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Elevations in Methylmalonic acid indicate a functional deficiency in B12 (20)

In the pivotal 2018 animal study by Neelakantan et al., systemic treat Mechanism of Action 5-Amino-1MQ inhibits NNMT (nicotinamide N-methyltransferase), an enzyme that catalyzes the N-methylation of nicotinamide using S-adenosylmethionine (SAM) as the methyl donor, producing 1-methylnicotinamide (MNA) and S-adenosylhomocysteine (SAH) as products

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The study also reported that epalrestat had less adverse events than methylcobalamin therapy, though side effects in neither group were serious and were most commonly headache or gastrointestinal upset [26]

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