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For patients with clinical deficiency, effective replacement therapy should lead to a normal blood count after two months of treatment, while improvement in neurologic symptoms begins within one week after initiation of therapy and is usually complete within 6 weeks to 3 months.13 For patients with an asymptomatic biochemical deficiency (ie, subclinical disease), measurement of serum B12 or MMA levels should be done 2 to 3 months after initiation of replacement therapy.12 Once metformin is started, this medication is seldom discontinued unless advanced renal impairment develops

Other symptoms of B12 deficiency, such as numbness and tingling in the hands and feet, are also common in people with diabetes and spinal stenosis