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| Metformin and B-12 Deficiency- A New Issue to Contemplate |
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by Bob Blumm, MA, PA-C, DFAAPA - August 30, 2010
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What makes an article great? When that article is personal and meets the need of the hour! I was reading through the August, 2010 Clinician Review issue when I encountered an article with the subject of B-12 deficiency and a question concerning Metformin. America can now boast that we have 1/3 of our citizens that are a normal weight, 1/3 that is obese and 1/3 that is morbidly obese. Obesity lends itself to a vulnerability to type II DM, which has risen as a disease among teenagers as well as all adult sub-groups in the United States. This disease increases risk of heart disease, stroke, blindness, renal failure and neurological disease. Early detection, behavior modification, weight control and medications, particularly Metformin, are used as first line weapons to fight this debilitating disease.
Sometimes, however, the cure can create other problems that are equally disturbing and can cause greater morbidity and possible mortality unless the problem is recognized early; medication is stopped or lowered and other complimentary vitamins or therapies are instituted. It has been proven that use of Metformin between 4 and 9 years has demonstrated a decline in Vit B-12, lowering of the oxygen carrying supply of RBCs and a pernicious anemia that resembles the anemia of chronic disease. This can impair major organ systems and, specifically, cause irreversible damage to the neurological system and neuropsychiatric disease.
This well-written article by Theresa J. Steele, MSN, MSH, RN, RD, LD/N, CDE has placed a spotlight on medication induced B-12 deficiency. I was found to have a vitamin B-12 deficiency by the VA and had this finding collaborated by my internal medicine team which consists of an MD/PA. There was concern. I was placed on a B-12 supplement. But it was this article that illuminated me to the probable culprit, Metformin.
As I read my new issue of Clinical Advisor, I happened upon the evidence Based Medicine section and discovered yet another piece of this puzzle under the heading of “Long Term Metformin treatment Associated With Reduced Vitamin B-12 Levels.” The article praises the benefits of Metformin in both the lowering of blood glucose levels as well as reducing cardiovascular mortality. In addition, the balance of the article revealed a study, a randomized trial on 390 patients revealing the long term effects which has been published in the BMJ May 2010 edition. The Metformin group had a significantly higher incidence of both Vit B-12 levels as well as increased homocystine level. These comments, with the appropriate figures, dovetail the article that was more informative and in-depth in Clinician Reviews. I am in the process of passing this information to the VA and my IM health care team. Knowledge is power and sometimes demands that we change our ways or prepare ourselves for negative consequences.
In short, we are aware of the associated problems with a society that has a pandemic of diabetes. We have just become aware that the collective “we" may be inducing a B-12 deficiency and all of the associated problems that may accompany it. My personal interest relates to the fact that I discovered this independently three years ago when I saw low normal hemoglobins on my labs but was missing the part concerning the possibility of it being Metformin related. I am placing this on AdvancedPracticeJobs.com as it has a circulation of 100,000 NPs and PAs. I am also going to post this on Clinician1.com as it has a circulation of over 10,000 PAs and NPs. If you are a primary care clinician or practice in IM or endocrinology, I would appreciate your comments on whether a person like me should remain on Metformin since I have a HGB A1C of 8 and still need to work more on the diet and exercise. I have no CAD but do have a history of A-Fib and HCM therefore the cardiac ramifications are a concern. It is only by polling my colleagues that I have the opportunity of getting other thoughts so that I can have an intelligent discussion with my Internist on the issue. I hope that this information stimulates your thinking and that you may also respond to a fellow clinician who appreciates your advice.
Thanks.
 Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Malissa FNPc- Idaho Falls, ID (Idaho) |
on 31 Aug 2010 at 6:59 pm |
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| Bob, interesting dilemma. One that has also been coming up with the rampant use of PPI's. It seems to come down to picking the lesser of two evils. With your cardiac history I personally would keep you on the metformin until you could get lifestyle and diet interventions up to par. The inflammation and damage caused by high insulin levels is concerning in someone with baseline cardiac issues. B12 deficiency is also concerning but the good thing about this is B12 levels can be monitored and replaced with injections as needed. The damage caused by insulin resistance could be irreversable. Malissa, FNPc |
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| Bob Blumm (Amityville, NY) |
on 31 Aug 2010 at 12:30 pm |
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The GI effects of metformin are legendary and diarrhea is high among them. I too had thhis problem and regulated this with dosing but along with GI discomfort, it continues to bee a problem for many patients. the argument from an endocrinolgy NP who specilizes in diabetic care is that it is still the gold standard for diabetic control. I hope that we have more professionals making comment as I would love to make a personal decision like yours. My A1C is 8 so I still need to play with control.
Bob |
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| George Argast RN,PA, MS, MBA (Rahway, NJ) |
on 31 Aug 2010 at 11:11 am |
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| In addition to the above adverse effect of Metformin, I suffered from Metformin induced chronic diarrhea which on one occasion resulted in an episode of dehydration with subsequent hypovolemic shock and near death. Discontinuation of the metformin corrected the problem immediately and has never recurred. |
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