2026 Southeastern Residency Conference

Authors: Abigail Murray, Brittany Melville, Micah Corriher, Camille P. Robinette 
 
Background: Metformin remains a cornerstone of type 2 diabetes treatment due to its efficacy and safety, but long-term use can reduce vitamin B12 absorption, potentially causing neuropathy, anemia, cognitive changes, and fatigue. The American Diabetes Association (ADA) Standards of Care 2026 recommend annual vitamin B12 monitoring for patients receiving long-term metformin. However, no standardized monitoring process exists within the Salisbury Veterans Affairs Health Care System (SVAHCS). This project evaluated adherence to ADA-recommended vitamin B12 monitoring among Veterans receiving long-term metformin therapy. 
 
Methodology: Veterans across SVAHCS, including Salisbury, Charlotte, and Kernersville locations aged ≥18 years prescribed metformin or Synjardy® (empagliflozin/metformin) for ≥4 consecutive years were included. Eligible Veterans had an active outpatient prescription filled between November 1, 2020, and October 31, 2021, and at least one additional fill between May 1, 2025, and October 31, 2025. The primary outcome was the percentage of eligible Veterans with a documented vitamin B12 level within the previous 12 months. Secondary outcomes included the percentage of Veterans with vitamin B12 deficiency or borderline deficiency within the past year.  Data were extracted from the VA Corporate Data Warehouse and included demographics and vitamin B12 laboratory results obtained within the previous 12 months. Descriptive statistics were used for analysis. 
Results: A total of 5,037 Veterans met inclusion criteria. The mean age was 70.6 years (range 29–100), and 94.4% were male. Among the cohort, 1,617 Veterans (32.1%) had a documented vitamin B12 level within the past 12 months, while 3,420 (67.9%) did not receive recommended monitoring. Among patients with laboratory testing, 13 Veterans (0.8%) had vitamin B12 deficiency and 244 (15.0%) had borderline vitamin B12 deficiency. 
Conclusions: Adherence to ADA-recommended annual vitamin B12 monitoring among Veterans receiving long-term metformin therapy was low. These findings highlight an opportunity to improve guideline-concordant care through targeted provider education and system-level interventions to increase routine vitamin B12 monitoring and support earlier identification of deficiency. 

Results: A total of 5,037 Veterans met inclusion criteria. The mean age was 70.6 years (range 29–100), and 94.4% were male. Among the cohort, 1,617 Veterans (32.1%) had a documented vitamin B12 level within the past 12 months, while 3,420 (67.9%) did not receive recommended monitoring. Among patients with laboratory testing, 13 Veterans (0.8%) had vitamin B12 deficiency and 244 (15.0%) had borderline vitamin B12 deficiency. 
Conclusions: Adherence to ADA-recommended annual vitamin B12 monitoring among Veterans receiving long-term metformin therapy was low. These findings highlight an opportunity to improve guideline-concordant care through targeted provider education and system-level interventions to increase routine vitamin B12 monitoring and support earlier identification of deficiency. 

Conclusion: Adherence to ADA-recommended annual vitamin B12 monitoring among Veterans receiving long-term metformin therapy was low. These findings highlight an opportunity to improve guideline-concordant care through targeted provider education and system-level interventions to increase routine vitamin B12 monitoring and support earlier identification of deficiency.