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Accordingly, it has issued new advice to check vitamin B12 serum levels in patients being treated with metformin who have symptoms suggestive of vitamin B12 deficiency.[] The proposed mechanisms to explain metformin-induced vitamin B12 deficiency among patients with T2DM include alterations in small bowel motility, which stimulates bacterial overgrowth and consequential vitamin B12 deficiency, competitive inhibition or inactivation of vitamin B12 absorption, alterations in IF levels, and interaction with the cubulin endocytic receptor

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This is because elevated homocysteine levels can be a marker for various conditions including heart disease, depression, cognitive disorders, and risk of fracture