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4,5 Dietary insufficiency, pernicious anemia (i.e., an autoimmune process that reduces available intrinsic factor and subsequent absorption of vitamin B 12 1,2,6,7 ), and long-term use of metformin or acid-suppressing medications have been implicated in B 12 deficiency

Methionine can also be converted to cytosine, the precursor of gluthione, which is essential in detoxification of the liver

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However, other people may experience severe illness and even death

Pernicious Anemia: Parenteral vitamin B 12is the recommended treatment and will be required for the remainder of the patient's life