intranasal administration of Nascobal Nasal Spray for the remainder of their lives.
Failure to do so will result in return of the anemia and in development of incapacitating
and irreversible damage to the nerves of the spinal cord. Also, patients should be warned

about the danger of taking folic acid in place of vitamin B12, because the former may

prevent anemia but allow progression of subacute combined degeneration of the spinal

cord. (Hot foods may cause nasal secretions and a resulting loss of medication; therefore,
patients should be told to administer Nascobal Nasal Spray at least one hour before or
one hour after ingestion of hot foods or liquids).

A vegetarian diet which contains no animal products (including milk products or eggs)

does not supply any vitamin B12. Therefore, patients following such a diet should be

advised to take Nascobal Nasal Spray weekly. The need for vitamin B12 is increased by

pregnancy and lactation. Deficiency has been recognized in infants of vegetarian mothers
who were breast fed, even though the mothers had no symptoms of deficiency at the time.

Because the nasal dosage forms of vitamin B12 have a lower absorption than

intramuscular dosage, nasal dosage forms are administered weekly, rather than the

monthly intramuscular dosage. As shown in the Figure above, at the end of a month,

weekly nasal administration results in significantly higher serum vitamin B12 levels than

after intramuscular administration. The patient should also understand the importance of

returning for follow-up blood tests every 3 to 6 months to confirm adequacy of the

therapy.

Careful instructions on the actuator assembly, removal of the safety clip, priming of the

actuator and nasal administration of Nascobal Nasal Spray should be given to the patient.
Although instructions for patients are supplied with individual bottles, procedures for use
should be demonstrated to each patient.