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Davis TME, Chubb SAP, Peters KE, Davis WA. Serum vitamin B12, distal symmetrical polyneuropathy and anaemia in type 2 diabetes: the Fremantle Diabetes Study Phase 2. Intern Med J 2024; 54:575-581. [PMID: 37665691 DOI: 10.1111/imj.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND There are limited data relating to the effects of metformin-associated vitamin B12 deficiency on the risk of distal symmetrical polyneuropathy (DSPN) and megaloblastic anaemia in well-characterised community-based cohorts. AIMS To assess inter-relationships between metformin therapy, vitamin B12 deficiency assessed using serum active B12 concentrations, and DSPN and anaemia in 1492 Fremantle Diabetes Study Phase 2 (FDS2) participants with type 2 diabetes. METHODS Prevalence rates of vitamin B12 deficiency (total <80 pmol/L, active <23 pmol/L) and borderline deficiency (total ≥80 and ≤200 pmol/L, active ≥23 and ≤35 pmol/L) were determined using baseline sera. The relationship between vitamin B12 status and both DSPN and anaemia was assessed using multivariable analyses. RESULTS Most FDS2 participants (94.4%) were vitamin B12 replete (total serum concentration >200 pmol/L, active >35 pmol/L), 2.0% were deficient (total <80 pmol/L, active <23 pmol/L) and the remainder (3.6%) borderline. Although metformin treatment increased the odds of deficiency (4.2%, 3.1% borderline) in a dose-dependent fashion (odds ratio (95% confidence interval) 39.4 (4.90-316) for >2000 mg daily compared with no treatment; P < 0.001), there was no significant association between vitamin B12 status and DSPN, anaemia (haemoglobin ≤130 g/L males, ≤120 g/L females), haemoglobin concentration or mean corpuscular volume (P ≥ 0.147). Metformin increased the likelihood of anaemia, especially at high doses, independent of vitamin B12 deficiency. CONCLUSIONS Since nutritional sources likely attenuate metformin-associated vitamin B12 malabsorption and its clinical sequelae in developed countries such as Australia, there is no need for routine/opportunistic serum vitamin B12 screening in metformin-treated patients.
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Affiliation(s)
- Timothy M E Davis
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Stephen A P Chubb
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Kirsten E Peters
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
- Proteomics International, QEII Medical Centre, Perth, Western Australia, Australia
| | - Wendy A Davis
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
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2
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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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Jin HY, Lee KA, Kim YJ, Gwak IS, Park TS, Yeom SW, Kim JS. Bidirectional association between diabetic peripheral neuropathy and vitamin B12 deficiency: Two longitudinal 9-year follow-up studies using a national sample cohort. Prim Care Diabetes 2023; 17:436-443. [PMID: 37344286 DOI: 10.1016/j.pcd.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
AIM This study aims to investigate the association among metformin use, vit B12 deficiency, and DPN occurrence in diabetes. METHODS This retrospective, propensity-matched cohort study was performed using National Health Insurance Service database - National Sample Cohort in South Korea. Study 1 analyzed DPN incidence according to vit B12 deficiency and study 2 analyzed vit B12 deficiency incidence according to the presence/absence of DPN. Moreover, we compared the results with respect to metformin use. RESULTS In study 1, DPN incidence per 10000 person-year (PY) was 179.7 and 76.6 in the vit B12 and non-vit B12 deficiency groups, respectively. The adjusted HR was 1.32 (95% CI; 1.21-1.44, P < 0.05) and metformin use elicited a more significant effect of DPN occurrence in patient with vit B12 deficiency (HR: 5.76 (95% CI; 5.28-6.29). In study 2, vit B12 deficiency incidence per 10000 PY was 250.6 and 129.4 in the DPN and non-DPN groups, respectively. The adjusted HR was 2.44 (95% CI; 2.24-2.66, P < 0.05), however, metformin prescription was associated with the reduced incidence of vit B12 deficiency in DPN patients (HR 0.68 (95% CI; 0.62-0.74, P < 0.05). CONCLUSION DPN occurrence increased in diabetes with vit B12 deficiency and the incidence of vit B12 deficiency was also high in DPN patients. However, metformin showed opposite effects in both cohorts. Further studies clarifying the causal relationship among DPN occurrence, vit B12 deficiency, and metformin use are warranted.
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Affiliation(s)
- Heung Yong Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Kyung Ae Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Yu Ji Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - In Sun Gwak
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Tae Sun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Sang Woo Yeom
- Department of Otorhinolaryngology-Head and Neck Surgery, Department of Medical Informatics, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Jong Seung Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Department of Medical Informatics, Medical School, Jeonbuk National University, Research Institute of Clinical Medicine of Jeonbuk National University - Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
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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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Hussain SIB, AlKhenizan A, Mahmoud A, Qashlaq H. The correlation between vitamin B12 and folate levels and bone mineral density among the Saudi population in a primary care setting. J Family Med Prim Care 2023; 12:1063-1068. [PMID: 37636170 PMCID: PMC10451589 DOI: 10.4103/jfmpc.jfmpc_1209_22] [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: 06/05/2022] [Revised: 08/06/2022] [Accepted: 09/30/2022] [Indexed: 08/29/2023] Open
Abstract
Purpose Bone health and osteoporosis are significant health problems in Saudi Arabia. Approximately 40%-50% of women and 25%-33% of men sustain osteoporotic fractures in their lifetimes. Hence, identifying the risk factors for osteoporosis is crucial in reducing the incidence of fractures. Materials and Methods We retrospectively reviewed the electronic medical records of 557 patients (female 60%, male 40%) aged ≥18 years (mean age, 66.53 years [standard deviation ± 14.169]) who underwent bone mineral density (BMD) scans at the Department of Family Medicine & Polyclinics, King Faisal Specialist Hospital and Research Centre (KFSH&RC) between January 2004 and June 2019. Data collected included demographics, BMD values, vitamin B12 levels, and folate levels. Results This study indicated that the prevalence rates of vitamin B12 and folate deficiencies among the study population were 8.4% and 1.3%, respectively. There was a statistically significant association between vitamin B12 levels and fracture risk (P =0.044). However, no statistically significant correlation was observed between BMD at either site (lumbar spine or femoral neck) and vitamin B12 (P =0.926.,070) and folate levels (P =.683.,79). BMD showed a significant positive correlation with body mass index at the lumbar spine and femoral neck (P = 0.000). There was no statistically significant association between vitamin B12 levels and the use of metformin (P =.26). Conclusion Vitamin B12 is associated with fracture risk; however, vitamin B12 and folate levels are not correlated to BMD (femoral neck and lumbar spine).
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Affiliation(s)
- Sarah I Bin Hussain
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Abdullah AlKhenizan
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Ahmed Mahmoud
- Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Hussain Qashlaq
- Department of Internal Medicine, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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Chen X, Zhang X, Nie Y, Gong Z, Sivaprasad S, Fung AT, Wang Q, Qiu B, Xie R, Wang Y. Circulating level of homocysteine contributes to diabetic retinopathy associated with dysregulated lipid profile and impaired kidney function in patients with type 2 diabetes mellitus. Eye (Lond) 2023; 37:1383-1389. [PMID: 35739242 PMCID: PMC10170092 DOI: 10.1038/s41433-022-02144-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To test the hypothesis that elevated plasma levels of homocysteine (Hcy) and lipoprotein (a) (LPA) contribute to diabetic retinopathy (DR) associated with dysregulated lipid profile, dyslipidaemia, and kidney function. METHODS A total of 83 patients with type 2 diabetes mellitus (T2DM) were enrolled in this prospective case-control study. Patients were categorized into those with no DR (DM), non-proliferative DR (NPDR), and proliferative DR (PDR). Age and sex-matched individuals with no diabetes were included in the control group. Biochemical tests, including fasting blood glucose (FBG), glycated hemoglobin (HbA1c), Hcy, LPA, lipid profile, and urine microalbumin (UMA), were evaluated. RESULTS Hcy was negatively correlated with high-density lipoprotein-cholesterol (HDL-C) (p < 0.05), but positively correlated with [total cholesterol (TC)-HDL-C)/HDL-C] (p < 0.05), low-density lipoprotein cholesterol (LDL-C)/HDL-C (p < 0.05), and UMA (p < 0.05). Traditional risk factors, Hcy, arteriosclerosis-associated plasma indices, and UMA, resulted as the independent risk factors for the occurrence of DM and DR. After controlling for age, sex, duration of DM, and FBG, a multiple ordinal logistic regression model showed that LPA [OR = 2.90, 95% confidence interval (95% CI) 1.16-7.23, p = 0.023)], LDL-C (OR = 4.28, 95% CI 1.24-14.79, p = 0.021), and (TC-HDL-C)/HDL-C (OR = 1.92, 95% CI 1.05-3.53, p = 0.035) were risk factors for DM and DR. CONCLUSIONS Hcy and LPA contributed to DM and DR. Hcy was positively correlated with kidney dysfunction and the ratios of lipid profiles, and negatively with HDL-C, LPA, LDL-C, and (TC-HDL-C)/HDL-C resulted as predictors of the occurrence of DM and severity of DR.
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Affiliation(s)
- Xiaosi Chen
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Retinal and Choroidal Vascular Diseases Study Group, Beijing, China
| | - Xinyuan Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
- Beijing Retinal and Choroidal Vascular Diseases Study Group, Beijing, China.
| | - Yao Nie
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Retinal and Choroidal Vascular Diseases Study Group, Beijing, China
| | - Zhizhong Gong
- Division of Medical Affairs, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Sobha Sivaprasad
- NIHR Moorfield's Biomedical Research Centre, Moorfield's Eye Hospital, London, UK
| | - Adrian T Fung
- Westmead and Central Clinical Schools, Specialty of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, NSW, Australia
- Department of Ophthalmology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Qiyun Wang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Retinal and Choroidal Vascular Diseases Study Group, Beijing, China
| | - Bingjie Qiu
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Retinal and Choroidal Vascular Diseases Study Group, Beijing, China
| | - Rui Xie
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Retinal and Choroidal Vascular Diseases Study Group, Beijing, China
| | - Yanhong Wang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences & School of Basic Medicine Peking Union Medical College, Beijing, China
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AlKhotani RY, Al-Dubai SA, Almeshaly MS, Alautabi AS, Maqulah SF, AlGhamdi ZJ, Alahmadi ZS. The Association Between Physical Activity and Peripheral Neuropathy in Diabetic Patients: A Cross-Sectional Multicenter Study From Saudi Arabia. Cureus 2023; 15:e34504. [PMID: 36874322 PMCID: PMC9983783 DOI: 10.7759/cureus.34504] [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: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Background Peripheral diabetic neuropathy (PDN) is a serious consequence of diabetes mellitus (DM) that can impair quality of life and result in physical disability. This study aimed to investigate the relationship between physical activity and the severity of PDN among a sample of Saudi diabetic patients in Medina city, Saudi Arabia. Methodology A total of 204 diabetic patients participated in this multicenter, cross-sectional study. A validated self-administered questionnaire was distributed electronically to patients on-site during follow-up. Physical activity and diabetic neuropathy (DN) were assessed using the validated International Physical Activity Questionnaire (IPAQ) and the validated Diabetic Neuropathy Score (DNS), respectively. Results The mean (SD) age of the participants was 56.9 (14.8) years. The majority of the participants reported low physical activity (65.7%). The prevalence of PDN was 37.2%. There was a significant correlation between the severity of DN and the duration of the disease (p = 0.047). Higher neuropathy score was noticed in those with hemoglobin A1C (HbA1c) level ≥7 compared to those with lower HBA1c (p = 0.045). Overweight and obese participants had higher scores compared to normal-weight participants (p = 0.041). The severity of neuropathy decreased significantly when the level of physical activity increased (p = 0.039). Conclusions There is a significant association between neuropathy and physical activity, body mass index, duration of diabetes mellitus, and HbA1c level.
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Affiliation(s)
- Rawan Y AlKhotani
- Neurosurgery Department, King Salman Bin Abdulaziz Medical City, Medina, SAU
| | - Sami A Al-Dubai
- Joint Program of Preventive Medicine Post Graduate Studies, Ministry of Health, Medina, SAU
| | | | | | - Saleh F Maqulah
- Family Medicine Department, Al Safiah Health Care Center, Medina, SAU
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Vitamin B12 Deficiency in Patients with Diabetes on Metformin: Arab Countries. Nutrients 2022; 14:nu14102046. [PMID: 35631186 PMCID: PMC9144422 DOI: 10.3390/nu14102046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Diabetes is a global pandemic, especially in Arab countries. Aim: The goal of this study was to review the published studies that were conducted to determine the relationship between metformin treatment for type 2 diabetes mellitus (T2DM) and vitamin B12 deficiency and to identify possible complications in this relationship. Methods: I searched for all relevant studies published in English before 2020 on the PubMed and Web of Knowledge databases using the following terms: “metformin”, “vitamin B12”, “neuropathy”, “diabetes mellitus”, and Middle Eastern countries. Results: Eleven studies were included in this review which indicated an association between taking metformin and B12 deficiency in patients with T2DM in Arab countries. This B12 deficiency was found to be negatively associated with the dose and duration of metformin therapy. The physician’s knowledge of current ADA recommendations regarding supplementation with and screening of the B12 level for T2DM patients on metformin was also found to have an effect. Conclusion: Metformin therapy is associated with B12 deficiency among people with T2DM in Arabic countries. Thus, diabetes must be managed in compliance with current guidelines and recommendations, and B12 levels must be routinely monitored, particularly in those who have been long-term takers of metformin, to ensure the suitable management of diabetes and its complications.
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Fakkar NFH, Marzouk D, Allam MF, Fouad MM, Aboromia MM, Gadallah M. Association between vitamin B12 level and clinical peripheral neuropathy in type 2 diabetic patients on metformin therapy. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00483-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Vitamin B12 malabsorption is one of the side effects of long-term metformin intake. Prolonged vitamin B12 deficiency can lead to irreversible nervous system damage. So, the current study aimed to determine the association between serum vitamin B12 level and clinical peripheral neuropathy among type 2 DM patients who are on metformin in comparison to those not taking it. It is a cross-sectional study that was conducted in Egypt and recruited 100 type 2 diabetic patients who were divided into 2 groups: metformin treated, and non-metformin treated (50 subjects per group). The collected data included personal history, medical history, dietetic history that included frequency of eating food rich in vitamin B12 and clinical peripheral neuropathy assessment by Toronto Clinical Scoring System (TCSS). Blood samples were collected for assessment of HbA1c and vitamin B12 level.
Results
Vitamin B12 deficiency was present in 4% of metformin group and 2% of non-metformin group. The mean value of vitamin B12 between metformin users (624.3 ± 364.1 pg/ml) and non-metformin users (991.0 ± 489.9 pg/ml) showed a high significant difference, p value < 0.001. There was a significant difference between study groups regarding HbA1c level (p value = 0.03). Peripheral neuropathy was significantly associated with HbA1c (p value = 0.04) and female gender (p value = 0.001).
Conclusions
Vitamin B12 level was lower in type 2 diabetic patients on metformin compared to those on other oral anti-diabetic drugs, but without significant deficiency. Peripheral neuropathy was significantly associated with poor glycemic control and female gender, but was not associated with vitamin B12 deficiency.
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Min HK, Kim SH, Choi JH, Choi K, Kim HR, Lee SH. Impacts of statin and metformin on neuropathy in patients with type 2 diabetes mellitus: Korean Health Insurance data. World J Clin Cases 2021; 9:10198-10207. [PMID: 34904090 PMCID: PMC8638058 DOI: 10.12998/wjcc.v9.i33.10198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/09/2021] [Accepted: 09/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neuropathy is a common chronic complication in type 2 diabetes mellitus (T2DM). Statin and metformin are commonly used medications in T2DM patients, and some studies showed statin- or metformin-induced neuropathy.
AIM To evaluate the incidence of neuropathy among patients with T2DM associated with statin and metformin therapies.
METHODS Korean Health Insurance Review and Assessment national patient sample data from 2016 and 2017 were used. Patients with T2DM and no complications were divided into statin/metformin/statin + metformin users and non-users. Neuropathy incidence was defined by International Statistical Classification of Diseases and Related Health Problems, 10th revision codes and concomitant prescriptions for anticonvulsants or antidepressants. Logistic regression analyses were conducted to examine the associations between statin/metformin/statin + metformin therapies and the incidence of neuropathy. Propensity score (PS) matching was performed on the basis of age, sex and comorbidities.
RESULTS Overall, 34964 and 35887 patients with T2DM and no complications were included in the Korean Health Insurance Review and Assessment national patient sample datasets from 2016 and 2017, respectively. Statin therapy was associated with increased risks of neuropathy in 2016 and 2017 [PS-matched odds ratio (OR) = 1.22, 95% confidence interval (CI): 1.08-1.38; PS-matched OR = 1.17, 95%CI: 1.03-1.33, respectively]. Metformin therapy was associated with reduced risks of neuropathy in 2016 and 2017 (PS-matched OR = 0.30, 95%CI: 0.21-0.42; PS-matched OR = 0.44, 95%CI: 0.32-0.60, respectively). Combined statin + metformin therapy was not significantly associated with neuropathy in 2016 or 2017 (PS-matched OR = 0.85, 95%CI: 0.61-1.19; PS-matched OR = 0.95, 95%CI: 0.66-1.38, respectively).
CONCLUSION Statin therapy was associated with enhanced risk of new-onset neuropathy in patients with T2DM, but metformin therapy showed the opposite association.
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Affiliation(s)
- Hong Ki Min
- Department of Internal Medicine, Konkuk University Medical Center, Seoul KS013, South Korea
| | - Se Hee Kim
- Department of Internal Medicine, Konkuk University Medical Center, Seoul KS013, South Korea
| | - Jong Han Choi
- Department of Internal Medicine, Konkuk University Medical Center, Seoul KS013, South Korea
| | - Kyomin Choi
- Department of Neurology, Konkuk University Medical Center, Seoul KS013, South Korea
| | - Hae-Rim Kim
- Division of Rheumatology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul KS013, South Korea
| | - Sang-Heon Lee
- Division of Rheumatology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul KS013, South Korea
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Yousef Khan F, Yousif AB, Suliman A, Saleh AO, Magdi M, Alshurafa A, Abdelmoneim Hassan E, Ghazy A, Salameh OK, Abdallah A. Association of vitamin B12 deficiency with metformin use in patients with type 2 diabetes treated in the largest tertiary care hospital in Qatar. Qatar Med J 2021; 2021:39. [PMID: 34540601 PMCID: PMC8428509 DOI: 10.5339/qmj.2021.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/24/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Data on the effect of metformin on serum vitamin B12 (VitB12) level in patients with type 2 diabetes mellitus (T2DM) in Qatar are limited; therefore, we aimed to assess the prevalence of VitB12 deficiency and its related factors among patients with tbl2DM treated with metformin at Hamad General Hospital in Doha, Qatar, from January 1, 2017, to December 31, 2017. METHODS This cross-sectional analytical study involved patients with tbl2DM aged ≥ 18 years who used metformin for at least 3 months. The serum VitB12 was quantified on a chemiluminescent enzyme immunoassay analyzer using Cobas e 801 module, Roche, and VitB12 deficiency was defined as serum VitB12 level of ≤ 145 pmol/L. All data were obtained from the patients' electronic medical records. RESULTS The study recruited 3124 eligible patients with tbl2DM. The overall prevalence of metformin-associated VitB12 deficiency was 30.7% [95% confidence of interval, 0.290-0.323]. A significant difference exists in the median VitB12 levels between the VitB12-normal and VitB12-deficient groups [129 vs. 286; p < 0.001]. Compared with the VitB12-normal group, the VitB12-deficient group had higher mean body mass index (BMI) (p < 0.001) and consumed higher doses of metformin (p = 0.001). They also more often used sulfonylurea (p = 0.004), dipeptidyl peptidase-4 inhibitor (p < 0.001), thiazolidinediones (p < 0.001), glucagon-like peptide 1 [GLP-1] receptor agonists (p < 0.001), alpha-glucosidase inhibitor (p < 0.001), and H2 blocker/proton pump inhibitors [PPI] (p < 0.001) than the VitB12-normal group. Moreover, the VitB12-normal group consumed more calcium supplements (p < 0.001) than the VitB12-deficient group. In the multivariate analysis, independent risk factors for metformin-associated VitB12 deficiency in patients with tbl2DM include high daily dose of metformin >2000 mg, male gender, high BMI, smoking, sulfonylurea, dipeptidyl peptidase-4 inhibitor, H2 blockers/PPI, low fasting blood glucose, and low hemoglobin. CONCLUSION This study showed a high prevalence of VitB12 deficiency in patients with tbl2DM taking metformin and a significant negative correlation between the daily dose of metformin and serum VitB12 level. Therefore, regular screening for serum VitB12 is necessary in patients with tbl2DM on metformin treatment, especially those who have the abovementioned risk factors.
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Affiliation(s)
| | | | - Aasir Suliman
- Department of Medicine, Hamad General Hospital, Doha, Qatar E-mail:
| | | | - Mohamed Magdi
- Department of Medicine, Hamad General Hospital, Doha, Qatar E-mail:
| | - Awni Alshurafa
- Department of Medicine, Hamad General Hospital, Doha, Qatar E-mail:
| | | | - Ahmed Ghazy
- Department of Medicine, Hamad General Hospital, Doha, Qatar E-mail:
| | - Omar K Salameh
- Department of Medicine, Hamad General Hospital, Doha, Qatar E-mail:
| | - Ahmed Abdallah
- Department of Medicine, Hamad General Hospital, Doha, Qatar E-mail:
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12
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Stein J, Geisel J, Obeid R. Association between neuropathy and B-vitamins: A systematic review and meta-analysis. Eur J Neurol 2021; 28:2054-2064. [PMID: 33619867 DOI: 10.1111/ene.14786] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/04/2021] [Accepted: 02/18/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peripheral neuropathy (PN) is common in patients with diseases that are in turn associated with deficiency of the B-vitamins, and vitamin treatment has shown mixed results. METHODS This systematic review and meta-analysis studied the association between PN/pain and B-vitamin biomarkers and investigated whether vitamin treatment can ameliorate the symptoms. PubMed and Web of Science were searched according to the study protocol. RESULTS A total of 46 observational and seven interventional studies were identified and included in the data synthesis. The presence of PN was associated with lowered B12 levels (pooled estimate [95% CIs] = 1.51 [1.23-1.84], n = 34, Cochran Q Test I2 = 43.3%, p = 0.003) and elevated methylmalonic acid (2.53 [1.39-4.60], n = 9, I2 = 63.8%, p = 0.005) and homocysteine (3.48 [2.01-6.04], n = 15, I2 = 70.6%, p < 0.001). B12 treatment (vs. the comparators) showed a non-significant association with symptom improvement (1.36 (0.66-2.79), n = 4, I2 = 28.9%). Treatment with B1 was associated with a significant improvement in symptoms (5.34 [1.87-15.19], n = 3, I2 = 64.6%, p = 0.059). Analysis of seven trials combined showed a non-significant higher odds ratio for improvement under treatment with the B-vitamins (2.58 [0.98-6.79], I2 = 80.0%, p < 0.001). CONCLUSIONS PN is associated with lowered plasma vitamin B12 and elevated methylmalonic acid and homocysteine. Overall, interventional studies have suggested that B-vitamins could improve symptoms of PN. Available trials have limitations and generally did not investigate vitamin status prior to treatment. Well-designed studies, especially in non-diabetes PN, are needed. This meta-analysis is registered at PROSPERO (ID: CRD42020144917).
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Affiliation(s)
- Johannes Stein
- Saarland University, Saarbrucken, Germany.,Department of Clinical Chemistry and Laboratory Medicine, Saarland University Hospital, Homburg, Germany
| | - Juergen Geisel
- Department of Clinical Chemistry and Laboratory Medicine, Saarland University Hospital, Homburg, Germany
| | - Rima Obeid
- Department of Clinical Chemistry and Laboratory Medicine, Saarland University Hospital, Homburg, Germany
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The relationship between exacerbated diabetic peripheral neuropathy and metformin treatment in type 2 diabetes mellitus. Sci Rep 2021; 11:1940. [PMID: 33479439 PMCID: PMC7820469 DOI: 10.1038/s41598-021-81631-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
Metformin-treated diabetics (MTD) showed a decrease in cobalamin, a rise in homocysteine, and methylmalonic acid, leading to accentuated diabetic peripheral neuropathy (DPN). This study aimed to determine whether or not metformin is a risk factor for DPN. We compared MTD to non-metformin-treated diabetics (NMTD) clinically using the Toronto Clinical Scoring System (TCSS), laboratory (methylmalonic acid, cobalamin, and homocysteine), and electrophysiological studies. Median homocysteine and methylmalonic acid levels in MTD vs. NMTD were 15.3 vs. 9.6 µmol/l; P < 0.001 and 0.25 vs. 0.13 µmol/l; P = 0.02, respectively with high statistical significance in MTD. There was a significantly lower plasma level of cobalamin in MTD than NMTD. Spearman’s correlation showed a significant negative correlation between cobalamin and increased dose of metformin and a significant positive correlation between TCSS and increased dose of metformin. Logistic regression analysis showed that MTD had significantly longer metformin use duration, higher metformin dose > 2 g, higher TCSS, lower plasma cobalamin, and significant higher homocysteine. Diabetics treated with metformin for prolonged duration and higher doses were associated with lower cobalamin and more severe DPN.
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Mohammed I, Hollenberg MD, Ding H, Triggle CR. A Critical Review of the Evidence That Metformin Is a Putative Anti-Aging Drug That Enhances Healthspan and Extends Lifespan. Front Endocrinol (Lausanne) 2021; 12:718942. [PMID: 34421827 PMCID: PMC8374068 DOI: 10.3389/fendo.2021.718942] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022] Open
Abstract
The numerous beneficial health outcomes associated with the use of metformin to treat patients with type 2 diabetes (T2DM), together with data from pre-clinical studies in animals including the nematode, C. elegans, and mice have prompted investigations into whether metformin has therapeutic utility as an anti-aging drug that may also extend lifespan. Indeed, clinical trials, including the MILES (Metformin In Longevity Study) and TAME (Targeting Aging with Metformin), have been designed to assess the potential benefits of metformin as an anti-aging drug. Preliminary analysis of results from MILES indicate that metformin may induce anti-aging transcriptional changes; however it remains controversial as to whether metformin is protective in those subjects free of disease. Furthermore, despite clinical use for over 60 years as an anti-diabetic drug, the cellular mechanisms by which metformin exerts either its actions remain unclear. In this review, we have critically evaluated the literature that has investigated the effects of metformin on aging, healthspan and lifespan in humans as well as other species. In preparing this review, particular attention has been placed on the strength and reproducibility of data and quality of the study protocols with respect to the pharmacokinetic and pharmacodynamic properties of metformin. We conclude that despite data in support of anti-aging benefits, the evidence that metformin increases lifespan remains controversial. However, via its ability to reduce early mortality associated with various diseases, including diabetes, cardiovascular disease, cognitive decline and cancer, metformin can improve healthspan thereby extending the period of life spent in good health. Based on the available evidence we conclude that the beneficial effects of metformin on aging and healthspan are primarily indirect via its effects on cellular metabolism and result from its anti-hyperglycemic action, enhancing insulin sensitivity, reduction of oxidative stress and protective effects on the endothelium and vascular function.
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Affiliation(s)
- Ibrahim Mohammed
- Department of Medical Education, Weill Cornell Medicine-Qatar, Al-Rayyan, Qatar
- *Correspondence: Chris R. Triggle, ; Ibrahim Mohammed,
| | - Morley D. Hollenberg
- Inflammation Research Network and Snyder Institute for Chronic Diseases, Department of Physiology & Pharmacology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Hong Ding
- Department of Medical Education, Weill Cornell Medicine-Qatar, Al-Rayyan, Qatar
- Departments of Medical Education and Pharmacology, Weill Cornell Medicine-Qatar, Al-Rayyan, Qatar
| | - Chris R. Triggle
- Department of Medical Education, Weill Cornell Medicine-Qatar, Al-Rayyan, Qatar
- Departments of Medical Education and Pharmacology, Weill Cornell Medicine-Qatar, Al-Rayyan, Qatar
- *Correspondence: Chris R. Triggle, ; Ibrahim Mohammed,
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15
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Kim SH, Park TS, Jin HY. Metformin Preserves Peripheral Nerve Damage with Comparable Effects to Alpha Lipoic Acid in Streptozotocin/High-Fat Diet Induced Diabetic Rats. Diabetes Metab J 2020; 44:842-853. [PMID: 32602278 PMCID: PMC7801759 DOI: 10.4093/dmj.2019.0190] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/28/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Metformin is widely marketed medication for the treatment of diabetes, but its pharmacological effect on diabetic peripheral neuropathy remains unclear. In this study, the effect of metformin on peripheral nerves in diabetic rats was investigated using diverse neuronal parameters of nerve fibers. METHODS Rats were assigned to one of four groups (n=7 to 10 per group): normal, diabetes mellitus (DM), DM+metformin (100 mg/kg), and DM+alpha lipoic acid (ALA, 100 mg/kg). DM was induced by streptozotocin/high-fat diet (STZ/HFD). After 12 weeks, the sensory thresholds to mechanical and heat stimuli were assessed. Repeated sensory tests, immunofluorescence microscopic comparison of peripheral nerves, and biochemical blood analysis were performed after 24 weeks. RESULTS Both DM+metformin and DM+ALA groups showed similar trends to diverse sensory tests at 24 weeks compared to DM group although the degree of change were different according to the stimulated senses. There was no significant difference in the comparison of the intraepidermal nerve fiber density (IENFD) of peripheral nerves between the DM+metformin and DM+ALA groups (11.83±0.07 fibers/mm vs. 12.37±1.82 fibers/mm, respectively). Both groups showed preserved IENFD significantly compared with DM group (8.46±1.98 fibers/mm, P<0.05). Sciatic nerve morphology of the experimental animals showed a similar trend to the IENFD, with respect to axonal diameter, myelin sheath thickness, and myelinated fiber diameter. CONCLUSION Metformin has beneficial pharmacological effects on the preservation of peripheral nerves in diabetic rats and its effects are comparable to those of ALA.
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Affiliation(s)
- Sun Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Tae Sun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Heung Yong Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
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Sugawara K, Okada Y, Hirota Y, Sakaguchi K, Ogawa W. Relationship between metformin use and vitamin B 12 status in patients with type 2 diabetes in Japan. J Diabetes Investig 2020; 11:917-922. [PMID: 31868971 PMCID: PMC7378433 DOI: 10.1111/jdi.13200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/09/2019] [Accepted: 12/15/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS/INTRODUCTION Metformin therapy has been associated with vitamin B12 (VB12) deficiency, but information regarding this adverse effect in Asian populations is limited. We have now examined the relationship between metformin use and VB12 status in individuals with type 2 diabetes mellitus in Japan. MATERIALS AND METHODS This cross-sectional study was carried out with type 2 diabetes mellitus patients treated (Met group, n = 122) or not treated (control group, n = 63) with metformin. The primary end-point was the difference in the serum concentration of homocysteine, a marker of VB12 activity, between the two groups. The serum concentrations of VB12, blood hemoglobin level and mean corpuscular volume were also compared between the groups. Subset analysis was carried out with individuals aged ≥70 years. The potential correlation between the daily dose or duration of metformin treatment and the other measured parameters was also examined. RESULTS The level of homocysteine, as well as the VB12 level, hemoglobin concentration and mean corpuscular volume, did not differ significantly between the control and treated with metformin groups. The level of homocysteine was positively and that of VB12 negatively correlated with the daily dose of metformin. Among elderly individuals, the hemoglobin level was significantly lower in the treated with metformin group than in the control group, although the mean corpuscular volume was similar in the two groups. CONCLUSIONS The risk of VB12 deficiency during metformin treatment appears to be low in Japanese type 2 diabetes mellitus patients. However, high doses of metformin might result in a moderate decrease in the circulating VB12 level, as well as in anemia in elderly individuals.
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Affiliation(s)
- Kenji Sugawara
- Division of Diabetes and EndocrinologyKobe University Graduate School of MedicineKobeJapan
| | - Yuko Okada
- Division of Diabetes and EndocrinologyKobe University Graduate School of MedicineKobeJapan
| | - Yushi Hirota
- Division of Diabetes and EndocrinologyKobe University Graduate School of MedicineKobeJapan
| | - Kazuhiko Sakaguchi
- Division of General Internal MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Wataru Ogawa
- Division of Diabetes and EndocrinologyKobe University Graduate School of MedicineKobeJapan
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17
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Miyan Z, Waris N. Association of vitamin B 12 deficiency in people with type 2 diabetes on metformin and without metformin: a multicenter study, Karachi, Pakistan. BMJ Open Diabetes Res Care 2020; 8:8/1/e001151. [PMID: 32448786 PMCID: PMC7252966 DOI: 10.1136/bmjdrc-2019-001151] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/01/2020] [Accepted: 03/18/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To assess the prevalence of vitamin B12 deficiency in people with type 2 diabetes mellitus (T2DM) on metformin and without metformin. METHODOLOGY Between May 2018 and January 2019, this prospective multicenter observational study recruited participants from seven centers in four provinces of Pakistan (Sindh, Punjab, Baluchistan and Khyber Pakhtunkhwa). Participants with T2DM treated with metformin for >2 years and those not on metformin underwent assessment of hemoglobin, vitamin B12, homocysteine and diabetic neuropathy (vibration perception threshold (VPT) >15V) and painful diabetic neuropathy (Douleur Neuropathique 4 (DN4) ≥4) and Diabetic Neuropathy Symptom (DNS) score ≥1. RESULTS Of 932 subjects, 645 (69.2%) were treated with metformin, while 287 (30.8%) were not on metformin. Overall, B12 deficiency (<200 pg/mL) was significantly higher in metformin users of 25 (3.9%), compared with non-metformin users of 6 (2.1%), while B12 insufficiency (200-300 pg/mL) was significantly lower in metformin users of 117 (18.4%) compared with non-metformin users of 80 (27.9%). Subjects with B12 deficiency and insufficiency with hyperhomocysteinemia (≥15) were found in 19 (76%) µmol/L and 69 (60.5%) µmol/L in metformin users compared with 6 (100%) µmol/L and 57 (73.1%) μmol/L in non-metformin users, respectively. VPT>25 and DN4 score ≥4 were significantly higher in B12-deficient metformin users compared with non-metformin users. Similarly, DNS score ≥1 was non-significantly higher in B12-deficient metformin users compared with non-metformin users. CONCLUSION This study shows that vitamin B12 insufficiency was frequently found in our population and may progress into B12 deficiency. It is also associated with neuropathy in subjects on metformin. Further interventional studies to assess the benefit of B12 treatment on painful neuropathy in patients on metformin may be warranted. B12 levels may be checked in people with T2DM using metformin for >2 years.
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Affiliation(s)
- Zahid Miyan
- Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
| | - Nazish Waris
- Clinical Biochemistry and Psychopharmacology Research Unit, Department of Biochemistry, University of Karachi, Karachi, Pakistan
- Department of Research, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
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Javed S, Hayat T, Menon L, Alam U, Malik RA. Diabetic peripheral neuropathy in people with type 2 diabetes: too little too late. Diabet Med 2020; 37:573-579. [PMID: 31797434 DOI: 10.1111/dme.14194] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2019] [Indexed: 12/12/2022]
Abstract
Diabetic peripheral neuropathy in people with type 2 diabetes is poorly managed because of its insidious onset, delayed diagnosis and more complex aetiology resulting from the contribution of not only hyperglycaemia, but also ageing, hyperlipidaemia, hypertension and obesity. Because there is no US Food and Drug Adminstration-approved disease-modifying therapy for diabetic peripheral neuropathy, the key to ameliorating it in type 2 diabetes has to be through earlier diagnosis and timely multi-factorial risk factor reduction. The management of painful diabetic peripheral neuropathy also requires a detailed appraisal of the choice of therapy, taking into account efficacy, patient wishes, comorbidities, side effect profile and potential for abuse.
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Affiliation(s)
- S Javed
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - T Hayat
- Primary Health Care Corporation, Doha, Qatar
| | - L Menon
- Department of Medicine, Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - U Alam
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - R A Malik
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
- Department of Medicine, Weill-Cornell Medicine-Qatar, Doha, Qatar
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Al-Hamdi A, Al-Gahhafi M, Al-Roshdi S, Jaju S, Al-Mamari A, Al Mahrezi AM. Vitamin B12 Deficiency in Diabetic Patients on Metformin Therapy: A cross-sectional study from Oman. Sultan Qaboos Univ Med J 2020; 20:e90-e94. [PMID: 32190375 PMCID: PMC7065694 DOI: 10.18295/squmj.2020.20.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/12/2019] [Accepted: 11/14/2019] [Indexed: 02/07/2023] Open
Abstract
Objectives This study aimed to determine the prevalence of vitamin B12 deficiency amongst diabetic patients on metformin therapy. Methods This cross-sectional study was conducted at general clinics at the University Health Center and diabetes outpatient clinics at Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2017. All Omani adults who were diagnosed with type 2 diabetes mellitus and took metformin were invited to participate in the study. The variables included in this study were age, gender, duration of diabetes, dose and duration of metformin therapy, haemoglobin and glycosylated haemoglobin level. Results A total of 248 subjects were included (response rate = 95.4%) of which 26 (10.5%) were vitamin B12 deficient and 53 (21.4%) were borderline deficient. The mean daily dose of metformin was highest among vitamin B12 deficient group (1,981 ± 222 mg; P = 0.004). Conclusion The prevalence of vitamin B12 deficiency is considerable among diabetic patients on metformin therapy. Further research is needed to confirm the need for routine screening and monitoring.
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Affiliation(s)
- Ahmed Al-Hamdi
- Directorate of Health Services of North Batinah, Ministry of Health, Sohar, Oman
| | - Mohammed Al-Gahhafi
- Directorate General of Health Services of North Sharqiya, Ministry of Health, Mudhaibi, Oman
| | - Shihab Al-Roshdi
- Directorate of Health Services of North Batinah, Ministry of Health, Saham, Oman
| | - Sanjay Jaju
- Department of Family Medicine & Public Health, Sultan Qaboos University, Muscat, Oman
| | - Ali Al-Mamari
- Department of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Abdulaziz M Al Mahrezi
- Department of Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman
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Wakeman M, Archer DT. Metformin and Micronutrient Status in Type 2 Diabetes: Does Polypharmacy Involving Acid-Suppressing Medications Affect Vitamin B12 Levels? Diabetes Metab Syndr Obes 2020; 13:2093-2108. [PMID: 32606868 PMCID: PMC7308123 DOI: 10.2147/dmso.s237454] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/27/2020] [Indexed: 12/13/2022] Open
Abstract
Metformin is the first-choice drug in uncomplicated type 2 diabetes (T2DM) and is effective in improving glycaemic control. It is the most widely prescribed oral antidiabetic medicine and has a good safety profile. However, there is an abundance of evidence that metformin use is associated with decreased Vitamin B12 status, though the clinical implications of this in terms of increased risk of diabetic peripheral neuropathy are debated. There is growing evidence that other B vitamins, vitamin D and magnesium may also be impacted by metformin use in addition to alterations to the composition of the microbiome, depending on the dose and duration of therapy. Patients using metformin for prolonged periods may, therefore, need initial screening with intermittent follow-up, particularly since vitamin B12 deficiency has similar symptoms to diabetic neuropathy which itself affects 40-50% of patients with T2DM at some stage. Among patients with T2DM, 40% are reported to experience symptomatic gastroesophageal reflux disease (GORD), of whom 70% use oral antidiabetic medications. The most common medications used to treat GORD are proton pump inhibitors (PPIs) and antagonists of histamine selective H2 receptors (H2RAs), both of which independently affect vitamin B12 and magnesium status. Research indicates that co-prescribing metformin with either PPIs or H2RAs can have further deleterious effects on vitamin B12 status. Vitamin B12 deficiency related to metformin and polypharmacy is likely to contribute to the symptoms of diabetic neuropathy which may frequently be under-recognised. This review explores current knowledge surrounding these issues and suggests treatment strategies such as supplementation.
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Affiliation(s)
- Michael Wakeman
- Faculty of Health and Wellbeing, Sciences Complex, University of Sunderland, SunderlandSR1, UK
- Correspondence: Michael Wakeman Faculty of Health and Wellbeing, Sciences Complex, University of Sunderland, SunderlandSR1 3SD, UKTel +44 191 5153381 Email
| | - David T Archer
- Faculty of Health and Wellbeing, Sciences Complex, University of Sunderland, SunderlandSR1, UK
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