International Journal of General Medicine

and Pharmacy (IJGMP)

ISSN(P): 2319-3999; ISSN(E): 2319-4006
Vol. 4, Issue 1, Jan 2015, 53-60
© IASET

“VITAMIN B12 DEFICIENCY IN TYPE 2 DIABETES PATIENTS ON LONG TERM

METFORMIN THERAPY FOR > 2YEARS”

M. NARAYANASWAMY, NAGAPPA H. HANDARGAL & AKSHATHA M.

Department of Medicine, Bangalore Medical College and Research Institute, Fort Road, Bangalore, India

ABSTRACT

The number of subjects in the present study was 100 type 2 diabetic patients. All patients were more than 35 years
and all were taking metformin therapy for > 2 years with different doses. Majority of patients were between the age group
of 51-60 years. Total of 48 females and 52 males were considered for the study. The Vitamin B12 level status was
assessed, in all of them by measuring serum Vitamin B12 levels. Total 24% of the patients had Vitamin B12 deficiency
with age group 61-70 years when compared to non deficient patients (51-60 years). Age could be a risk factor for the
development of Vitamin B12 levels. 91% of the patients were asymptomatic condition. FBS and PPBS were higher in the
Vitamin B12 deficient people when compared to non deficient people with a mean of 227.38±22.92 and 317.04±31.1 and
statistically significant p<0.01. The mean duration of diabetes was 12.33±3.55 years with HbA1c mean was 8.61±1.30 and
found to be statistically significant p<0.01 when compared to non deficient patients. Most of the Vitamin B12 deficient
patients (58.3%) were taking 1.5-2grams single dose orally metformin per day as compared with non deficient patients
(98.7%) who were taking 500mg per day. 6% patients who were taking metformin 1gram per day have normal Vitamin
B12 levels but on the lower side. All patients (4%) have been taking metformin sustained release and Vitamin B12
deficiency. Thus metformin sustained release will be cause the deficiency. Most of the Vitamin B12 deficient patients were
taking metformin therapy for longer years (IQR 11-20 years) when compared to non deficient individuals taking for
IQR 5-10 years with a mean of 12.33±3.55 years. Thus longer duration of metformin therapy causes more deficiency and
found to be statistically significant p<0.001. Total 37% of patients who were taking metformin for comparatively lesser
duration had normal Vitamin B12 levels but on the lower side. Out of 24 Vitamin B12 deficient patients 15 had levels
between 190-210pg/ml and 2 patients had Vitamin B12 levels between 150-170pg/ml

KEYWORDS: Hba1c, Vitamin B12, Metformin, Asymptomatic

INTRODUCTION

Diabetes Mellitus (DM) comprises a common group of metabolic disorders that share the phenotype of
hyperglycemias and are caused by complex interaction of genetics, environmental factors and life style choices. Based on
etiopathogenic categories, it is classified as Type-1 and Type-2 diabetes mellitus. In Type-1 there is absolute deficiency of
insulin secretion. In Type-2 there is a combination of resistance to insulin action and inadequate compensatory insulin
secretor response Diabetes mellitus is accompanied by wide spread biochemical, morphological and functional
abnormalities which may precipitate certain complications that affect the renal, cardio-vascular, neural systems and also
skin, liver, collagen and elastic fibers. The incidence of Type 2 diabetes has been steadily increasing in urban areas to
8.4%. The rapid urbanization, change in the lifestyle coupled with ethnic susceptibility has increased the incidence of
diabetes mellitus. This globally important condition needs to be understood with a proper perspective to deliver effective

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54 M. Narayanaswamy, Nagappa H. Handargal & Akshatha M

strategies to the individual and also the population. 2 This metabolic disorder is a risk factor precipitating micro vascular
pathologies leading to autonomic neuropathy, nephropathy, retinopathy and peripheral neuropathy, and macro vascular
pathologies leading to coronary artery disease, cerebrovascular accidents and peripheral vascular disease. us diabetes is a
multisystem disorder that affects many organs of the body.1

The micro vascular complications appear early, within 5 to 10 years and macro vascular complications appear
within 15 to 20yrs from the onset of diabetes 3. If diabetes is detected early and adequate steps are taken, it may be
possible to significantly delay the occurrence of complications and thereafter the progression. The number of people with
diabetes in world is expected to approximately double between 2000 and 2030 from 2.8% to 4.4% (171 million to 366
million). The greatest absolute increase in the number of people with diabetes will be in India. WHO estimates a projected
rise to 80 million diabetics in India by 2030 from 32 million in 2000. Type 2 Diabetes mellitus accounts for 90-95% of all
diabetics in India 4,5. The burden of the disease and its complications is increasing and hence there is greater need to
recognize and manage the disease at earliest. India needs to implement the preventive measures to reduce the burden of
diabetics as it poses a medical challenge, which is not matched by budget allocated for diabetes care in India. It is
estimated that the annual cost of diabetes care were approximately Rs 90,200 million. The average expenditure per patient
per year is about a minimum of Rs 4,500. Metformin is considered as a cornerstone in the treatment of diabetes and is the
most frequently prescribed first line therapy for individuals with type 2 diabetes. In addition it is one of the few anti
hyperglycemic agents associated with improvements in cardiovascular morbidity and mortality6.Vitamin B12- Intrinsic
factor complex uptake by ileal cell surface receptors is known to be a process dependent on calcium availability.
Metformin gives a positive charge to the surface of the membrane which acts to displace divalent cation like calcium.
Impaired calcium availability due to metformin activity therefore interfere with calcium dependent process of vitamin B12
absorption. Hence intestinal absorption of Vitamin B12 is often decreased during chronic metformin therapy and calcium
supplements reverse the effect of metformin on vitamin B12 absorption7-9. Decrease in vitamin B12 deficiency is a
independent risk factor for cardiovascular disease, especially among individuals with type 2 diabetes. Vitamin B12
deficiency causes megaloblastic anaemia, peripheral neuropathy and subacute combined degeneration. Anaemia caused by
Vitamin B12 deficiency is reversible; the progress of the neuropathy can at least be arrested as it cannot be reversed10-12.
Both short term & long term use of metformin causes vitamin B12 deficiency but more pronounced with long term use.
Normal blood levels of vitamin B12 is 211-900pg/ml. 10-30% of diabetic patients on long term treatment with metformin
had vitamin B12 deficiency 13. The objective of this study is to find out the prevalence of vitamin B12 deficiency in type 2
diabetic patients on long term metformin therapy for >2yrs. Hence this study is been undertaken to know the VitaminB12
deficiency in Type 2 Diabetes patients on long term Metformin therapy for >2yrs.

MATERIALS AND METHODS

A Patients visiting medicine OPD and patients who are admitted in IPD of Victoria and Bowring & Lady Curzon
Hospital, BMCRI, Bangalore for the accrual the period of 1st January 2012 to 31st December 2012 were considered for the
study. Total 100 patients recruited prospectively with written consent. All patients meet their inclusion and exclusion
criteria. The secondary data was collected through pretested questionnaires. Type 2 diabetic subjects taking metformin
therapy for >2yrs meeting the inclusion criteria of the study.

Inclusion Criteria

Patients with fasting blood glucose > 126mg/dl on two different occasions, postprandial > 200mg/dl. HbA1C

Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0

“Vitamin B12 Deficiency in Type 2 Diabetes Patients on Long Term Metformin Therapy for > 2 years” 55

>6.5%, OGTT >200mg/dl. Type 2 Diabetic patients of age >18yrs. Type 2 Diabetic patients on intake of metformin for
>2yrs

Exclusion Criteria

The patients who have not given written informed consent, Type 1 diabetes mellitus Diabetic complications.
Intake of calcium, Malabsorption Syndrome, Intestinal infection Partial/total gastrectomy, Patients on vitamin B12
supplements & Thyroid disorders

Data was collected by using proforma meeting the objectives of the study. Purpose of the study was carefully
explained to patients and consent was taken. All patients were interviewed, detailed history was taken with respect to risk
factors and detailed physical examination was carried out and appropriate investigations were carried out

Investigations

After applying inclusion and exclusion criteria a randomly selected group of patients underwent detailed history,
clinical examination and following set of investigations, Fasting blood glucose, postprandial blood glucose, HbA1C. Urine
routine. Serum vitamin B12 levels, Complete blood picture with peripheral smear, Renal function test, serum electrolytes,
Lipid profile. Thyroid function test , Stool for ova, cyst & occult blood , Chest X-ray, ECG & USG abdomen, Colonoscopy
if required

Protocol

Type 2 diabetics were selected as per the criteria laid down. Their written consent was taken. The screening of
diabetic subjects was done for exclusion criteria. The history was elicited. Age, duration of diabetes, duration of metformin
therapy were recorded. Each subject was instructed to visit laboratory with 6 hrs of fasting on a specific date, the blood
samples [3ml volume] was drawn for estimation of FBS and glycated hemoglobin. The fasting sample was also taken for
serum Vitamin B12 level estimation. The subject was asked to take breakfast and blood sample was drawn 2 hrs later for
PPBS estimation. The blood glucose parameters and glycated Hb levels, serum Vitamin B12 levels and other investigations
were recorded in their respective proforma. The master chart containing this data of 100 type 2 diabetic patients was
prepared

RESULT

A total of 100 type 2 diabetic subjects were included in the present study, Among the 100 patients of study group
highest number of cases were in age group of 51-60 years making 41% of the total. Least number of subjects belonged to
age group of 71-80 years making about 1% of the total. Eldest and youngest age group was 75 and 38 respectively. Total
100 patients 52% were males and female comprises 48%. 91 cases were found to be asymptomatic forming and 9 cases
were symptomatic. Among these 3 cases had viral fever, and burning micturition, 2 had easy fatigability
(generalized weakness) 1 cases were notices trauma. Diabetes is found between 6-10 years with mean duration 20.0 years
duration. 75% cases were taking metformin 500mg once in daily forming and 5% cases were taking metformin 500 mg for
sustained release. Total 15% of patients single dose of metformin 500mg three with mean duration 6-10 years duration. 22
patients were noticed longer duration of metformin intake. The patients FBS is ranged from 126mg/dl - 300mg/dl. None of
the patients were not noticed that FBS < 126mg/dl and also FBS between 200mg/dl to 300mg/dl forming 52% of the cases
were found.

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56 M. Narayanaswamy, Nagappa H. Handargal & Akshatha M

The PPBS range between 150mg/dl - 400mg/dl. The highest 66.0% number of patients had PPBS between
201mg/dl - 300mg/dl. The Vitamin B12 levels in the study group ranged from 150-1300pg/ml.2% of the cases have found
that Vitamin B12 levels in the study group were > 1000pgml and 61.0% low Vitamin B12 levels; 150-450pg/ml.
The highest level was 1236 and the least was 159pg/ml. Most (61%) of the patients in the study group had Vitamin B12
levels on the upper side of lower limit. Present study noticed 24 had Vitamin B12 levels less than the normal value forming
24% and 76 patients who had normal Vitamin B12 levels and a total 37 had Vitamin B12 levels on the side of lower limits.
24 cases had Vitamin B12 deficiency. The mean of various clinical variables, age and duration of diabetes and duration of
metformin intake were compared between the normal and Vitamin B12 patients. The concomitant variables like of age,
duration of diabetes, duration of metformin intake, and mean of clinical variables like FBS, PPBS, HbA1c were found to
be higher in Vitamin B12 deficiency when compared to normal patients and statistically significant (P <0.001). The
maximum age distribution in Vitamin B12 deficiency patients was found between the age group 61-70 years. Higher in the
age is statistically significantly p<0.05 with Vitamin B12 deficiency. Males as compared to female, the female patients had
more Vitamin B12 deficiency and statistically significant p<0.05.The comparison of clinical features with normal and
Vitamin B12 deficiency patients was done. Most of the patients were asymptomatic in both normal category forming
89.5% of the total and Vitamin B12 deficiency patients forming 95.8% of the total. Among symptoms both most of the
normal patients and Vitamin B12 deficiency patients had hypertension forming 13.2% and 29.2% respectively. HbA1c
levels < 7% forming (55.3%) of the total. Most of the Vitamin B12 deficiency type 2 diabetic patients had HbA1c levels
between 7.1-8% (41.7%) and also found to be statistically significant P value <0.001. Vitamin B12 deficient patients had
higher HbA1c >10 when compared to 3.9% of normal patients giving significant P value <0.001. Dose of metformin intake
was compared between normal patients and Vitamin B12 deficiency patients. Most of the normal patients were taking
metformin therapy 500mg once in daily (98.7%). The Vitamin B12 deficiency patients were taking metformin therapy
500mg three times daily forming 58.3% of the total. 58.3% Vitamin B12 deficiency patients were taking higher dose of
metformin when compared to 1.3% of normal patients. Higher dose of metformin intake is significantly associated with
Vitamin B12 deficiency with P value <0.001. The Duration of diabetes was compared between normal diabetes patients
and Vitamin B12 deficiency diabetes patients. Most of the normal patients had diabetes between 6-10 years forming 48.7%
of the total. Most of the Vitamin B12 deficiency had diabetes between 11-20 years forming 70.8% of the total. 70.8%
Vitamin B12 deficiency patients were having diabetes for longer duration (11-20yrs) when compared to 6.6% of normal
patients. Longer duration of diabetes is significantly associated with Vitamin B12 deficiency with P<0.001. Duration of
metformin therapy was compared between normal patients and Vitamin B12 deficiency patients. Most of the normal
patients were taking metformin between 6-10 years forming 48.7% of the total. Most of the Vitamin B12 deficiency was
taking metformin between 11-20 years forming 70.8% of the total. 70.8% Vitamin B12 deficiency patients were taking
metformin for longer duration when compared to 1.3% of normal patients. Longer duration of metformin intake is
significantly associated with Vitamin B12 deficiency with P<0.001

DISCUSSIONS

Present study was undertaken to assess Vitamin B12 deficiency in subjects with type2 diabetes mellitus taking
long term metformin therapy for >2years. Larger population-based studies have been more consistent, demonstrating
reduced Vitamin B12 levels in type 2 diabetic patients with metformin therapy. Metformin is considered as a cornerstone
in the treatment of diabetes and is the most frequently prescribed first line therapy for individuals with type 2 diabetes.
Absorption of Vitamin B12 is through the formation of Vitamin B12- Intrinsic factor complex uptake by ileal cell surface

Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0

“Vitamin B12 Deficiency in Type 2 Diabetes Patients on Long Term Metformin Therapy for > 2 years” 57

receptors. Metformin gives a positive charge to the surface of the membrane which acts to displace divalent cation and thus
interferes with process of vitamin B12 absorption. Hence intestinal absorption of Vitamin B12 is often decreased during
chronic metformin therapy.

The prevalence of Vitamin B12 deficiency in various studies carried out previously in type 2 diabetes patients all
over the world and the results of this study. Most of the previous studies like Pflipsen et al., total 60 cases have been
compared the Vitamin B12 levels in diabetes patients, who are taking with or without metformin. The prevalence of
Vitamin B12 deficiency was in the range of 15-30%. In the present study 24% of type 2 diabetes patients on metformin
therapy were found to have Vitamin B12 less than normal. Few studies like Lael Reinstatler et al study have measured
homocysteine and folate levels along with Vitamin B12 levels for better correlation. Almost all the studies shows low
Vitamin B12 levels in diabetic patients taking metformin therapy. Out of the total 100 cases studied the number of male
subjects was 52 and female subjects were 48. Males were higher in normal Vitamin B12 level group and females were
comparatively higher in the deficient group. There was no significant difference found to be gender matched. None of the
above studies showed any gender difference with Vitamin B12 deficiency. Largest number of patients belongs to the age
group of 51 – 60 years. Patients with Vitamin B12 deficiency were found to be higher age group between 61-70 years with
a mean of 61.92±6.04 compared to normal level individuals who were of age group between 51-60 years and it was
statistical significant( P value <0.001). Monique Nervo et al 65 studied that type 2 diabetes patients who had low Vitamin
B12 levels having higher age with the mean of 63.7+ 11.30. Jolien de Jager et al13 found that the age group of type 2
diabetes patients taking metformin in higher age group when compared to the patients not taking metformin therapy with a
mean of 65.92±5.05 it is indicating that , the longer duration of metformin intake found to be statistically non significant.
The duration of diabetes was higher in Vitamin B12 deficiency age group between 11-20 years with a mean of 12.33±3.55
when compared to non deficient group age group between 6-10 years and found to be statistically significant. Similar
studies reported by others were not found to be statistical significance difference between the duration of diabetes and
Vitamin B12 deficiency. Most of the B12 deficient patients were asymptomatic forming (95.8%) when compared to non
deficient patients forming (89.5%). Pflipsen et al total 94% of metformin induced vitamin B12 deficient type 2 diabetic
patients will be asymptomatic. FBS was high in deficient patients when compared to non deficient patients forming a mean
of 227.38±22.92 when compared to non deficient (p<0.001). PPBS was high in deficient patients when compared to non
deficient patients forming a mean of 317.04±31(p <0.001). Above studies were not showed any positive relation between
lower Vitamin B12 levels and elevated FBS and PPBS levels. Though many patients had good control of HbA1c but the
HbA1c was moderately higher in the deficiency group with a mean of 8.61±1.30 when compared to the normal group
indicating (p< 0.001). Bauman et al reported in his study HbA1c was lower in the deficient group as they were not on
metformin therapy and it would be control the HbA1c levels. Similar studies showed that the association between Vitamin
B12 deficiency and HbA1c level were not showed any statistical significance differences p>0.05. The dose of metformin
intake was higher in Vitamin B12 deficient groups (1500mg daily) when compared to non deficient individuals (500mg
once daily) P <0.001. Raheel et al studied that ,the mean dose among B12 deficient patient was 2100 mg while in patients
with normal B12 levels mean dose was 1582mg p>0.05. The dose of metformin had inversely related with B12 levels and
the mean difference is found to be statistically significant p < 0.001. Ting et al ., studied that each 1g/d dose increment
conferred a more than 2-fold increased risk of developing vitamin B12 deficiency with metformin with a significant P
<0.001. The duration of metformin intake was higher in deficient group age group between 11-20 years with a mean of
12.33±3.55, when compared to non deficient age group between 5-10 years with a mean of 6.58±2.56 which were

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58 M. Narayanaswamy, Nagappa H. Handargal & Akshatha M

statistically significant p <0.001. Raheel et al studied that mean B12 levels in patients on metformin for less than 24
months were 414 pg/ml (± 202) while those on more than 24 months was 188 pg/ml (± 78) with p <0.002. When
comparing patients on metformin for less than 24 months with those on metformin for more than 24 months in B12
deficient patients results were found to be statistically significant with p <0.001. Pongchaidecha, Daryl wile and Leif sparre
studied that metformin therapy given for 6months is sufficient to cause Vitamin B12 deficiency giving a statistically
significant p<0.01 and the deficiency can be reversed by supplementing Vitamin B12 in early course of treatment.

CONCLUSIONS

• The present study has explored that, the relation between the metformin intake and Vitamin B12 deficiency in
type 2 diabetes mellitus. This study has proved that age as well as the duration of diabetes increases the risk of
developing Vitamin B12 deficiency in type 2 diabetes patients who are taking metformin therapy.

• The study also showed that most of the patients were asymptomatic. This indicates that clinical manifestations of
Vitamin B12 deficiency will take years later to manifest after depletion of Vitamin B12 levels in the body and
hence measurement of Vitamin B12 levels is required in patients taking metformin therapy.

• Longer duration of diabetes is associated with longer duration of metformin intake and hence Vitamin B12
deficiency. This study has also showed that Vitamin B12 deficient type 2 diabetes patients on longer metformin
therapy have higher FBS, PPBS and HbA1C levels

• The higher dose of metformin intake has inverse relation with Vitamin B12 levels

This study has proved that longer duration of metformin intake in type 2 diabetes patients causes Vitamin B12
deficiency. Hence type 2 diabetes patients taking long term metformin therapy should be screened for Vitamin B12
deficiency and should be supplemented with Vitamin B12

ACKNOWLEDGEMENTS

The author acknowledge the Professor and Head, Dean BMCRI, Bangalore

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