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Any fraction that is not conjugated, then undergoes CYP 450 metabolic pathway being converted to cytotoxic metabolite, N-acetyl-p-benzoquinone-imine (NAPQI)

Whilst gout flare-ups are not listed as a recognised adverse effect in the Summary of Product Characteristics, some patients have reported joint symptoms during treatment

Gradual Dose Adjustments Digestive side effects are often more noticeable when starting treatment or moving to a higher dose

Cell 81 , 323330 (1995)

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Those allergic to vitamin B12 or cobalt should avoid them