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Ultra-High Dose Vitamin B12 Slows Progression of ALS

Cyanocobalamin injection USP 1,000 mcg/mL is FDA-approved (e.g., ANDA 080737) and cyanocobalamin nasal spray (Nascobal, NDA 021642) is FDA-approved for B12 deficiency

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The most dangerous window is the first 48 hours to two weeks of correcting severe deficiency, when restarted red cell production can cause hypokalemia (with reported fatal arrhythmias), rebound thrombocytosis, gout flares, and pulmonary edema in fragile patients—so potassium should be checked at baseline and around day 3–7 in severely anemic patients (hemoglobin 6–8), those on diuretics, or those with kidney disease