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Additional tests may include: Serum folate — as folate deficiency can present similarly Thyroid function tests and ferritin (iron stores) — particularly relevant when investigating hair loss Holotranscobalamin (active B12) and/or methylmalonic acid (MMA) or homocysteine — these may be used to help confirm deficiency in borderline cases where serum B12 alone is inconclusive, in line with British Society for Haematology (BSH) guidance Intrinsic factor antibodies and gastric parietal cell antibodies — if pernicious anaemia is suspected As outlined in NICE Clinical Knowledge Summary (CKS): Anaemia — B12 and folate deficiency, clinicians should interpret blood results alongside the clinical context, as some individuals may experience symptoms even when serum B12 falls within the lower end of the normal range

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Direct comparison studies testing simultaneous versus sequential protocols would provide definitive guidance, but current evidence supports either approach

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