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Identifying the underlying cause is essential for appropriate management: Dietary history to assess B12 intake Medication review (metformin, proton pump inhibitors, H2-receptor antagonists) Assessment for malabsorption disorders (coeliac disease, Crohn's disease) Previous gastric surgery Autoimmune conditions History of nitrous oxide exposure (recreational or medical) NICE guidance emphasises that treatment should not be delayed whilst awaiting test results if clinical suspicion of B12 deficiency with neurological involvement is high, as delayed treatment may result in irreversible neurological damage