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The specific reasons identified include intensive insulin therapy, decreased renal function, severe liver disease, alcohol ingestion, defective counter regulatory hormone release, missing meals/fasting, and gastroparesis

The driver may be mast-cell-mediated or systemic rather than NF-B-local, so dose escalation will not reach it see the mast-cell note under Phenotype Considerations

Physicians typically prescribe these injections in individuals with low B12 levels from inadequate diet, illness, or age-related changes

Most common is injection site irritation (redness, swelling, or itching)