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61 In practice, some patients may be able to switch to very high dose (ie, 2000 mcg daily) oral supplementation instead of continuing parenteral administration, but it is impossible to predict in whom this can be done safely, and many are at risk of worsening symptoms which may become permanent

Potential mechanisms include: Alterations in methylation pathways Changes in NAD+ availability Mild dehydration secondary to metabolic shifts Headaches are generally mild but may become persistent in sensitive individuals

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