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Haematological symptoms are among the earliest manifestations and include: Fatigue and generalised weakness Pallor due to anaemia (which may be macrocytic, though this is not universal) Shortness of breath on exertion Palpitations or tachycardia Neurological symptoms can be particularly concerning and may include: Peripheral neuropathy with tingling, numbness, or burning sensations in the hands and feet (paraesthesia) Loss of vibration sense and proprioception Ataxia and difficulty with balance or coordination Cognitive impairment, including memory problems and difficulty concentrating Mood disturbances, including depression and irritability In patients with diabetes, distinguishing between diabetic neuropathy and B12 deficiency-related neuropathy can be challenging, as both conditions may coexist

The TB-500 dosing protocols recommend preparing only what will be used within a short timeframe to minimize stability concerns