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The driver may be systemic or involve a different pathway, including mast-cell activation

If pepsin formation is compromised, the ability of protein bound vitamin B12 to be freed for additional preparations for absorption will be compromised.2-7 In addition, the increase gastric pH also contributes to a greater degree of bacterial colonization and replication within the gastrointestinal tract, thus potentially leading to bacterial overgrowth.2 If bacterial overgrowth also occurs then additional vitamin B12 that was originally ingested for absorption will be utilized by the enteric bacteria thereby reducing the final amount of vitamin B12 available for absorption in the terminal ileum of the small intestine

Prolonged use of metformin not only reduced vitamin B 12 levels but also significantly aggravated neuropathy

[6] If that occurs, it can sometimes be salvaged by allowing it to warm to room temperature