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Food intake triggers insulin release, which blunts the growth hormone response

References Ng FM, Sun J, Sharma L, Libinaka R, Jiang WJ, Gianello R

When serum B12 results are equivocal or clinical suspicion remains high despite normal B12 levels, additional tests may be requested: Methylmalonic acid (MMA) : Elevated levels indicate functional B12 deficiency at the cellular level, though availability may be limited in primary care and levels can be elevated in renal impairment Homocysteine : Also elevated in B12 deficiency, though less specific and also affected by renal function Intrinsic factor antibodies : To investigate pernicious anaemia, the most common cause of B12 deficiency in the UK Anti-parietal cell antibodies : May be tested if pernicious anaemia is suspected but intrinsic factor antibodies are negative Identifying the underlying cause is crucial for appropriate management

If tolerated well and improvements continue, they may maintain or cautiously increase to 300400 mcg every other day or daily depending on individual response