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Safety considerations: Common side effects of hydroxocobalamin include injection site pain, mild diarrhoea, itching, and rash Rarely, anaphylaxis may occur In severe deficiency, monitoring potassium levels may be necessary as rapid cell production can cause hypokalaemia Suspected adverse reactions should be reported via the MHRA Yellow Card Scheme If symptoms fail to improve or progress despite adequate treatment, alternative diagnoses should be reconsidered, and referral to neurology may be appropriate

Doses are large enough to measure precisely with a standard insulin syringe, and small enough that injection volumes stay comfortable

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doi:10.1111/jth.12986 Betts JG, Young KA, Wise JA, et al