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It is to be noted that the BCKDH reaction is essentially irreversible in mammalian cells such that BCKA synthesis depends on essential amino acids, BCAAs, due to the lack of BCKAs de novo synthetases

Obtain a serum B12 level and peripheral blood count one month after treatment initiation, then subsequently at intervals of 3 to 6 months [see Warnings and Precautions (5.3)]