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[8] [9] The risk of low blood sugar increases meaningfully only when these agents are combined with insulin or sulfonylureas

[16] Although cyanocobalamin lacks a defined upper-toxicity threshold due to its water solubility and renal elimination, exceptionally high cumulative doses have been temporally associated with acneiform eruptions, altered potassium homeostasis, and theoretical thrombotic risk, emphasizing the importance of evidence-based dosing

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However, no peer-reviewed human clinical trials have been published to date

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Patients can continue on topical therapy alone