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Thats one of the challenges Ive gotten to in my career

doi: 10.1111/j.1751-553X.2007.00911.x

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FACT 3 OF 6 IM injections for severe deficiency or absorption failure If your sublingual dose doesnt maintain serum B12 above 400 pg/mL, switch to intramuscular injections: 1,000 mcg monthly (more often initially if very deficient)

We are transparent about that distinction with every patient who asks about it