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rare adverse effects include hypersensitivity reactions (including anaphylaxis) and injection-site reactions Report suspected adverse reactions via the MHRA Yellow Card Scheme (yellowcard.mhra.gov.uk) IM hydroxocobalamin is preferred for treatment during pregnancy and breastfeeding Monitoring and follow-up includes: Repeat FBC after 8 weeks to confirm haematological response Assessment of symptom improvement, particularly neurological features No routine monitoring of serum B12 levels once treatment is established, as these become unreliable Addressing underlying causes is essential: Dietary counselling for vegans and vegetarians Review of medications (metformin, PPIs) where appropriate Management of gastrointestinal conditions Cessation of nitrous oxide use if relevant Screening for other autoimmune conditions in pernicious anaemia Patients should be informed that whilst haematological improvements occur within weeks, neurological recovery may take months and may be incomplete if deficiency was prolonged

Correction of the underlying cause typically resolves the erythrocytosis

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