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Megaloblastic Anemia And Metformin

New Metformin Warning: Mandatory Supplementation With Vitamin B12

New Metformin Warning: Mandatory Supplementation With Vitamin B12

The most common medication used in women with PCOS is the insulin-sensitizer metformin. Research is strongly showing that long-term use of metformin and at high doses (1.5mg or higher daily) can deplete levels of vitamin B12. A deficiency of vitamin B12 can cause permanent neurological and nerve damage as well as mood changes and decreased energy. Here’s what you need to know to avoid a vitamin B12 deficiency if you take metformin. About Metformin Metformin is a medication that became available in the U.S. in 1995 for the treatment of type 2 diabetes. Metformin is the most widely used medication used to lower insulin levels in those with polycystic ovary syndrome. Other names for metformin include glucophage, glucophage XR, glumetza, and fortamet. Metformin lowers blood glucose levels in three ways: It suppresses the liver’s production of glucose. It increases the sensitivity of your liver, muscle, fat, and cells to the insulin your body makes. It slows the absorption of carbohydrates you consume Metformin use may affect the absorption of vitamin B12 possibly through alterations in intestinal mobility, increased bacterial overgrowth, or alterations of the vitamin B12-intrinsic factor complex. Metformin can cause a malabsorption in B12 due to digestive changes, which leads to the binding of B12-intrinsic factor complex (intrinsic factor is needed to absorb B12 in the gut) and a reduction of B12 absorption. Vitamin B12 Deficiency in Metformin Users The largest study thus far to examine the link between metformin and vitamin B12 is the Diabetes Prevention Program Outcomes Study (DDPOS). This study looked at B12 levels of individuals with prediabetes who took 850 mg Metformin 2x/day and compared them to those taking a placebo. At 5 years, 4.3% of the metformin users had Continue reading >>

Metformin-related Vitamin B12 Deficiency

Metformin-related Vitamin B12 Deficiency

Medical and Geriatric Unit, Shatin Hospital, New Territories, Hong Kong, China Address correspondence to: Kin Wah Liu. Email: [email protected] Search for other works by this author on: Medical and Geriatric Unit, Shatin Hospital, New Territories, Hong Kong, China Search for other works by this author on: Medical and Geriatric Unit, Shatin Hospital, New Territories, Hong Kong, China Search for other works by this author on: Age and Ageing, Volume 35, Issue 2, 1 March 2006, Pages 200201, Kin Wah Liu, Lok Kwan Dai, Woo Jean; Metformin-related vitamin B12 deficiency, Age and Ageing, Volume 35, Issue 2, 1 March 2006, Pages 200201, Metformin is an invaluable hypoglycaemic agent. We report two cases who had symptomatic vitamin B12 deficiency related to metformin use; the mechanisms are discussed. The clinician must be aware of the possibility of metformin-associated B12 deficiency in users who suffer cognitive impairment, peripheral neuropathy, subacute combined degeneration of the cord or anaemia. Metformin , elderly , Vitamin B12 deficiency The UK Prospective Diabetes Study Group 34 showed metformin to be an effective hypoglycaemic agent with less weight gain, and decreased hypoglycaemia, myocardial infarction, stroke and death [ 1 ]. Gastrointestinal side-effects and lactic acidosis related to metformin are commonly recognised; however, the associated vitamin B12 deficiency is less well known. Two cases illustrate the problem. An 82-year-old Asian non-vegetarian had type 2 diabetes mellitus for 20 years. Medications included metformin 1 g BD for many years and famotidine for gastritis. She presented with memory loss and progressive leg weakness. Her legs were hypotonic with decreased power, absent reflexes and bilateral extensor plantar reflexes. Vibration and propriocept Continue reading >>

Vitamin B12 Deficiency Associated With Metformin

Vitamin B12 Deficiency Associated With Metformin

Vitamin B12 Deficiency Associated With Metformin Metformin is the only biguanide that is currently in use as an oral hypoglycemic in type II (noninsulin dependent) patients with diabetes. Like all hypoglycemic medications, metformin is not to be taken without careful analysis of associated risks. Lactic acidosis is the most studied and feared side effect; however, vitamin B12 (cobalamin) malabsorption is an underappreciated side effect in up to 30% of patients on metformin (Glucophage Label and Approval History. US Food and Drug Administration. Accessed October 1, 2008). The goal of this article is to examine the role of metformin in cobalamin deficiency, as well as outline the steps that are necessary to assess the incidence of B12 deficiency and its potential reversal with calcium supplementation in a clinical setting. *4th-yr Medical Student, the University of New England, Biddeford, ME. Chief Editor's Note: This article is the 2nd of 18 that will be published in 2010 for which a total of up to 18 AMA PRA Category 1 Credits can be earned. Instructions for how credits can be earned precede the CME Examination at the back of this issue. Unless otherwise noted below, each faculty's spouse/life partner (if any) has nothing to disclose. The authors have disclosed that they have no significant relationships with or financial interests in any commercial organizations pertaining to this educational activity. All staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Reprints: Sahil Parikh, MSIV, Hills Beach Road, Biddeford, ME 04005. E-mail: [email protected] 2010 Lippincott Williams & Wilkins, Inc. Thought Continue reading >>

A Case Of Type 2 Diabetes With Megaloblastic Anemia Due To Vitamin B 12 Deficiency During Long-term Administration Of Metformin

A Case Of Type 2 Diabetes With Megaloblastic Anemia Due To Vitamin B 12 Deficiency During Long-term Administration Of Metformin

A Case of Type 2 Diabetes With Megaloblastic Anemia Due to Vitamin B 12 Deficiency During Long-Term Administration of Metformin Department of Internal Medicine, Seikeikai Hospital Department of Internal Medicine, Seikeikai Hospital Department of Internal Medicine, Seikeikai Hospital Department of Internal Medicine, Seikeikai Hospital Department of Internal Medicine, Seikeikai Hospital Department of Internal Medicine, Seikeikai Hospital DOI Published: February 20, 2017 Received: August 24, 2016 Released on J-STAGE: February 28, 2017 Accepted: November 18, 2016 [Advance Publication] Released: - Revised: - A 78-year-old man developed megaloblastic anemia (hemoglobin 11.5 g/dL, mean corpuscular volume [MCV] 109 fL) 3.8 years after metformin was first administered. Because we suspected that metformin had induced megaloblastic anemia, metformin administration was immediately discontinued. Thereafter, the hemoglobin and MCV levels improved (13.6 g/dL and 104 fL, respectively) immediately after administration of oral and intramuscular cobalamin for approximately 1 month. Biguanide has recently been used to treat type 2 diabetes. Therefore, we must be careful when administering particularly high doses of metformin because of the gradual and delayed progression of megaloblastic anemia after metformin administration. Continue reading >>

Metformin - Dppos.org

Metformin - Dppos.org

During DPP and DPPOS, the pharmacological intervention is metformin 850 mg bid, as tolerated. DPP participants who had been randomized to active metformin and are still eligible to takemedication will remain in the medication arm of the follow up study. This will allow the longestpossible period of continued exposure to metformin to determine its longer-term effects.Metformin is an investigational drug for the treatmentof IGT and is used under an Investigational New Drug (IND 49,782) application with the Foodand Drug Administration (FDA). Metformin is an antihyperglycemic drug of the biguanide class used in the managementof Type 2 diabetes in over 90 countries for over 30 years. It was approved for use in the U.S. in1995 and is distributed by Bristol Myers-Squibb under the trade name Glucophage, andmanufactured by Lipha, a French pharmaceutical firm. Generic products are now available aswell. Metformin reduces the excess hepatic glucose production that characterizes Type 2diabetes without increasing insulin secretion. With reduced hyperglycemia, glucose uptake bymuscle and other insulin sensitive tissues is enhanced while insulin levels remain stable ordecline. In addition to its antihyperglycemic action, metformin also has antihyperlipidemiceffects; particularly the lowering of serum triglyceride levels and is associated with weight loss.Metformin has been found to cause lactic acidosis rarely (about 0.03 cases per 1,000person years) and then only when used in persons with renal or hepatic insufficiency or duringepisodes of hypoxia or circulatory failure. Before its 1995 release in the U.S., and after review of extensive metformin use inCanada, Europe and other parts of the world, Bristol-Myers Squibb issued an FDA approvedpackage insert providing detailed contraindic Continue reading >>

Jabfp | Mobile

Jabfp | Mobile

This study used a descriptive, cross-sectional design to determine the prevalence of vitamin B12 deficiency among a sample of approximately 4000 type 2 diabetic patients cared for by the Madigan Army Medical Center (MAMC) Family Medicine Clinic (FMC). The MAMC Institutional Review Board approved the study. Inclusion criteria were patients aged 45 years and older with the diagnosis of type 2 diabetes. The MAMC FMC appointment schedule was used daily to identify potential volunteers. Study personnel subsequently solicited diabetic patients presenting for a diabetic appointment for enrollment into the study. Diabetic patients that declined participation in the study were not tracked. Recruitment started in May 2005 and concluded in March 2006. We obtained informed consent and asked those meeting the inclusion criteria to complete a questionnaire querying demographic information, medication and supplement use, and exclusion criteria. Patients were excluded if they had a history of pernicious anemia, chronic renal insufficiency defined by a creatinine >3.0, prior bariatric surgery, gastrectomy, B12 supplementation with B12 shots or an oral vitamin B12 dose of >500 mcg/day, prior ileum resection, or Crohn's disease. Medications and supplements queried were metformin, insulin (any form), other hypoglycemic medications, acid blockers (H2 blockers and/or proton pump inhibitors), herbal supplements, multivitamins, and B-complex vitamins. Demographic information solicited were age, sex, and time of original diabetes diagnosis. We did not obtain dietary histories. The military Composite Health Care System database was cross-referenced to confirm metformin dosage and length of use. On enrollment, participants presented to the laboratory for phlebotomy. The individual blood samples Continue reading >>

Prevalence Of Vitamin B12 Deficiency In Patients With Type 2 Diabetes Taking Metformin: A Developing Country Perspective - Scopemed.org - Deposit For Medical Articles

Prevalence Of Vitamin B12 Deficiency In Patients With Type 2 Diabetes Taking Metformin: A Developing Country Perspective - Scopemed.org - Deposit For Medical Articles

Prevalence of vitamin B12 deficiency in patients with type 2 diabetes taking metformin: a developing country perspective Pawan Kumar, Amrat Kumar, Muhammed Tanveer Alam, Arvind Kumar Sharda, Tazeen Rasheed, Muhammed Aurangzeb, Muhammed Masroor. Objective: To determine the prevalence of vitamin B12 deficiency in patients with type 2 diabetes taking metformin attending a tertiary care facility. Methodology: This cross-sectional study was conducted at Diabetic OPD, Civil Hospital, Karachi, from January 2012 to July 2012. Patients of 35 to 60 years of age with type 2 Diabetes Mellitus (DM) and compliant with metformin (500 mg/day) for more than 3 years were included. Patients with partial or total gastrectomy, pernicious anemia, Crohns disease, on supplemental vitamin B12, and strict vegetarians were excluded. Brief history regarding the duration of DM, duration of metformin use, daily dose of metformin, mean blood sugar levels and monthly family income was taken. One blood sample from each patient was obtained to determine vitamin B12 level. Vitamin B12 deficiency was defined as serum level 50 years of age, 16 (30.1%) were 40-50 years of age and 6 (11.30%) were Key words: Biguanides, diabetes mellitus, vitamin B12, metformin, megaloblastic anemia. Continue reading >>

Association Of Biochemical B12 Deficiency With Metformin Therapy And Vitamin B12 Supplements

Association Of Biochemical B12 Deficiency With Metformin Therapy And Vitamin B12 Supplements

Association of Biochemical B12 Deficiency With Metformin Therapy and Vitamin B12 Supplements The National Health and Nutrition Examination Survey, 19992006 Rollins School of Public Health, Emory University, Atlanta, Georgia Corresponding author: Godfrey P. Oakley Jr., [email protected] . Received 2011 Aug 17; Accepted 2011 Oct 30. Copyright 2012 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See for details. This article has been cited by other articles in PMC. To describe the prevalence of biochemical B12 deficiency in adults with type 2 diabetes taking metformin compared with those not taking metformin and those without diabetes, and explore whether this relationship is modified by vitamin B12 supplements. Analysis of data on U.S. adults 50 years of age with (n = 1,621) or without type 2 diabetes (n = 6,867) from the National Health and Nutrition Examination Survey (NHANES), 19992006. Type 2 diabetes was defined as clinical diagnosis after age 30 without initiation of insulin therapy within 1 year. Those with diabetes were classified according to their current metformin use. Biochemical B12 deficiency was defined as serum B12 concentrations 148 pmol/L and borderline deficiency was defined as >148 to 221 pmol/L. Biochemical B12 deficiency was present in 5.8% of those with diabetes using metformin compared with 2.4% of those not using metformin (P = 0.0026) and 3.3% of those without diabetes (P = 0.0002). Among those with diabetes, metformin use was associated with biochemical B12 deficiency (adjusted odds ratio 2.92; 95% CI 1.266.78). Consumption of any supplement containing B12 was not associated with a reduction in the prevalence o Continue reading >>

Metformin And Risk For Vitamin B12 Deficiency

Metformin And Risk For Vitamin B12 Deficiency

Metformin (brand names Glucophage, Glucophage XR, Fortamet, Riomet, Glumetza, and others) is a popular and highly effective oral diabetes drug used to help manage Type 2 diabetes. This drug works by lowering the amount of glucose made by the liver and by making the body’s cells more sensitive to insulin. Metformin also has some other beneficial effects in that it may help lower blood lipid, or fat, levels (cholesterol and triglycerides) and can, in some people, promote a small amount of weight loss. Metformin can be used with other diabetes pills and with insulin. Side effects of taking metformin are relatively rare, the most common being bloating, nausea, and diarrhea, all of which are temporary. Some people shouldn’t take metformin, including people with kidney disease, liver disease, or congestive heart failure, for example, because of an increased risk of a potentially fatal condition called lactic acidosis. In recent years, there’s been some concern over the risk of vitamin B12 deficiency in people who take metformin. Vitamin B12 (also known as cyanocobalamin or cobalamin) plays many important roles in the body, such as keeping your blood cells and nervous system in tip top shape. There’s also some evidence that vitamin B12 may help prevent heart disease and possibly even Alzheimer disease (the jury is still out on this one). This vitamin is found primarily in animal foods, such as beef, seafood, eggs, and dairy products, which is why some vegetarians are at risk for a B12 deficiency. Elderly people are often at risk for deficiency as well, due to problems with absorption from the gastrointestinal tract. Symptoms of B12 deficiency include certain types of anemia, neuropathy, memory loss, confusion, and even dementia. So, why would taking metformin possibly Continue reading >>

Vitamin B12 Deficiency In Diabetic Subjects Taking Metformin: A Cross Sectional Study In A Lebanese Cohort

Vitamin B12 Deficiency In Diabetic Subjects Taking Metformin: A Cross Sectional Study In A Lebanese Cohort

Highlights • Thirty three percent of the patients were found to have borderline values of the serum vitamin B12 (148–220 pg/dl) while 22.5% had a clear, unambiguous deficiency (levels less than 148 pg/dl). • We found a highly significant inverse correlation between the dose and duration of metformin treatment and the serum levels of vitamin B12. • Furthermore, both borderline and low levels of vitamin B12 were associated with the presence of different neuropathies and macrocytic anemia in a dose dependent manner. • Based on our results, we strongly recommend the routine screening of T2D patients on metformin for vitamin B12 deficiency due to its high prevalence and the significant clinical effects it may result in. • Furthermore, we recommend, based on our data to start treating patients with B12 once a borderline or low level is detected. Abstract Metformin is the only biguanide derivative used to treat type 2 diabetes mellitus (T2D). Several studies documented that its use contributes to vitamin B12 deficiency in 10–30% of diabetics. The incidence of deficiency varies among populations and studies reported. There has been no reports documenting this incidence in the Middle East and Lebanon. The objectives of this study were to establish the incidence of vitamin B12 in our population, to investigate and characterize any specific associations between taking metformin and vitamin B12 deficiency to establish clear recommendations based on this data. During the first 6 months of 2015, we conducted a cross sectional study on 200 Lebanese individuals. The cohort consisted of subjects with an established diagnosis of T2D and who have been on metformin for at least three months. The patients were subjected to a questionnaire, medical record review, and vitamin B1 Continue reading >>

Metformin-induced Vitamin B12 Deficiency Presenting As A Peripheral Neuropathy

Metformin-induced Vitamin B12 Deficiency Presenting As A Peripheral Neuropathy

Home / Specialties / Neuropathy & Pain / Metformin-induced Vitamin B12 Deficiency Presenting as a Peripheral Neuropathy Metformin-induced Vitamin B12 Deficiency Presenting as a Peripheral Neuropathy Chronic metformin use results in vitamin B12 deficiency in 30% of patients. Exhaustion of vitamin B12 stores usually occurs after twelve to fifteen years of absolute vitamin B12 deficiency. Vitamin B12 deficiency, which may present without anemia and as a peripheral neuropathy, is often misdiagnosed as diabetic neuropathy, although the clinical findings are usually different. Failure to diagnose the cause of the neuropathy will result in progression of central and/or peripheral neuronal damage which can be arrested but not reversed with vitamin B12 replacement. Metformin has been available in the United States for approximately fifteen years. Vitamin B12 deficiency, which may present without anemia and as a peripheral neuropathy, is often misdiagnosed as diabetic neuropathy, although the clinical findings are usually different. Failure to diagnose the cause of the neuropathy will result in progression of central and/or peripheral neuronal damage which can be arrested but not reversed with vitamin B12 replacement. Metformin is now recommended as initial therapy for Type 2 diabetes. Because of this, metformin used either as monotherapy or in combination with other antidiabetic oral agents and insulin has become the most widely utilized antidiabetic oral agent. Metformins best known and most feared side effect, i.e. lactic acidosis almost never occurs if metformin is not used inappropriately.The common side effects of metformin are gastrointestinal and can be overcome by initiating metformin therapy at a lower dose and slowly increasing the dose, by giving metformin after meal Continue reading >>

Metformin-associated Vitamin B12 Deficiency

Metformin-associated Vitamin B12 Deficiency

Metformin-Associated Vitamin B12 Deficiency Copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2002 Arch Intern Med. 2002;162(19):2251-2252. doi: We read with great interest the case report by Gilligan 1 about metformin-associated vitamin B12 deficiency. To date, only case reports or small studies have described patients with biguanide-associated decreased vitamin B12 levels or true vitamin B12 deficiency. Thus, we would like to offer some elements about our own experience with this unfamiliar cause of cobalamin deficiency in adults. Andrs E, Noel E, Goichot B. Metformin-Associated Vitamin B12 Deficiency. Arch Intern Med. 2002;162(19):22512252. doi: New! JAMA Network Open is now accepting submissions. Learn more. Customize your JAMA Network experience by selecting one or more topics from the list below. Challenges in Clinical Electrocardiography Clinical Implications of Basic Neuroscience Health Care Economics, Insurance, Payment Scientific Discovery and the Future of Medicine United States Preventive Services Task Force JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Facial Plastic Surgery JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA OtolaryngologyHead & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) AMA Manual of Style Art and Images in Psychiatry Breast Cancer Screening Guidelines Colorectal Screening Guidelines Declaration of Helsinki Depression Screening Guidelines Evidence-Based Medicine: An Oral History Fishbein Fellowship Genomics and Precision Health Health Disparities Hypertension Guidelines JAMA Network Audio JAMA Network Conferences Med Men Medical Education Opioid Management Guidelin Continue reading >>

Megaloblastic Anaemia Due To Vitamin B12 Malabsorption Associated With Long-term Metformin Treatment.

Megaloblastic Anaemia Due To Vitamin B12 Malabsorption Associated With Long-term Metformin Treatment.

Megaloblastic anaemia due to vitamin B12 malabsorption associated with long-term metformin treatment. This article has been cited by other articles in PMC. Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (493K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References . These references are in PubMed. This may not be the complete list of references from this article. Tomkin GH, Hadden DR, Weaver JA, Montgomery DA. Vitamin-B12 status of patients on long-term metformin therapy. Br Med J. 1971 Jun 19;2(5763):685687. [ PMC free article ] [ PubMed ] Tomkin GH. Malabsorption of vitamin B12 in diabetic patients treated with phenformin: a comparison with metformin. Br Med J. 1973 Sep 29;3(5882):673675. [ PMC free article ] [ PubMed ] Nattrass M, Alberti KG. Biguanides. Diabetologia. 1978 Feb;14(2):7174. [ PubMed ] Articles from British Medical Journal are provided here courtesy of BMJ Publishing Group Continue reading >>

Rawal Medical Journal

Rawal Medical Journal

Prevalence of vitamin B12 deficiency in patients with type 2 diabetes taking metformin: a developing country perspective Pawan Kumar, Amrat Kumar, Muhammed Tanveer Alam, Arvind Kumar Sharda, Tazeen Rasheed, Muhammed Aurangzeb, Muhammed Masroor. Objective: To determine the prevalence of vitamin B12 deficiency in patients with type 2 diabetes taking metformin attending a tertiary care facility. Methodology: This cross-sectional study was conducted at Diabetic OPD, Civil Hospital, Karachi, from January 2012 to July 2012. Patients of 35 to 60 years of age with type 2 Diabetes Mellitus (DM) and compliant with metformin (500 mg/day) for more than 3 years were included. Patients with partial or total gastrectomy, pernicious anemia, Crohns disease, on supplemental vitamin B12, and strict vegetarians were excluded. Brief history regarding the duration of DM, duration of metformin use, daily dose of metformin, mean blood sugar levels and monthly family income was taken. One blood sample from each patient was obtained to determine vitamin B12 level. Vitamin B12 deficiency was defined as serum level <125 pmol/L. The data were analyzed using SPSS version 19. Results: Out of 155 patients enrolled, 84 (54.2%) were male and 71 (45.8%) were female. The vitamin B12 deficiency was found in 53 (34.2%) cases. Of these, 31 (58.49%) patients were >50 years of age, 16 (30.1%) were 40-50 years of age and 6 (11.30%) were <40 years of age (p=0.01); 29 (54.71%) patients were male and 24 (45.28%) were female (p=0.53); 34 (64.15%) patients had duration of DM <7 years and 19 (35.84%) had duration 7 years (p=0.05). 18 (33.96%) patients were taking dose between 1000-2000 mg and 35 (66.03%) were taking dose of >2000 mg (p<0.001); 36 (67.92%) patients were complaint to metformin and 17 (32.07%) patients Continue reading >>

Should Patients Taking Metformin Also Take Vitamin B12?

Should Patients Taking Metformin Also Take Vitamin B12?

Should Patients Taking Metformin Also Take Vitamin B12? Should I recommend vitamin B12 to patients taking metformin? Response from Gayle Nicholas Scott, PharmD Assistant Professor, Eastern Virginia Medical School, Norfolk, Virginia; Clinical Pharmacist, Chesapeake Regional Medical Center, Chesapeake, Virginia Metformin is a first-line type 2 diabetes treatment that effectively lowers blood glucose and has a good long-term safety record. (It has been available in the United Kingdom since 1958 and the United States since 1995).[ 1 ] Metformin also offers the important advantage over most other antihyperglycemic drugs of improved cardiovascular morbidity and mortality risk.[ 2 ] Beyond monitoring renal and hepatic function and avoiding concomitant drugs that interfere with renal tubular secretion (eg, cimetidine), metformin use has become rather mundane. A sometimes forgotten disadvantage of metformin is its effect on vitamin B12 absorption. Although the liability of metformin to lower vitamin B12 levels has been well described,[ 3 ] interest in the need for monitoring for vitamin B12 deficiency is more recent.[ 1 , 4 , 5 , 6 ] Vitamin B12 deficiency is estimated to be present in up to 30% of patients with diabetes taking metformin.[ 1 ] The risk for vitamin B12 deficiency increases with patient age and the dose and duration of metformin use.[ 5 , 7 ] Concomitant conditions such as suboptimal dietary intake, which is common among vegetarians and alcohol abusers, and malabsorption due to atrophic gastritis, pernicious anemia, chronic pancreatitis, and celiac disease may further increase risk for vitamin B12 deficiency.[ 5 ] The combination of metformin with proton pump inhibitors has been reported to have an additive effect on risk for vitamin B12 deficiency.[ 8 ] Vitamin Continue reading >>

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