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Systemic Toxicity: Symptoms like tinnitus, blurred vision, or tremors indicating high systemic levels

A patient who started surgery with adequate B12 can come through the perioperative period slightly depleted, particularly if appetite was reduced in the early recovery weeks or if there were any complications affecting oral intake

Temperature fluctuations, light exposure, and physical agitation can cause the peptide chains to break down or aggregate, potentially reducing the medication's effectiveness