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According to the NICE Clinical Knowledge Summary (CKS) and the British National Formulary (BNF) , the standard treatment for B12 deficiency without neurological symptoms involves: Hydroxocobalamin 1 mg intramuscularly three times weekly for two weeks Followed by maintenance doses of 1 mg every three months For patients with neurological symptoms (such as paraesthesia, numbness, cognitive changes, or gait disturbances), more intensive treatment is required: Hydroxocobalamin 1 mg intramuscularly on alternate days until no further improvement occurs Followed by 1 mg every two months for maintenance Pernicious anaemia , an autoimmune condition where the body cannot produce intrinsic factor, requires lifelong treatment

If symptoms persist despite these measures, healthcare providers may consider slower dose titration schedules, temporary dose reductions, or prescribing anti-nausea medications for short-term relief

NNMT is a cytoplasmic enzyme that catalyzes the transfer of a methyl group from S-adenosylmethionine (SAM) to nicotinamide, producing 1-methylnicotinamide (1-MNA) and S-adenosylhomocysteine (SAH)