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But heres the quiet detail most people miss: In certain patients, this combination can contribute to high anion gap metabolic acidosis (5-oxoproline accumulation), especially where there are risk factors like sepsis, malnutrition, renal impairment, chronic alcohol use, or prolonged high-dose paracetamol

1 Vitamin B 12 levels greater than 350 pg per mL seem to be protective against symptoms of vitamin B 12 deficiency

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