Anaemia and Metformin

[LittleGreyCat]

Just had a blood test and they included a Full Blood Count (no idea why as they don't usually).

"Full blood count
Haemoglobin concentration 132 g/L [135.0 - 175.0]
Below low reference limit
Total white blood count 7.0 10*9/L [4.0 - 11.0]
Platelet count - observation 255 10*9/L [135.0 - 450.0]
Red blood cell count 4.05 10*12/L [4.5 - 5.5]
Below low reference limit
Mean cell volume 97 fL [80.0 - 100.0]
Haematocrit 0.39 L/L [0.38 - 0.5]
Mean cell haemoglobin level 32.6 pg [27.0 - 34.0]
Red blood cell distribution width 13.7 [10.0 - 15.0]
Neutrophil count 3.1 10*9/L [2.0 - 7.5]
Lymphocyte count 2.7 10*9/L [1.0 - 4.0]
Monocyte count - observation 0.7 10*9/L [0.1 - 1.0]
Eosinophil count - observation 0.5 10*9/L [0.0 - 0.5]
Basophil count 0.1 10*9/L [0.0 - 0.2]
Nucleated red blood cell count 0.0 10*9/L [0.0 - 0.2]"

So my haemoglobin concentration and red blood cell count are below recommendation but everything else is in range.

A bit of searching, and it seems that Metformin can lead to this long term with loss of B12 and Folate (B9).

I'm now checking through my supplements to see if any contain this.

Nutrof Total - no.
Fish oil - no.

So perhaps I need to take a B12/Folate supplement?

Anyone else hit this?

 

[zand]

Don't know about all of the things you mention, but I tend to take B12 with metformin as I have noticed my B12 getting borderline on the occasions I have had metformin before.

 

[Dr Snoddy]

The leaflet in the Metformin packet now clearly stated that B12 levels should be routinely monitored so you could ask to have this done. My B12 levels plummeted from high normal to subnormal within 3 weeks of starting Metformin and I supplemented with a B12 spray. Since stopping Metformin my levels have returned to my previous level. The same goes for having folate checked. I get this done as a matter of routine every year but I have to ask for B12 still.
You might possibly also be short on iron. Don't assume that because you are supplementing that nutrients are being absorbed and assimilated.

 

[LittleGreyCat]

The leaflet in the Metformin packet now clearly stated that B12 levels should be routinely monitored so you could ask to have this done. My B12 levels plummeted from high normal to subnormal within 3 weeks of starting Metformin and I supplemented with a B12 spray. Since stopping Metformin my levels have returned to my previous level. The same goes for having folate checked. I get this done as a matter of routine every year but I have to ask for B12 still.
You might possibly also be short on iron. Don't assume that because you are supplementing that nutrients are being absorbed and assimilated.

Thanks.

I am scheduled for another test in a few weeks to confirm.

Reading suggests that B12 should be boosted first then Folate checked, because low B12 can reduce Folate production, and Folate supplementation can mask B12 deficiency.

Contemplating for a B12 test along with the repeat BC.
Otherwise I could be at this for months!

I am holding off on any supplementation until the second test, so that I have a baseline to work from.

 

[Oldvatr]

Just had a blood test and they included a Full Blood Count (no idea why as they don't usually).

"Full blood count
Haemoglobin concentration 132 g/L [135.0 - 175.0]
Below low reference limit
Total white blood count 7.0 10*9/L [4.0 - 11.0]
Platelet count - observation 255 10*9/L [135.0 - 450.0]
Red blood cell count 4.05 10*12/L [4.5 - 5.5]
Below low reference limit
Mean cell volume 97 fL [80.0 - 100.0]
Haematocrit 0.39 L/L [0.38 - 0.5]
Mean cell haemoglobin level 32.6 pg [27.0 - 34.0]
Red blood cell distribution width 13.7 [10.0 - 15.0]
Neutrophil count 3.1 10*9/L [2.0 - 7.5]
Lymphocyte count 2.7 10*9/L [1.0 - 4.0]
Monocyte count - observation 0.7 10*9/L [0.1 - 1.0]
Eosinophil count - observation 0.5 10*9/L [0.0 - 0.5]
Basophil count 0.1 10*9/L [0.0 - 0.2]
Nucleated red blood cell count 0.0 10*9/L [0.0 - 0.2]"

So my haemoglobin concentration and red blood cell count are below recommendation but everything else is in range.

A bit of searching, and it seems that Metformin can lead to this long term with loss of B12 and Folate (B9).

I'm now checking through my supplements to see if any contain this.

Nutrof Total - no.
Fish oil - no.

So perhaps I need to take a B12/Folate supplement?

Anyone else hit this?

Yes I am iron deficient anemic, but my B12 is fine. My doc has prescribed an iron tablet and a folate tablet daily. The iron tab turns my poop black which was a bit disconcerting, Since you have this result, you can ask to be tested for B12. Not all doctors know about the metformin link to B12 deficiency since it is a long-term effect.

I do not think this is in the BNF or patient info. It is mainly the FDA in the US that is flagging this as a problem, NICE do not necessarily follow the FDA warnings.

Here is the science study from the US,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6867725/

It does get a small mention in the BNF as a rare or very rare effect
https://bnf.nice.org.uk/drug/metformin-hydrochloride.html

 

[jjraak]

Just had a blood test and they included a Full Blood Count (no idea why as they don't usually).

"Full blood count
Haemoglobin concentration 132 g/L [135.0 - 175.0]
Below low reference limit
Total white blood count 7.0 10*9/L [4.0 - 11.0]
Platelet count - observation 255 10*9/L [135.0 - 450.0]
Red blood cell count 4.05 10*12/L [4.5 - 5.5]
Below low reference limit
Mean cell volume 97 fL [80.0 - 100.0]
Haematocrit 0.39 L/L [0.38 - 0.5]
Mean cell haemoglobin level 32.6 pg [27.0 - 34.0]
Red blood cell distribution width 13.7 [10.0 - 15.0]
Neutrophil count 3.1 10*9/L [2.0 - 7.5]
Lymphocyte count 2.7 10*9/L [1.0 - 4.0]
Monocyte count - observation 0.7 10*9/L [0.1 - 1.0]
Eosinophil count - observation 0.5 10*9/L [0.0 - 0.5]
Basophil count 0.1 10*9/L [0.0 - 0.2]
Nucleated red blood cell count 0.0 10*9/L [0.0 - 0.2]"

So my haemoglobin concentration and red blood cell count are below recommendation but everything else is in range.

A bit of searching, and it seems that Metformin can lead to this long term with loss of B12 and Folate (B9).

I'm now checking through my supplements to see if any contain this.

Nutrof Total - no.
Fish oil - no.

So perhaps I need to take a B12/Folate supplement?

Anyone else hit this?

Late this @LittleGreyCat

I was surprised the full count or at least B12 wasn't a normal part of our first blood test after DX.

I read up, got concerned enough to request it be added..ended up with a score in lower 3rd of range, so supplement.

Sublingual, is reportedly the best method, equal to injections so some reports say.

It's mislabelled for a lot of other issues, so it's good to be aware of how it can manifest.

Under my signature is a link, more a B movie, then blockbuster,
But does highlight some instances I found of interest.

Sally Pacholok.

While not all blood tests include a B12 check, All of mine so far included MCV value, which as my linked post explains, can be an indicator you "Might" have an issue.

https://www.diabetes.co.uk/forum/th...se-full-on-chat.163627/page-2108#post-2383616

Maybe of use to someone.

 

[LittleGreyCat]

While not all blood tests include a B12 check, All of mine so far included MCV value, which as my linked post explains, can be an indicator you "Might" have an issue.

Thank you.
Still thrashing around wildly but does a rise in MCV suggest B12 deficiency?

Mean cell volume 97 fL [80.0 - 100.0]

It looks as though my MCV is top of the range.

Edit:
https://pubmed.ncbi.nlm.nih.gov/10757449/
High MCV is an indicator but not accurate enough to rule in/out B12 deficiency.

 

[jjraak]

Hi @LittleGreyCat.

i hope all of this is of an informational purpose, certainly not intended to scare any one,
but to just raise awareness that a simple B12 test as soon as available, IF concerned, would make sense if on Metformin.

Have you looked back and tracked it over previous tests ?
is it rising?

I tracked mine back to DX.

As i understood it, it points to a 'Potential' in amongst a number of other issue as the below 'quoted' screenshot suggests.
(quoted post came from my NHS app link to my details, 'More information about what the test mean' type thing)

For me, not having previous B12 checks done, it intrigued me, so i back tracked, and for ME
it correlated with a POSSIBLE link to the depletion of my b12 as time line rise begins at DX aug 2018,
the beginning of the taking of METFORMIN,
and the 1st B12 check on Aug 2019.
(due to Covid have had no other blood tests done since then, be interesting to see if any changes to levels since supplementing)

Possibly unrelated, Probably not, imo

I merely pointed it out, as said, in the hope that others who are unaware of the risk of B12 deficiencies,
who like myself may have had other Blood tests done, that DO contain MCV data,
Might consider it sensible to check to see IF it's rising over time.

NO rise ?, that might offer real or false comfort, I'm unqualified to say.
But being a reasonable person, that might allay my concerns slightly.

BUT if the MCV gives evidence it HAS risen since beginning METFORMIN,
i would suggest it wise at next blood test to ask for B12 to be included.

it looks like my MCV rate from DX to first B12 test, was running at a rise of around 3.2 fl a year
Aug 2018: 90.7 / June 2019: 93.9

Only take 3 years and that would top the range, and 'Potentially' any B12 issue might be more difficult to resolve easily with supplements*

*No doctor or doctors qualifications,
whole post is merely an opinion, and simple advice to be aware and get checked by authorised professionals if concerned.

Kindest regards.

 

[Oldvatr]

Thank you.
Still thrashing around wildly but does a rise in MCV suggest B12 deficiency?

It looks as though my MCV is top of the range.

https://www.ebmconsult.com/articles/lab-test-mcv-mean-corpuscular-volume-level
It is a marker for B12.

 

[LittleGreyCat]

Yes I am iron deficient anemic, but my B12 is fine. My doc has prescribed an iron tablet and a folate tablet daily. The iron tab turns my poop black which was a bit disconcerting, Since you have this result, you can ask to be tested for B12. Not all doctors know about the metformin link to B12 deficiency since it is a long-term effect.

I do not think this is in the BNF or patient info. It is mainly the FDA in the US that is flagging this as a problem, NICE do not necessarily follow the FDA warnings.

Here is the science study from the US,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6867725/

It does get a small mention in the BNF as a rare or very rare effect
https://bnf.nice.org.uk/drug/metformin-hydrochloride.html

Just getting back to this.

Was there any indication that your anaemia was affecting your HbA1c values?

 

[Oldvatr]

Just getting back to this.

Was there any indication that your anaemia was affecting your HbA1c values?

I don't think so. My GP gave me iron and folate tabs, and I have increased my Vit C and I am snarking my wife's Vit D3 so the anemia has abated, but HbA1c continued to drop a bit more this last time.

What does change is the hematocrit value, and this can interfere with home testing kits. But I think there needs to be a major shift out of range for it to have much impact.

What I do suspect, but have no proof for, is that the bgl tester chemistry can be affected by LDL values, I notice my SD Codefree normally reads a mmol or so higher than my Caresense Dual, and I see that the difference after a meal seems to worsen, then recover at the 4 hr mark. So I seem to spike worse on my SD. I think that since the hematocrit is the ratio of RBC over the rest, then a fat-heavy meal may increase the LDL content of the blood thus affecting the meter while the lipids are in transit. Or I am generating extra trigs. This is covered by the paper I will share here about bgl meter accuracy
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769960/

 

[LittleGreyCat]

@Oldvatr
Just had most of my next set of tests back.
B12 and Folate are fine.
Ferritin is fine.
Gamma-GT is fine (was I being checked out for alcoholic liver damage, I wonder?)

Now just waiting for my full BC to see if I still register as anaemic.

Going from the previous test I have low haemoglobin concentration and low red blood cell count (which I assume go together) but as yet no pointer as to why that might be.
The first obvious suspects seem to be ruled out.