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Al Zoubi MS, Al Kreasha R, Aqel S, Saeed A, Al-Qudimat AR, Al-Zoubi RM. Vitamin B 12 deficiency in diabetic patients treated with metformin: A narrative review. Ir J Med Sci 2024:10.1007/s11845-024-03634-4. [PMID: 38381379 DOI: 10.1007/s11845-024-03634-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
Metformin is the most prescribed oral hypoglycemic drug and is considered by many health practitioners as the first-line treatment for non-insulin-dependent diabetes mellitus (T2DM). It is used either as a monotherapy or adjuvant to other anti-hyperglycemic agents. Most of its side effects are usually mild and self-limiting. However, several studies have shown an association between the use of metformin and low vitamin B12 levels in diabetic patients. The current review aimed to provide a literature review of the current published reports on the association, the possible mechanisms, and the related individualized risk factors that might lead to this incidence. The most accepted mechanism of the effect of metformin on vitamin B12 level is related to the absorption process where metformin antagonism of the calcium cation and interference with the calcium-dependent IF-vitamin B12 complex binding to the ileal cubilin receptor. In addition, many risk factors have been associated with the impact of metformin on vitamin B12 levels in diabetic patients such as dose and duration where longer durations showed a greater prevalence of developing vitamin B12 deficiency. Male patients showed lower levels of vitamin B12 compared to females. Black race showed a lower prevalence of vitamin B12 deficiency in metformin-treated patients. Moreover, chronic diseases including T2DM, hyperlipidemia, coronary artery disease, polycystic ovary disease (PCOD), obesity, and metformin therapy were significantly associated with increased risk of vitamin B12 deficiency.
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Affiliation(s)
- Mazhar Salim Al Zoubi
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Rasha Al Kreasha
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Sarah Aqel
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Ahmad Saeed
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, 211-63, Jordan
| | - Ahmad R Al-Qudimat
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Raed M Al-Zoubi
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, 3050, Doha, Qatar.
- Department of Biomedical Sciences, College of Health Sciences, QU-Health, Qatar University, Doha, 2713, Qatar.
- Department of Chemistry, Jordan University of Science and Technology, P.O.Box 3030, Irbid, 22110, Jordan.
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Al Quran T, Khader A, Allan H, Al-Momani R, Aqel HT, Alsaleh M, Bataineh Z. Prevalence of vitamin B12 deficiency in type 2 diabetic patients taking metformin, a cross-sectional study in primary healthcare. Front Endocrinol (Lausanne) 2023; 14:1226798. [PMID: 37732117 PMCID: PMC10507406 DOI: 10.3389/fendo.2023.1226798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/18/2023] [Indexed: 09/22/2023] Open
Abstract
Background Several studies documented that metformin use contributes to vitamin B12 deficiency in patients with type 2 diabetes mellitus (T2DM). However, there has been a lack of data assessing this issue in Jordan. Aims Assess the vitamin B12 serum levels, frequency of vitamin B12 deficiency, and related factors among Jordanian patients with T2DM patients treated with metformin. Methods a total of 447 subjects attending a primary health care center were included in this cross-sectional study consisting of T2DM patients who use metformin and a control group of non-diabetics. Serum B12 levels were evaluated and B12 deficiency was defined as serum B12 levels ≤ 200 pmol/L. Associations of B12 serum levels or B12 deficiency with other factors like gender, age, and duration of T2DM were analyzed. Results There was no significant difference in serum B12 levels nor the frequency of vitamin B12 deficiency between T2DM metformin-treated patients and control groups. Among metformin-treated patients there was no difference relating to age, type 2 diabetes mellitus duration, proton pump inhibitors use, and metformin use (duration, dose) between patients with or without B12 deficiency. Conclusion The prevalence of vitamin B12 deficiency among T2DM patients on metformin treatment in this study was high (48.9%). However, the treatment with metformin and the dose of metformin use was not associated with vitamin B12 deficiency.
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Affiliation(s)
- Thekraiat Al Quran
- Faculty of Medicine, Department of Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ateka Khader
- Hijjawi Faculty for Engineering Technology, Department of Biomedical Systems and Informatics Engineering, Yarmouk University, Irbid, Jordan
| | - Hadeel Allan
- Faculty of Medicine, Department of Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Rua’a Al-Momani
- Faculty of Medicine, Department of Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Hamzeh T. Aqel
- Faculty of Medicine, Department of Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mu’taz Alsaleh
- Faculty of Medicine, Department of Anesthesia and Recovery, Jordan University of Science and Technology, Irbid, Jordan
| | - Ziad Bataineh
- Faculty of Medicine, Department of General Surgery, Jordan University of Science and Technology, Irbid, Jordan
- Department of General Surgery, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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Gao L, Ran X, Liu X, Shen X, Chen S, Liu F, Zhao D, Bi Y, Su Q, Lu Y, Lei M, Wang Y, Ji L. The effects of daily dose and treatment duration of metformin on the prevalence of vitamin B12 deficiency and peripheral neuropathy in Chinese patients with type 2 diabetes mellitus: A multicenter cross-sectional study. J Diabetes 2023; 15:765-776. [PMID: 37310028 PMCID: PMC10509512 DOI: 10.1111/1753-0407.13428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/27/2023] [Accepted: 05/22/2023] [Indexed: 06/14/2023] Open
Abstract
AIMS To evaluate the prevalence of vitamin B12 deficiency in Chinese patients with type 2 diabetes mellitus receiving metformin treatment and to investigate the effects of metformin daily dose and treatment duration on the prevalence of vitamin B12 deficiency and peripheral neuropathy (PN). MATERIALS AND METHODS In this multicenter cross-sectional study, 1027 Chinese patients who had been taking ≥1000 mg/day metformin for ≥1 year were enrolled using proportionate stratified random sampling based on daily dose and treatment duration. Primary measures included the prevalence of vitamin B12 deficiency (<148 pmol/L), borderline B12 deficiency (148 pmol/L-211 pmol/L), and PN. RESULTS The prevalence of vitamin B12 deficiency, borderline deficiency, and PN were 2.15%, 13.66%, and 11.59%, respectively. Patients receiving ≥1500 mg/day metformin had significantly higher prevalence of borderline vitamin B12 deficiency (16.76% vs. 9.91%, p = .0015) and serum B12 ≤221 pmol/L (19.25% vs. 11.64%, p < .001) than patients receiving <1500 mg/day metformin. No difference was found in prevalence of borderline vitamin B12 deficiency (12.58% vs. 15.49%, p = .1902) and serum B12 ≤221 pmol/L (14.91% vs. 17.32%, p = .3055) between patients receiving metformin for ≥3 and <3 years. Patients with vitamin B12 deficiency had numerically higher PN prevalence (18.18% vs. 11.27%, p = .3192) than patients without it. Multiple logistic analyses revealed that HbA1c and metformin daily dose were associated with the prevalence of borderline B12 deficiency and B12 ≤221 pmol/L. CONCLUSIONS High daily dosage (≥1500 mg/day) played an important role in metformin-associated vitamin B12 deficiency while not contributing to the risk of PN.
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Affiliation(s)
- Leili Gao
- Department of EndocrinologyPeking University People's HospitalBeijingChina
| | - Xingwu Ran
- Department of EndocrinologyWest China Hospital Sichuan UniversityChengduChina
| | - Xuejun Liu
- Department of EndocrinologyMetabolic Disease Hospital of Tianjin Medical UniversityTianjinChina
| | - Xingping Shen
- Department of EndocrinologyZhongshan Hospital Xiamen UniversityXiamenChina
| | - Shuchun Chen
- Department of EndocrinologyHebei General HospitalShijiazhuangChina
| | - Fuqiang Liu
- Department of EndocrinologyQilu Hospital of Shangdong UniversityJinanChina
| | - Dong Zhao
- Department of EndocrinologyBeijing Luhe Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Yan Bi
- Department of EndocrinologyNanjing Drum Tower HospitalNanjingChina
| | - Qing Su
- Department of EndocrinologyXinhua Hospital Affiliated to Shanghai Jiaotong University School of MedicineShanghaiChina
| | - Yao Lu
- Department of EndocrinologySecond Affiliated Hospital of Xinjiang Medical UniversityXinjiangChina
| | - Minxiang Lei
- Department of EndocrinologyXiangya Hospital Central South UniversityChangshaChina
| | - Yanfang Wang
- Department of EndocrinologyHenan Provincial People's HospitalZhengzhouChina
| | - Linong Ji
- Department of EndocrinologyPeking University People's HospitalBeijingChina
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Ts R, Ranganathan RS, Solai Raja M, Srivastav PSS. Prevalence of Vitamin B12 Deficiency in Type 2 Diabetes Mellitus Patients on Metformin Therapy. Cureus 2023; 15:e37466. [PMID: 37187650 PMCID: PMC10176038 DOI: 10.7759/cureus.37466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Background Long-term metformin treatment in individuals with type 2 diabetes mellitus causes vitamin B12 insufficiency, which is typically neglected, undetected, and under-treated. A severe deficit may cause life-threatening neurological problems. This study assessed the prevalence of vitamin B12 deficiencies among T2DM patients and its factors at a tertiary hospital in the Tamil Nadu district of Salem. Materials and Methods This is an analytical cross-sectional study conducted in a tertiary care hospital in the Salem district, Tamil Nadu, India. Patients with type 2 diabetes mellitus who were prescribed metformin at the outpatient department of general medicine took part in the trial. Our research instrument was a structured questionnaire. We used a questionnaire containing information on sociodemographic characteristics, metformin use among diabetic mellitus patients, diabetes mellitus history, lifestyle behaviors, anthropometric measurement, examination findings, and biochemical markers. Prior to administering the interview schedule, each participant's parents provided written informed consent. A thorough medical history, physical exam, and anthropometric examination were performed. Data were entered in Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using SPSS version 23 (IBM Corp., Armonk, NY). Results Among the study participants, we diagnosed nearly 43% of diabetes cases in participants between the ages of 40-50 years, while we diagnosed 39% aged under 40 years. Nearly 51% had diabetes for 5-10 years, while only 14% had diabetes for over 10 years. In addition, 25% of the study sample had a positive family history of type 2 diabetes. Nearly 48% and 13% of the study group had been on metformin for 5-10 years and >10 years, respectively. The majority, 45%, were found to take 1000 mg of metformin per day, whereas just 15% take 2 g per day. In our study, the prevalence of vitamin B12 insufficiency was 27%, and nearly 18% had borderline levels. The duration of diabetes mellitus, the duration of metformin intake, and the dose of metformin were statistically significant (p-value = 0.05) among the variables associated with diabetes mellitus and vitamin B12 deficiency. Conclusion The results of the study show that a deficiency in vitamin B12 increases the likelihood that diabetic neuropathy would worsen. Therefore, individuals with diabetes who take larger dosages of metformin (more than 1000mg) for an extended period must have their vitamin B12 levels monitored often. Preventative or therapeutic vitamin B12 supplementation can mitigate this issue.
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Affiliation(s)
- Rathis Ts
- General Medicine, Vinayaka Mission Kirupananda Variyar Medical College and Hospital, Salem, IND
| | | | - Moogaambiga Solai Raja
- Internal Medicine, Vinayaka Mission Kirupananda Variyar Medical College and Hospital, Salem, IND
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Kushnir MM, Nelson GJ, Frank EL, Rockwood AL. LC-MS/MS Method for High-Throughput Analysis of Methylmalonic Acid in Serum, Plasma, and Urine: Method for Analyzing Isomers Without Chromatographic Separation. Methods Mol Biol 2022; 2546:295-309. [PMID: 36127599 DOI: 10.1007/978-1-0716-2565-1_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Measurement of methylmalonic acid (MMA) plays an important role in the diagnosis of vitamin B12 deficiency. Vitamin B12 is an essential cofactor for the enzymatic carbon rearrangement of methylmalonyl-CoA (MMA-CoA) to succinyl-CoA (SA-CoA), and the lack of vitamin B12 leads to elevated concentrations of MMA. Measurement of MMA in biological samples is complicated because of the presence of succinic acid (SA), isomer of MMA. We developed a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for MMA. The method utilizes derivatization and positive ion mode ionization, which is specific to polycarboxylic acids (MMA and SA are dicarboxylic acids), while derivatives of monocarboxylic acids at these conditions are not ionizable and not detectable. The only organic acid, other than MMA, that is detected in this method is SA. The described method does not require chromatographic resolution of the peaks of MMA and SA; quantitative measurement of MMA is performed using a deconvolution algorithm, which mathematically resolves signal corresponding to MMA, from the combined signal of MMA/SA. Because of the high selectivity of detection, this method utilizes isocratic chromatographic separation; reconditioning and re-equilibration of the chromatographic column between injections is unnecessary. The above features allow high-throughput analysis of MMA with injection-to-injection cycle time of approximately 1 minute.
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Affiliation(s)
- Mark M Kushnir
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA.
- ARUP Laboratories, Salt Lake City, UT, USA.
- Department of Pathology, University of Utah Health School of Medicine, Salt Lake City, UT, USA.
| | | | - Elizabeth L Frank
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
- Department of Pathology, University of Utah Health School of Medicine, Salt Lake City, UT, USA
| | - Alan L Rockwood
- Department of Pathology, University of Utah Health School of Medicine, Salt Lake City, UT, USA
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Alam MS, Kamrul-Hasan A, Kalam ST. Serum vitamin B12 status of patients with type 2 diabetes mellitus on metformin: A single-center cross-sectional study from Bangladesh. J Family Med Prim Care 2021; 10:2225-2229. [PMID: 34322416 PMCID: PMC8284194 DOI: 10.4103/jfmpc.jfmpc_2388_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/21/2021] [Accepted: 03/12/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Metformin use is a known cause of B12 deficiency in patients with type 2 DM (T2DM). Diabetic peripheral neuropathy (DPN) often has clinically indistinguishable clinical features of B12 deficiency-induced peripheral neuropathy (PN). Objective: The present study aims to assess serum vitamin B12 levels in patients with T2DM on metformin. Subjects and Methods: This cross-sectional study was conducted at a specialized endocrine outpatient clinic in Cumilla, Bangladesh, over six months from January 2020 to June 2020. Non-pregnant adults (≥18 years age) receiving metformin for T2DM for at least six months were evaluated for PN and assessed for serum B12 levels. Results: Among 90 subjects evaluated, 28 (31.1%) had B12 deficiency and 6 (6.7%) had borderline B12 deficiency; 56 (62.2%) had normal B12 levels. Study subjects with subnormal B12 used metformin for a longer duration [8.5 (7.0-14.0) vs. 5.0 (2.25-10.0) years, median (IQR), P = 0.006], gram-years of metformin use was higher in them [12.0 (7.9-14.0) vs. 5.75 (2.0-13.6) years, median (IQR), P = 0.005] and they had a higher mean corpuscular volume [85.9±7.2 vs. 82.4±6.4 fL, mean±SD, P = 0.020] compared to those having normal B12 levels. Serum B12 levels had a strong negative correlation with duration of metformin use and gram-years of metformin use. B12 status did not influence the presence and severity of PN. Conclusions: A considerable number of patients with T2DM have subnormal B12 levels. Periodic screening for serum vitamin B12 level may be of clinical benefit in such patients.
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Affiliation(s)
| | - Abm Kamrul-Hasan
- Department of Endocrinology, Mymensingh Medical College, Mymensingh, Bangladesh
| | - Syeda Tanzina Kalam
- Department of Psychiatry, Cumilla Medical College Hospital, Cumilla, Bangladesh
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