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do not vortex or shake vigorously, as this can denature peptide bonds

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This explains why patients who only rely on external supplementation may not achieve lasting improvement unless metabolic efficiency is addressed

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Children presenting neurological signs or symptoms, those unable to take oral medication, individuals with known malabsorption syndromes, infants under 6 months old, and patients using medications that may interfere with vitamin B12 absorption are typically treated with a parenteral protocol (1)