Date of Degree


Document Type

Doctoral Project

Degree Name

Doctor of Nursing Practice (DNP)




Julio Lujano


Peripheral neuropathy is a significant co-morbidity for patients with diabetes and as early as 1969, metformin was linked to reductions in vitamin B12, leading to deficiency. Vitamin B12 deficiency causes increased levels of homocysteine and methylmalonyl-CoA which are toxic to the nervous system and therefore can contribute to demyelination. This quality improvement study aimed to optimize the management of peripheral neuropathy symptoms by implementing a process to identify patients with clinical or subclinical vitamin B12 deficiency and initiating replacement therapy. Adult patients presenting for a scheduled office visit with a diagnosis of type two diabetes and are taking metformin or medications containing metformin were included in the study. The Michigan Neuropathy Screening Instrument (MNSI) and the NC-stat DPNcheck was used to evaluate symptoms of neuropathy, and serum vitamin B12 levels were used to evaluate vitamin B12 status. The implementation of this process increased the identification of patients with low vitamin B12, thereby reducing the risk of patients in the sample population from developing peripheral neuropathy, reducing symptoms of peripheral neuropathy, or limiting the progression of peripheral neuropathy symptoms. This therefore, has the potential to improve the quality of life for patients living with type two diabetes that are taking metformin.