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Among the proteins with increased expression in ME/CFS were 3-hydroxybutyrate dehydrogenase type 1 (BDH1) and acetyl-CoA acetyltransferase 2 (ACAT2), both of which are integral to fatty acid metabolism and processing of ketone bodies

[1] Compounded medications are not subject to the same rigorous manufacturing standards and quality controls as FDA-approved drugs, which raises important considerations regarding consistency, sterility, and potency

This means that the vitamin B12 does not have to cross digestive barriers where loss of potency can occur

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This dual dependency on CYP3A4 and P-gp creates a well-defined vulnerability