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Because lysine at position 34 would compete with position 26 for the fatty acid chain attachment described below

She had gastric bypass surgery and started taking a host of pills and supplements, including biotin, because her hair was falling out

The timeframe for B12 levels to increase following supplementation varies considerably depending on the severity of deficiency, route of administration, dosage, and individual absorption capacity

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Starting at 0.25 mg provides almost no therapeutic benefit for this patient and wastes 16 weeks of gradual titration that is unnecessary given their existing tolerance