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(Even a few months of high-dose continuing steroid can cause bone loss.) Patients are advised to get adequate calcium/vitamin D, and periodic bone density monitoring is prudent

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If corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity, close observation is necessary since reactivation of the disease may occur

Decreased stomach acid Atrophic gastritis Autoimmune pernicious anaemia Helicobacter pylori Gastrectomy, partial or complete Gastric bypass surgery (weight loss) Intestinal resection Partial or complete ileectomy Gastrointestinal neoplasms Malnutrition Eating disorders anorexia bulimia Inadequate diet Vegetarianism / veganism Malabsorption syndromes Alcoholism Crohns disease Coeliac disease (gluten enteropathy) Dipphyllobothrium infection blind loop syndrome diverticulosis inflammatory bowel disease small bowel overgrowth tropical sprue gastric irradiation ileal irradiation (bladder,cervix, uterus,prostate) Inborn errors of B12 metabolism Transcobalamin II deficiency Pancreatic exocrine insufficiency & Chronic pancreatitis Imerslund Gresbeck syndrome Zollinger Ellison Syndrome Bacterial overgrowth (small bowel) Fish tapeworm Advanced liver disease Drug induced causes Please note

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If fatigue is part of the story, the team can review whether B12 fits the picture or whether broader evaluation would be smarter