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Mechanisms of Vitamin B12 deficiency with Metformin Use: It has been proposed that metformin reduces Vitamin B12 absorption by following mechanisms Alterations in small bowel motility which stimulates bacterial overgrowth and consequential vitamin B12 deficiency Competitive inhibition or inactivation of vitamin B12 absorption Alterations in intrinsic factor (IF) levels and interaction with the cubulin endocytic receptor Inhibition of the calcium dependent absorption of the vitamin B12-IF complex at the terminal ileum Reference: Fatima, S., Noor, S