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George I. Varughese, MRCPI, MRCP(UK); Abd A. Tahrani, MD, MRCP; John H. B. Scarpello, MD, FRCP

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We applaud Ting et al¹ for their study demonstrating the risk of vitamin B₁₂ deficiency with increasing dose and duration of metformin use. In contrast to previous reports, their study demonstrated no excess risk of vitamin B₁₂ deficiency among metformin users who currently use histamine₂-receptor blockers or proton pump inhibitors.¹ This statement should be interpreted very cautiously, although the authors allude to the fact that the lack of association in their study may stem from imprecise hospital-based medication records and inability to track the use of histamine₂-receptor blockers or proton pump inhibitors. Gastrointestinal symptoms can be a limiting factor in optimizing metformin therapy, and metformin has been recognized not to alter intestinal motility or bacterial overgrowth.^1-2 Interestingly, almost one half of adult consumers of over-the-counter histamine₂-receptor blockers have been reportedly using . . . [Full Text of this Article]

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