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By David Prince, MD | Montefiore Medical Center Although new GLP-1 agonist weight loss drugs such as Ozempic, Wegovy, Trulicity, and Byetta are currently dominating the headlines, the majority of overweight Americans may not qualify for these medications due to limited availability and insurance plan restrictions

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Others * Long-term metformin use * Proton pump inhibitors (reduce acid absorption) Pathophysiology * Impaired DNA synthesis megaloblastic anemia * Accumulation of methylmalonic acid nerve damage Clinical features Hematological * Fatigue, pallor * Shortness of breath * Megaloblastic anemia Neurological (key distinguishing feature) * Peripheral neuropathy (tingling, numbness) * Loss of vibration and position sense * Ataxia (unsteady gait) * Cognitive changes Severe untreated cases irreversible nerve damage Others * Glossitis (smooth, beefy red tongue) * Mild jaundice Investigations * Serum vitamin B12 * CBC macrocytic anemia ( MCV) * Blood film hypersegmented neutrophils * methylmalonic acid (specific for B12 deficiency) * homocysteine Differentiate from folate deficiency * Both megaloblastic anemia * Only B12 neurological symptoms Management Replacement therapy * Hydroxocobalamin (preferred IM) * Frequent doses initially, then maintenance * Oral B12 if mild and absorption intact Important rule Never give folate alone if B12 deficiency is possible may worsen neurological damage Prevention * Adequate diet (meat, eggs, dairy) * Supplementation in vegans * Monitor high-risk patients (elderly, post-surgery)

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