Med 2009;122(10):896–903 .
Key learning points
• Fatigue is the subjective perception
of generalised tiredness, exhaustion
or lack of energy.
• Proton pump inhibitors may
decrease the absorption of vitamin
B12 by preventing its cleavage from
• Studies investigating the association
between vitamin B12 deficiency and
acid suppression have produced
• The possibility of dietary vitamin B12
malabsorption should be considered
in patients receiving chronic PPI
therapy and presenting with signs
and symptoms of its deficiency.
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