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In another study 13 of patients with known pernicious anemia who had not received maintenance vitamin B 12 injections for months to years, the rise of methylmalonic acid and homocysteine levels was found to precede the decrease in serum vitamin B 12 and the decline in hematocrit

Another consideration is dosage

The percentages of Slc7a11 (+) MRP1 (+) dendritic cells and fibroblasts within TLS