April 19, 2012

Metformin and B12 Deficiency

This is something my endocrinologist tests for and tells patients taking Metformin to take a Vitamin B12 supplement. Yet there are many doctors that do not tell their patients to add Vitamin B12 to their supplement regimen. One of the members of our group (Allen) is taking Metformin and was surprised when we told him to take Vitamin B12. After his last appointment, he said his doctor told him not to be taking supplements and said there was no reason to be on supplements if he was eating the right foods.

We decided to use this blog to discuss this with Allen. After reading this and following the links, he was still hesitant to go against his doctor. We did take time to explain that doctor or not, Metformin would cause the Vitamin B12 deficiency and that he should add this to his regimen. He did state that he had been on Metformin for almost eight years and we suggested strongly that he have the test to determine the level of B12. A call to his regular doctor confirmed that they would not do the test. We then suggested he go to the doctor that I see and he agreed

I was able to get him in the following day and went with him. After a quick talk with the doctor, he wanted to do several tests that his doctor was not doing. We waited for the lab to be available and he had a blood draw. Next, we sat for about 20 minutes and Allen asked if they will have the results that quickly. I said this was normal and depending on the tests ordered, he should receive most of them in another 10 to 15 minutes. He did ask me to accompany him when he saw the doctor and I agreed.

After updating and reviewing his medications, the nurse left and the doctor came in. He sat down, asked a couple of questions about allergies, and said he was going to get two shots. The first shot would be a Vitamin B12 injection. Then he surprised both of us by saying he would also have a large dose injection of Vitamin D. I stepped out for a few minutes and then was invited back in.

Allen was asking why the two shots. The doctor said that his Vitamin B12 was very low and required another test already ordered from the blood sample. The Vitamin D level was below minimum guidelines and he was given the shot just to prevent something that the doctor feared might happen. He did not say what it was, but for three days, Allen would need to return for the two shots. Or he said he could be admitted to the hospital. Allen said he could drive back and forth and the doctor said no driving until after two weeks or the tests were at or above minimum guidelines.

Then the doctor said he was also prescribing both B12 and D3 for him to start on the fifth day. He was to return in seven days for another round to tests and then in 14 days for repeat of tests to see if he could then drive. We asked why and he would only say that he was the first person they had seen with deficiencies that low and he and the head of the department did not want him to drive. He then asked for his license stating he could surrender it temporarily to them, or possibly a lot longer to the highway patrol. Allen looked at me and gave it up.

The doctor did say that the remainder of the tests would be available the next day and the head of the department was requesting two additional tests that would also be available. On the way home with me driving, Allen was somewhat surprised at the thoroughness and was wondering if he should consider changing doctors. I did suggest that he wait until the two weeks were done and see what he thought then. He agreed, but commented this had raised some serious issues in his mind and I had to agree.

Allen wanted to meet with Tim when we returned so he called him and Tim was there when we arrived. Tim was surprised at what had transpired, but agreed with the tests and asked if he was needed to drive. I said yes, to get me home, and for at least one or two trips. Allen asked about their taking his drivers license, and Tim said no, it was probably not legal, but that it was preferable to giving it up to the highway patrol where it would become part of his records, and that they could enforce it longer. Tim asked about which doctor he would keep and I said that Allen should not make a decision until at least this was done. Tim said that was probably best, but should be seriously considered. I agreed and said this should be discussed along with other possibilities.

Allen did want some reading and Tim said he would stop back after he took me home. We did discuss some reading and search words for him to leave Allen. Tim said he would take Allen the next day and we could alternate. I said that would work, but we should let Allen decide if he had preferences. Tim said he would, but that he could not go every time.

The next day, Allen asked me to come by when he returned home. So with Tim and me present, Allen asked what was he to do. He had all the test results now and he was really frightened. All the tests had been out of range on the low to extreme low side and the doctor had suggested he see another doctor for more tests. I agreed with Tim when he said that he should see the second doctor and get his health checked out. Tim did state that it was time to decide on making a change in doctors. He said he felt from what had been discussed today, that Allen was being given a second chance and he should take full advantage of it by switching doctors now and having his records transferred.

I could see some fear in Allen, so I asked him when his VA appointment would be. He said in about five months and I said that would be good. Therefore, if he ended up with some expensive medications and the VA had them or ones in the same drug family, the doctors would synchronize with the VA and he would be ready. I could see Allen relax visibly and he asked if the doctors 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 they would send a fax or call them with what they were suggesting for medications and see if the VA could get them started coming to him. The doctors would also forward copies of the tests and the reasons for the drug request.

Tim did say that the doctor had suggested that with his A1c and creatinine level that Allen should consider changing oral medications or start on insulin. He also said he would make a referral to the endocrinologist. Allen did say he would like to stay on oral medications if possible, but he was going to pay more attention to our discussions about insulins and not leave it as a medication of last resort. We said that was okay. I suggested that he should ask for the test for determining how much insulin he was still producing before he made that decision. Tim said that was another test they had done and his own insulin production was still okay, but on the low side. He said to Allen that just the fact he wanted to learn about insulin was a good sign and would make him ready when the change was right.

The following two days I drove Allen and we had some interesting discussions about the different oral medications and insulin. He did say that since the doctor had given him some time to read about the different oral medications and their side effects, he was thinking seriously about insulin. I did suggest that he ask which oral medications they would be recommending and Allen said that would give him a better idea instead of learning about all the oral medications.

One the fourth day, Allen said doctor (after conferring with the endocrinologist) would have a recommendation for him when he came in for the blood draw the following Tuesday, and that he should seriously consider insulin. So we asked several others to meet with us on Saturday and we would research and discuss oral medications in more detail and insulin. Even Brenda asked to be included so we would be only short one person as Sue had another commitment.

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