Enterogermine (Vitamin B12) Is NOT Given Routinely
Routine supplementation with vitamin B12 is not recommended for the general population without underlying deficiencies or specific risk factors. 1
Evidence Against Routine Supplementation
The American Diabetes Association guidelines explicitly state there is no clear evidence of benefit from vitamin or mineral supplementation for people without underlying deficiencies 1. This recommendation applies broadly to the general population, not just those with diabetes.
Multiple high-quality guidelines consistently emphasize that:
- Routine supplementation with vitamins and minerals lacks efficacy evidence in individuals without documented deficiencies 1
- Supplementation should be targeted based on identified deficiencies or specific risk factors, not given universally 1, 2
- The approach should be individualized based on assessment of deficiency risk rather than blanket supplementation 2, 3
When B12 Supplementation IS Indicated
High-Risk Populations Requiring Screening and Treatment
Metformin users should have periodic B12 testing, particularly those with anemia or peripheral neuropathy, as metformin is associated with B12 deficiency 1. Screening is warranted after more than 4 months of metformin use 2, 3.
Post-bariatric surgery patients require 1000-2000 mcg daily orally OR 1 mg intramuscular monthly indefinitely due to permanent malabsorption 4, 5.
Elderly adults over 75 years have significantly higher rates of metabolic B12 deficiency (18.1% in those >80 years) and warrant screening 6, 2.
Patients with gastrointestinal conditions including:
- Gastric or small intestine resections (>20 cm ileal resection requires prophylactic 1000 mcg IM monthly for life) 5, 2
- Inflammatory bowel disease with ileal involvement 5, 2
- Pernicious anemia (requires lifelong treatment) 5
Long-term medication users:
Vegans and strict vegetarians should consume fortified foods or take B12 supplements due to limited dietary intake 1, 2, 3
Treatment Approach When Deficiency Is Confirmed
Oral vitamin B12 (1000-2000 mcg daily) is as effective as intramuscular administration for most patients and costs less 7, 3, 8. This applies regardless of the etiology of deficiency 3, 8.
Intramuscular therapy should be reserved for:
- Severe neurological symptoms requiring rapid improvement 2, 3
- Confirmed malabsorption that fails oral therapy 2
- Compliance concerns or swallowing difficulties 7
Monitoring After Treatment Initiation
Recheck B12 levels at 3 months, then 6 and 12 months in the first year, followed by annual monitoring 4, 5. This ensures adequate response and prevents recurrence in high-risk populations 5.
Critical Pitfalls to Avoid
Never administer folic acid before ensuring adequate B12 treatment, as folic acid can mask B12 deficiency anemia while allowing irreversible neurological damage to progress 4, 5, 6.
Do not stop monitoring after one normal result in patients with malabsorption or dietary insufficiency, as they often require ongoing supplementation and can relapse 5.
Do not rely solely on serum B12 levels in high-risk populations (especially >60 years), as up to 50% may have metabolic deficiency despite "normal" serum levels 6. Consider measuring methylmalonic acid (MMA >271 nmol/L confirms functional deficiency) in borderline cases 6, 2, 3.