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For drug-refractory patients who are eligible for a device, a trial of GES may be considered

0.6 mg steps) Temporarily reduce dose if symptoms are severe If goals are achieved before reaching maintenance: Continue to planned maintenance dose for stability Maintain achieved dose for extended period Monitor for continued benefits or plateau Develop long-term maintenance strategy Understanding peptide dosing principles across different compounds helps professionals develop intuition for protocol optimization

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

Pain due to pressure on the sciatic nerve in the lower back (sciatica)