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A nasal spray is also available but is not considered the best treatment for severe deficiency because B12 is not absorbed as well as it is via injection

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Gastric mucosa performs limited first-pass metabolism before ethanol reaches portal circulation, reducing bioavailability slightly before systemic distribution begins

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The most commonly reported side effects at therapeutic doses include mild nausea, particularly in the first week of a protocol, which typically resolves by day 7 to 10 without any dose adjustment