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However, passive absorption may be well below 1% in many patients,60 and high biliary B 12 excretion may add to a negative B 12 balance.59 Prospective studies on this topic have focused mainly on normalising serum B 12 concentrations and should be interpreted with caution since the specific goal of treatment in symptomatic B 12 deficiency is alleviating symptoms.92326 A recent Cochrane Review found that available studies only provide very low quality evidence that oral B 12 is as efficacious as intramuscular B 12 in improving symptoms.13 A recent survey of 204 patients suggested that oral B 12 was associated with less effective symptom improvement than parenteral treatment.61 In practice, some patients may be able to switch to very high dose (ie, 2000 mcg daily) oral supplementation instead of continuing parenteral administration, but it is impossible to predict in whom this can be done safely, and many are at risk of worsening symptoms which may become permanent.24 Patient experiences Data from a review of patient experiences and surveys involving more than 2200 patients with B 12 deficiency in the UK indicate that many patients have concerns related to healthcare quality, safety, and treatment,626364 with nearly two thirds of respondents reporting that their treatment is insufficient to manage symptoms.2425 Some patients may experience recurrence or worsening of symptoms when the interval between injections is extended or extended too quickly, and report that continuation of frequent intramuscular hydroxocobalamin injections, varying between twice weekly and once every three to four weeks,65 is needed to remain asymptomatic

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