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It can also be depleted by chronic stress, alcohol, smoking, digestive issues, cardiovascular disease, illness, and aging because stomach acid production decreases with age, reducing B12 absorption significantly

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[DOI] [PubMed] [Google Scholar] Mathieu 2009 Mathieu S, Boutron I, Moher D, Altman DG, Ravaud P

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Bolaman Z, Kadikoylu G, Yukselen V, Yavasoglu I, Barutca S, Senturk T: Oral versus intramuscular cobalamin treatment in megaloblastic anemia: a single-center, prospective, randomized, open-label study

Treatment is often initiated at a high dose, followed by a maintenance dose given less frequently, as determined by the patient's B12 levels and clinical response