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Many patients with B12 deficiency, especially those with pernicious anemia, have difficulty clearing cyanide

[28] It is a cofactor and acts on glutathione peroxidase

After reviewing literature and conducting a two-round Delphi survey with 42 experts, a consensus emerged that emphasizes prioritizing clinical symptoms in diagnosis, with serum B12 as a screening marker supported by methylmalonic acid or homocysteine levels for additional confirmation

[11] Long-term metformin therapy reduces calcium-dependent intrinsic-factor binding, lowering B12 absorption and potentially necessitating higher or more frequent parenteral doses

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