Metformin and B12 Deficiency

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This is something my endocrinologisttests for and tells patients taking Metformin to take a Vitamin B12supplement. Yet there are many doctors that do not tell theirpatients to add Vitamin B12 to their supplement regimen. One of themembers of our group (Allen) is taking Metformin and was surprisedwhen we told him to take Vitamin B12. After his last appointment, hesaid his doctor told him not to be taking supplements and said therewas no reason to be on supplements if he was eating the right foods.
We decided to use this blog to discussthis with Allen. After reading this and following the links, he wasstill hesitant to go against his doctor. We did take time to explainthat doctor or not, Metformin would cause the Vitamin B12 deficiencyand that he should add this to his regimen. He did state that he hadbeen on Metformin for almost eight years and we suggested stronglythat he have the test to determine the level of B12. A call to hisregular doctor confirmed that they would not do the test. We thensuggested he go to the doctor that I see and he agreed
I was able to get him in the followingday and went with him. After a quick talk with the doctor, he wantedto do several tests that his doctor was not doing. We waited for thelab to be available and he had a blood draw. Next, we sat for about20 minutes and Allen asked if they will have the results thatquickly. I said this was normal and depending on the tests ordered,he should receive most of them in another 10 to 15 minutes. He didask me to accompany him when he saw the doctor and I agreed.
After updating and reviewing hismedications, the nurse left and the doctor came in. He sat down,asked a couple of questions about allergies, and said he was going toget two shots. The first shot would be a Vitamin B12 injection. Then he surprised both of us by saying he would also have a largedose injection of Vitamin D. I stepped out for a few minutes andthen was invited back in.
Allen was asking why the two shots. The doctor said that his Vitamin B12 was very low and requiredanother test already ordered from the blood sample. The Vitamin Dlevel was below minimum guidelines and he was given the shot just toprevent something that the doctor feared might happen. He did notsay what it was, but for three days, Allen would need to return forthe two shots. Or he said he could be admitted to the hospital. Allen said he could drive back and forth and the doctor said nodriving until after two weeks or the tests were at or above minimumguidelines.
Then the doctor said he was alsoprescribing both B12 and D3 for him to start on the fifth day. Hewas to return in seven days for another round to tests and then in 14days for repeat of tests to see if he could then drive. We asked whyand he would only say that he was the first person they had seen withdeficiencies that low and he and the head of the department did notwant him to drive. He then asked for his license stating he couldsurrender it temporarily to them, or possibly a lot longer to thehighway patrol. Allen looked at me and gave it up.
The doctor did say that the remainderof the tests would be available the next day and the head of thedepartment was requesting two additional tests that would also beavailable. On the way home with me driving, Allen was somewhatsurprised at the thoroughness and was wondering if he should considerchanging doctors. I did suggest that he wait until the two weekswere done and see what he thought then. He agreed, but commentedthis had raised some serious issues in his mind and I had to agree.
Allen wanted to meet with Tim when wereturned so he called him and Tim was there when we arrived. Tim wassurprised at what had transpired, but agreed with the tests and askedif he was needed to drive. I said yes, to get me home, and for atleast one or two trips. Allen asked about their taking his driverslicense, and Tim said no, it was probably not legal, but that it waspreferable to giving it up to the highway patrol where it wouldbecome part of his records, and that they could enforce it longer. Tim asked about which doctor he would keep and I said that Allenshould not make a decision until at least this was done. Tim saidthat was probably best, but should be seriously considered. I agreedand said this should be discussed along with other possibilities.
Allen did want some reading and Timsaid he would stop back after he took me home. We did discuss somereading and search words for him to leave Allen. Tim said he wouldtake Allen the next day and we could alternate. I said that wouldwork, but we should let Allen decide if he had preferences. Tim saidhe would, but that he could not go every time.
The next day, Allen asked me to come bywhen he returned home. So with Tim and me present, Allen asked whatwas he to do. He had all the test results now and he was reallyfrightened. All the tests had been out of range on the low toextreme low side and the doctor had suggested he see another doctorfor more tests. I agreed with Tim when he said that he should seethe second doctor and get his health checked out. Tim did state thatit was time to decide on making a change in doctors. He said he feltfrom what had been discussed today, that Allen was being given asecond chance and he should take full advantage of it by switchingdoctors now and having his records transferred.
I could see some fear in Allen, so Iasked him when his VA appointment would be. He said in about fivemonths and I said that would be good. Therefore, if he ended up withsome expensive medications and the VA had them or ones in the samedrug family, the doctors would synchronize with the VA and he wouldbe ready. I could see Allen relax visibly and he asked if thedoctors would work with the VA? I said not the way he was thinking,but that he would give the doctors the name of his VA doctor and theywould send a fax or call them with what they were suggesting formedications and see if the VA could get them started coming to him. The doctors would also forward copies of the tests and the reasonsfor the drug request.
Tim did say that the doctor hadsuggested that with his A1c and creatinine level that Allen shouldconsider changing oral medications or start on insulin. He also saidhe would make a referral to the endocrinologist. Allen did say hewould like to stay on oral medications if possible, but he was goingto pay more attention to our discussions about insulins and not leaveit as a medication of last resort. We said that was okay. Isuggested that he should ask for the test for determining how muchinsulin he was still producing before he made that decision. Timsaid that was another test they had done and his own insulinproduction was still okay, but on the low side. He said to Allenthat just the fact he wanted to learn about insulin was a good signand would make him ready when the change was right.
The following two days I drove Allenand we had some interesting discussions about the different oralmedications and insulin. He did say that since the doctor had givenhim some time to read about the different oral medications and theirside effects, he was thinking seriously about insulin. I did suggestthat he ask which oral medications they would be recommending andAllen said that would give him a better idea instead of learningabout all the oral medications.
One the fourth day, Allen said doctor(after conferring with the endocrinologist) would have arecommendation for him when he came in for the blood draw thefollowing Tuesday, and that he should seriously consider insulin. Sowe asked several others to meet with us on Saturday and we wouldresearch and discuss oral medications in more detail and insulin. Even Brenda asked to be included so we would be only short one personas Sue had another commitment.