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Metformin treatment of diabetes causes B12 to accumulate in the liver, thus lowering serum B12 concentrations (Allen et al., 2018)

Some patients may require injections more frequently, and if a true deficiency is identified, several injections over 1-2 weeks are needed, known as a loading dose

Surgery involving partial or complete removal of any part of the gastrointestinal tract, including some bariatric surgery procedures, will reduce food-bound B12 absorption and lower serum B12 concentrations

The freeze-thaw cycle can damage the peptide structure, similar to how shaking does

Such evidence highlights the urgent need for strict regulatory measures to limit both environmental and occupational exposures