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A corresponding moderate increase in the functional metabolic biomarkers plasma methymalonic acid and homocysteine suggests that some depletion of maternal intracellular vitamin B12 has occurred even though serum B12 concentrations are high (Varsi et al., 2018)

Check vitamin B12 levels in people treated with metformin who have symptoms suggestive of vitamin B12 deficiency This will also include patients found to have megaloblastic anaemia (raised mean corpuscular volume [MVC]), who may be asymptomatic (MHRA, 2022)

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The rate of change during this phase depends heavily on baseline body composition, caloric intake, activity level, and adherence to protocol