Why take Vitamin B12 with Proton Pump Inhibitors (PPIs)?

From the Guidelines

Taking vitamin B12 supplements is highly recommended when using proton pump inhibitors (PPIs) to prevent deficiency and related health issues. PPIs reduce stomach acid production, which is necessary for absorbing dietary vitamin B12 from food sources 1. The stomach normally produces intrinsic factor and acid that help release and absorb B12 from proteins in food. When this process is disrupted by PPIs, B12 deficiency can develop over time, potentially causing symptoms like fatigue, weakness, nerve problems, mood changes, and memory issues.

Some key points to consider:

• Long-term use of PPIs has been associated with a higher risk of vitamin B12 deficiency, especially in older adults 1.
• The risk of deficiency increases with the duration and dosage of PPI use, with a mean daily PPI dose of >1.5 pills having a stronger association with vitamin B12 deficiency compared to <0.75 pills/day 1.
• Vitamin B12 supplements can help prevent deficiency, and sublingual forms may be particularly effective for those on PPIs since they bypass the stomach absorption process.
• The ESPEN micronutrient guideline recommends considering vitamin B12 supplementation for patients taking PPIs, as they are at risk of deficiency 1.

It is essential to note that vitamin B12 deficiency can have severe health consequences, including neurological problems and anemia. Therefore, taking vitamin B12 supplements with PPIs is a crucial step in maintaining overall health and preventing potential complications. If you've been on PPIs long-term, consider having your B12 levels checked with a blood test to determine if supplementation is necessary 1.

From the FDA Drug Label

5.7 Cyanocobalamin (Vitamin B-12) Deficiency Daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than three years) may lead to malabsorption of cyanocobalamin (Vitamin B12) caused by hypo- or achlorhydria. 5.7 Cyanocobalamin (Vitamin B12) Deficiency Daily treatment with any acid-suppressing medications over a long period of time (e.g., longer than three years) may lead to malabsorption of cyanocobalamin (Vitamin B12) caused by hypo- or achlorhydria.

Vitamin B12 deficiency is a potential risk associated with long-term use of Proton Pump Inhibitors (PPIs), such as omeprazole and lansoprazole.

• The malabsorption of cyanocobalamin (Vitamin B12) is caused by hypo- or achlorhydria, which can occur with daily treatment of acid-suppressing medications over a long period of time (e.g., longer than three years) 2 3.
• Therefore, taking Vitamin B12 with PPIs may be necessary to prevent or treat Vitamin B12 deficiency.

From the Research

Reasons for Taking B12 with PPIs

• Proton pump inhibitors (PPIs) can reduce serum vitamin B-12 concentrations by inhibiting the absorption of the vitamin 4
• Long-term usage of acid suppression drugs like PPIs or H2 receptor blockers in the elderly population has been found to result in vitamin B12 deficiency 5
• PPIs use for 12 months did not result in clinically significant iron and/or vitamin B12 deficiency, but monitoring in elderly and malnourished may be of precious value 6
• Literature suggests that there is an increased risk of developing vitamin B12 deficiency in patients who are exposed to extended durations of therapy with PPIs 7
• The pooled Odds Ratio (OR) of vitamin B12 deficiency among PPI users was higher than non-users, but there was significant heterogeneity, and the pooled OR was too low to imply an association clearly 8

Key Findings

• Nearly 50% of the patients on prolonged acid suppression therapy were either "deficient" or "insufficient" in serum vitamin B12 levels 5
• Significant changes within PPIs group and specific PPIs subgroups between the two-time points in serum ferritin and vitamin B12 levels, respectively 6
• No evidence was found to support the extended use of H2RA monotherapy causing vitamin B12 deficiency 7
• Most studies found no difference between serum vitamin B12 levels among PPI users compared to non-users 8

Implications

• Strategies for assessing vitamin B-12 status and diagnosing vitamin B-12 deficiency have evolved in recent years beyond solely measuring serum total vitamin B-12 4
• A reasonable recommendation for physicians and their patients who are taking these drugs is to monitor vitamin B-12 status and to provide vitamin B-12 supplements if altered blood biomarkers or clinical signs consistent with low or deficient vitamin B-12 status develop 4
• Better-designed prospective studies in long-term users may clarify the issue of PPI use and vitamin B12 deficiency 8