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Metformin And Vitamin B12 Deficiency

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 >>

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 And Vitamin B12 Deficiency

Metformin And Vitamin B12 Deficiency

Allan S. Brett, MD reviewing Wile DJ and Toth C. Diabetes Care 2010 Jan Evidence suggests that metformin lowers vitamin B12 levels in patients with diabetes. Observational studies have suggested that metformin causes vitamin B12 deficiency in some patients; researchers have proposed several possible mechanisms whereby metformin might interfere with B12 absorption. Understanding this interaction is important, because B12 deficiency could exacerbate neuropathic symptoms in patients with diabetes. In this prospective case-control study, Canadian investigators identified 122 type 2 diabetic patients with peripheral neuropathy: Half had taken metformin for at least 6 months, and half had never received metformin. Otherwise, clinical characteristics of the groups were similar. Median serum B12 level was significantly lower in the metformin group than in the no-metformin group (231 vs. 486 pmol/L). Metformin recipients also had significantly higher levels of homocysteine and methylmalonic acid (markers of B12 deficiency) and significantly worse scores on standardized clinical assessments of severity of neuropathy. In multivariate analyses controlled for age, duration of diabetes, and glycosylated hemoglobin (HbA1c) level, metformin therapy was associated independently with worse neuropathic symptoms. This study strengthens the case for an effect of metformin therapy on vitamin B12 levels. The analysis also suggests that this interaction worsens neuropathy, but confounding by unknown factors could be responsible for this observation. In one randomized placebo-controlled trial, metformin lowered B12 levels ( J Intern Med 2003; 254:455 ); now, we need a trial to determine whether B12 supplementation is beneficial for diabetic patients who take metformin. Wile DJ and Toth C. Asso 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 Linked To B12 Deficiency

Metformin Linked To B12 Deficiency

Peripheral Neuropathy Patients Who Take Diabetes Drug May Have Vitamin B12 Deficiency June 8, 2009 -- The popular diabetes drug metformin may contribute to vitamin B12 deficiency , according to a new study. Researchers found that 40% of type 2 diabetes patients using metformin had vitamin B12 deficiency or were in the low-normal range for the essential vitamin. And 77% of metformin users with vitamin B12 deficiency also had peripheral neuropathy , a common form of nerve damage associated with type 2 diabetes . Peripheral neuropathy is a type of nerve damage most often characterized by pain, tingling, and numbness in the hands and feet. Because peripheral neuropathy is such a major complication of diabetes , researchers say the results suggest that people using metformin be screened for vitamin B12 deficiency or supplemented with vitamin B12 . Also, anyone already diagnosed with peripheral neuropathy who uses metformin should be screened for vitamin B12 deficiency. Vitamin B12 is primarily found in meat and dairy products. In the body, it plays a critical role in making red blood cells and keeping the nervous system functioning properly. Symptoms of vitamin B12 deficiency include anemia (low red blood cell count), depression , or dementia ; but often there are no symptoms if the vitamin levels are just a little low. B12 deficiency can lead to nerve symptoms similar to that of diabetic peripheral neuropathy, although the researchers note that they cannot be certain that B12 deficiency contributed to the peripheral neuropathy seen in their study. Vitamin B12 Screening Urged for Metformin Users The study, presented this week at the American Diabetes Associations 69th Annual Scientific Sessions, looked at the prevalence of vitamin B12 deficiency in 76 people with type 2 dia Continue reading >>

The Low Down On Metformin And Vitamin B12 Deficiency

The Low Down On Metformin And Vitamin B12 Deficiency

So many women with PCOS are prescribed Metformin (an insulin-sensitizing drug) to manage their Polycystic Ovarian Syndrome. And for good reason too. Metformin has been shown to improve many aspects of PCOS, including weight loss, fertility and improved testosterone levels (1). But, it also leads to Vitamin B12 deficiency if used at high doses or for long periods of time. So, here’s what you need to know about Metformin and Vitamin B12 deficiency with PCOS. What is Metformin? As I have already mentioned, Metformin is an insulin sensitizing drug that is often prescribed for women withPCOS. It works by decreasing absorption of glucose through the intestines, lowering the amount of glucose produced by the liver and making the body more sensitive to the insulin that is being produced. The overall effect of Metformin use for PCOS is lowered testosterone levels, improved ovulation and fertility as well as a more regular menstrual cycle. This is all sounding good, right? Well, it is good although there are some nasty side effects. A full discussion on Metformin is not going to be dealt with now, though. I really want to hone in on Metformin’s effect of Vitamin B12 levels as this could be affecting you right now. A free 6 lesson course that has helped women with PCOS around the world learn how to see lasting changes in their PCOS symptoms. Ready to join? Vitamin B12 Vitamin B12 is a vitamin that is vital for the body’s functioning. It is important for red blood cell formation, neurological function and DNA formation. If you are deficient in this important vitamin, it could lead to anaemia and neurological problems. (including memory loss – something that I have seen cropping up more often in PCOS communities). (2) Metformin and Vitamin B12 Right, so this is where it gets Continue reading >>

Should You Take B12 Supplements If You Take Metformin?

Should You Take B12 Supplements If You Take Metformin?

Metformin is the most widely prescribed medication to treat diabetes (usually type 2 diabetes) in the world. Its effectiveness equals or exceeds many of the other oral medications available and has an excellent safety profile for most individuals. However, for the last ten to fifteen years there has been a question as to whether metformin causes B12 deficiency in those who take the drug for long periods of time. Several studies and clinical cases have noted suboptimal blood levels of B12 in those who have taken metformin for extended periods. The National Nutrition and Health Examination reviewed the blood work on 1,621 people with diabetes, more than a third of whom were taking metformin, and demonstrated a reduction in serum B12 levels in people who took metformin compared to those who did not. But just because these people taking metformin had lower levels of B12 in their bloodstream doesn’t necessarily mean the B12 that’s there isn’t getting the job done. New measurements of B12 activity have indicated that although metformin does seem to reduce blood levels of B12, this may not reduce the vitamin’s effectiveness in carrying out it its functions in the body. When B12 doesn’t work the way it’s supposed to, levels of something called total plasma homocysteine (tHcy) go up. But newer studies looking at the levels of tHcy in people who take metformin have found that they have not been elevated. According to an article published this year in Diabetes Care, “low serum B12 alone without disturbances in the metabolic markers has no diagnostic value.” From a practical standpoint, this means that if a B12 deficiency is suspected from a serum B12 test, further testing should be undertaken before assuming the patient is B12 deficient. B12 is one of the B-family Continue reading >>

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 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 >>

Long-term Metformin Use Linked With Vitamin B12 Deficiency

Long-term Metformin Use Linked With Vitamin B12 Deficiency

With commentary by Jill Crandall, MD, professor of clinical medicine, Albert Einstein College of Medicine, New York. Long-term use of the popular diabetes drug metformin is linked with vitamin B12 deficiency and anemia, according to new research that solidifies some previous research. "We have essentially confirmed what many smaller studies have suggested," says Jill Crandall, MD, professor of clinical medicine at the Albert Einstein College of Medicine, the Bronx, who led the new study. "There is a small but significant risk of developing Vitamin B12 deficiency when people take metformin." The finding, she adds, ''has implications for the consequences of B12 deficiency." These can include cognitive impairment, nerve problems (neuropathy) and anemia (low red blood cell count). B12 is crucial for the proper formation of red blood cells, for neurological functioning and for making DNA. The link between taking the popular diabetes drug and deficiencies in vitamin B12 has been discussed as long ago as 1969, according to Dr. Crandall. However, few studies have looked at long term use, as her new study has done, tracking people for up to 13 years. The new study was published online Feb. 22 in the Journal of Clinical Endocrinology & Metabolism. Overview of the Metformin Study The researchers evaluated more than 2,000 men and women enrolled in the Diabetes Prevention Program and the Diabetes Prevention Program Outcomes Study. In these studies, researchers enrolled overweight people who had prediabetes (blood sugar levels higher than normal but not high enough to be termed diabetes) to see if modest weight loss or treatment with metformin could prevent or delay the onset of type 2 diabetes, then followed them to see if the effects endured. Half of the participants were given 850 Continue reading >>

Metformin-induced Vitamin B12 Deficiency Presenting As A Peripheral Neuropathy.

Metformin-induced Vitamin B12 Deficiency Presenting As A Peripheral Neuropathy.

South Med J. 2010 Mar;103(3):265-7. doi: 10.1097/SMJ.0b013e3181ce0e4d. Metformin-induced vitamin B12 deficiency presenting as a peripheral neuropathy. Southside Endocrinology and Division of Diabetes, Endocrinology, and Metabolism, University of Alabama Medical School, Birmingham, AL 35205, USA. [email protected] 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. 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. To my knowledge, this is the first report of metformin-induced vitamin B12 deficiency causing neuropathy. Continue reading >>

Long-term Metformin Use And Vitamin B12 Deficiency In The Diabetes Prevention Program Outcomes Study

Long-term Metformin Use And Vitamin B12 Deficiency In The Diabetes Prevention Program Outcomes Study

Secondary analysis from the DPP/DPPOS. Participants were assigned to the placebo group (PLA) (n = 1082) or the metformin group (MET) (n = 1073) for 3.2 years; subjects in the metformin group received open-label metformin for an additional 9 years. DPP eligibility criteria were: elevated fasting glucose, impaired glucose tolerance, and overweight/obesity. The analytic population comprised participants with available stored samples. B12 levels were assessed at 5 years (n = 857, n = 858) and 13 years (n = 756, n = 764) in PLA and MET, respectively. Low B12 (≤ 203 pg/mL) occurred more often in MET than PLA at 5 years (4.3 vs 2.3%; P = .02) but not at 13 years (7.4 vs 5.4%; P = .12). Combined low and borderline-low B12 (≤ 298 pg/mL) was more common in MET at 5 years (19.1 vs 9.5%; P < .01) and 13 years (20.3 vs 15.6%; P = .02). Years of metformin use were associated with increased risk of B12 deficiency (odds ratio, B12 deficiency/year metformin use, 1.13; 95% confidence interval, 1.06–1.20). Anemia prevalence was higher in MET, but did not differ by B12 status. Neuropathy prevalence was higher in MET with low B12 levels. All parameters decreased to their respective nadir at 1 month and then gradually returned toward baseline values. White blood cells (WBCs) and platelets (PLTs) were the most significantly affected cells. At 1 month, the decrease was 29.6% (P < .0001) for WBCs and 25% (P < .0001) for PLTs, whereas at 12 months, the decrease was 15.5% (P < .0001) and 13% (P < .0001), respectively. Lymphocytes appeared to be more susceptible to I-131 than neutrophils (ANCs). The decreases were small in absolute numbers for red blood cells, hematocrit and hemoglobin not surpassing 10%. Multivariate analysis demonstrated that the ratio of administered prescribed activity-t Continue reading >>

Long Term Treatment With Metformin In Patients With Type 2 Diabetes And Risk Of Vitamin B-12 Deficiency: Randomised Placebo Controlled Trial

Long Term Treatment With Metformin In Patients With Type 2 Diabetes And Risk Of Vitamin B-12 Deficiency: Randomised Placebo Controlled Trial

Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomised placebo controlled trial Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomised placebo controlled trial BMJ 2010; 340 doi: (Published 20 May 2010) Cite this as: BMJ 2010;340:c2181 Philippe Lehert, professor of statistics 4 , Michiel G Wulffel, general practitioner 2 3 , Jan van der Kolk, biochemical engineer 5 , Joop Verburg, chief laboratory attendant 5 , Ab J M Donker, professor of internal medicine 7 , Coen D A Stehouwer, professor and chair 8 1Department of Ophthalmology, Academic Medical Center, Amsterdam, Netherlands 2Bethesda Diabetes Research Centre, Bethesda General Hospital, Hoogeveen, Netherlands 3Department of Internal Medicine, Bethesda General Hospital, Hoogeveen, Netherlands 4Department of Statistics, Faculty of Economics, Facults Universitaires Catholiques de Mons, Louvain Academy, Mons, Belgium 5Clinical Laboratory, Bethesda General Hospital, Hoogeveen, Netherlands 6Clinical Research and Development, Merck Netherlands, Amsterdam, Netherlands 7Department of Internal Medicine, Free University Medical Center, Amsterdam, Netherlands 8Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Netherlands Correspondence to: C D A Stehouwer cda.stehouwer{at}mumc.nl Objectives To study the effects of metformin on the incidence of vitamin B-12 deficiency (<150 pmol/l), low concentrations of vitamin B-12 (150-220 pmol/l), and folate and homocysteine concentrations in patients with type 2 diabetes receiving treatment with insulin. Design Multicentre randomised placebo controlled trial. Setting Outpatient clinics of three non-academic hospitals in the Netherlands. P Continue reading >>

Metformin And Vitamin B12 Deficiency

Metformin And Vitamin B12 Deficiency

Providers need to be aware of the possibility of B12 deficiency and monitor patients. Jill Crandall, MD, Professor of Medicine at Albert Einstein College of Medicine in New York, shares insights about metformin and vitamin B12. Thank you, Dr. Crandall, for sharing your expertise. To learn more about metformin and diabetes, check out blog posts from other experts in the series. Stay tuned to more information on this topic from Kieren Mather, MD. Dont want to miss the next post in our series on metformin? Subscribe to the blog . The mechanism for low B12 with metformin, I dont think it has been completely sorted out, but it appears to be a problem with absorption. Its not related to intrinsic factorsso the classic pernicious anemia that we all learned about in medical school, thats not really the mechanism, but there seems to be something about the effect of metformin in the gut that impairs absorption. We studied B12 levels in our metformin-treated participants at two time points during DPP. Unfortunately we didnt have samples available at the very beginning, but we were able to measure samples after people had been treated for roughly 5 years and then again after 9 years of treatment, and we found that there was a significant prevalence of biochemical B12 deficiency that was higher in the metformin-treated participants than in the placebo group. It depends on how you define B12 deficiency, which is sort of an issue unto itself, but the people who definitely had low B12 was approximately 5 percent after 5 years of treatment and went up to about 9 percent after longer duration treatment. What should we do clinically at this point given what we know so far about the relationship between metformin and B12 deficiency? I think there is some debate about whether everyone taki Continue reading >>

Diabetes And B12: What You Need To Know

Diabetes And B12: What You Need To Know

Vitamin B12 is necessary for a healthy nervous system and healthy blood cells. The best way to get vitamin B12 is through your diet. This important vitamin is found in meat, fish, poultry, and dairy products. If you don’t eat enough of these foods, it could leave you with a deficiency. Consuming enough vitamin B12 isn’t the only problem. Your body also needs to be able to absorb it efficiently. Some medications like Pepcid AC, Prevacid, Prilosec, and Zantac, as well as others used to treat acid reflux, peptic ulcer disease, and infection, may make it harder for your body to absorb B12. Another medication that may interfere with B12 absorption is metformin, a common type 2 diabetes treatment. Simply having diabetes may make you more prone to B12 deficiency. A 2009 study found that 22 percent of people with type 2 diabetes were low in B12. Read on to learn the symptoms of B12 deficiency, what it could mean for your overall health, and what you can do about it. Symptoms of vitamin B12 deficiency may be mild at first, and not always obvious. If you’re slightly low on B12, you may not have any symptoms at all. Some of the more common early symptoms are: tiredness weakness loss of appetite weight loss constipation It may be easy to dismiss these as minor complaints, but over time, insufficient B12 can lead to bigger problems. Very low levels of B12 can result in serious complications. One of these is called pernicious anemia. Anemia means you don’t have enough healthy red blood cells. This deprives your cells of much-needed oxygen. According to a study in the Journal of Oral Pathology Medicine, less than 20 percent of those with a B12 deficiency experience pernicious anemia. Symptoms of anemia include: fatigue pale skin chest pain dizziness headache You may even lose Continue reading >>

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