Biotin- or Thiamine-Responsive Encephalopathy Type 2

Another names
Types
Causes
Symptoms
Diagnostic tests
Core treatment
Drug treatments
Dietary molecular supplements
Drugs (immunity booster / regenerative / stem-cell category)
Surgeries (why and when)
Preventions (practical)
When to see a doctor (or go to the ER)
What to eat and what to avoid
FAQs

Biotin- or Thiamine-Responsive Encephalopathy Type 2 (THMD2) is a rare, inherited brain energy problem. It happens because cells—especially in deep movement-control areas of the brain called the basal ganglia—cannot get enough thiamine (vitamin B1) into the brain. The usual reason is a harmful change in the SLC19A3 gene, which makes the thiamine transporter-2 protein; when this transporter does not work well, thiamine cannot cross into brain cells, energy drops, and nerve cells in the basal ganglia get sick. Many patients improve quickly when treated early and for life with high-dose thiamine and biotin, which is why the condition is called “biotin- or thiamine-responsive.” Without early treatment, attacks can lead to coma or even death. NCBI+1

Biotin- or thiamine-responsive encephalopathy type 2 is a rare, inherited brain energy disorder caused by harmful changes in the SLC19A3 gene. This gene makes thiamine transporter-2, a protein that moves vitamin B1 (thiamine) into cells, especially brain cells. When the transporter does not work well, the brain cannot use sugar efficiently for energy. During stress (fever, infection, fasting), this energy failure can injure deep brain structures (basal ganglia), leading to sudden confusion, seizures, movement problems (dystonia), and trouble speaking or swallowing. The condition often improves dramatically when high-dose thiamine and biotin are started quickly and taken for life. Early recognition and lifelong vitamins prevent relapse and disability. NCBI+2PMC+2

Thiamine (vitamin B1) is a cofactor for key enzymes that turn food into energy inside mitochondria (e.g., pyruvate dehydrogenase). Biotin (vitamin B7) supports carboxylase enzymes in energy and lipid metabolism. In SLC19A3 deficiency, giving much higher-than-normal doses of thiamine (and biotin) increases vitamin availability to the brain despite poor transport, restoring energy pathways and reducing brain injury. NCBI

Another names

Doctors and articles may use different names for the same condition. These include: Biotin-thiamine–responsive basal ganglia disease (BTBGD), Biotin-responsive basal ganglia disease (BBGD), Thiamine metabolism dysfunction syndrome 2 (THMD2), and Thiamine transporter-2 deficiency. All of these refer to the same SLC19A3-related disorder. NCBI

Types

BTBGD shows up in three main ways, mostly defined by the age when symptoms start:

1) Early-infantile (Leigh-like) BTBGD (before 3 months): Babies develop vomiting, poor feeding, weak muscle tone, seizures, severe acidosis, and breathing problems. Sadly, outcomes can be poor even with treatment, which makes quick recognition critical. NCBI

2) Classic childhood BTBGD (usually ages 3–10 years): The most common form. Children have repeated “brain attacks” (subacute encephalopathy) after a trigger like fever or minor injury. They become confused, may have seizures, trouble walking (ataxia), slurred speech, trouble swallowing, eye movement problems, and often painful twisting postures (dystonia) with rigidity. Many signs improve within days if thiamine and biotin are started right away and continued lifelong. NCBI

3) Adult Wernicke-like BTBGD (>10 years): Much rarer. Teenagers or adults can present like Wernicke encephalopathy (ataxia, jerky eye movements, double vision, eyelid droop) and sometimes status epilepticus; they also respond dramatically to high-dose thiamine plus biotin. NCBI

Causes

Strictly speaking, the cause of BTBGD is biallelic (both-copy) harmful variants in SLC19A3. Everything else below are triggers or worsening factors that can bring on an attack or make it worse in someone who already has SLC19A3-related disease:

Biallelic SLC19A3 variants (the fundamental genetic cause). NCBI+1
Febrile illnesses (any fever, including viral infections such as SARS-CoV-2). NCBI
Mild head trauma or bodily injury. NCBI
Intense physical exercise beyond usual levels. NCBI
Psychological stress or other acute stressors. NCBI
Alcohol ingestion in older patients. NCBI
Recent vaccination (likely due to fever/metabolic stress—not because vaccines “cause” the disease). NCBI
Gastroenteritis with dehydration and reduced intake. BioMed Central
Poor adherence or sudden stopping of thiamine/biotin therapy. NCBI
Late diagnosis with long untreated periods. BioMed Central
Intercurrent infections beyond simple fever (e.g., pneumonia) increasing energy demand. BioMed Central
Prolonged fasting during illness (less intake, higher stress). PMC
Very high carbohydrate load during stress (raises thiamine need). PMC
Use of sodium valproate in BTBGD (to be avoided; can worsen dystonia/encephalopathy). NCBI
ACTH treatment for spasms (reported to precipitate status dystonicus in this disorder). NCBI
Genetic founder effect (e.g., p.Thr422Ala variant common in some Saudi families), which raises community risk. NCBI
Co-existing mitochondrial stressors (overlap in energy failure pathways can worsen episodes). NCBI
Medication interruptions during hospitalizations or surgery. NCBI
Delayed treatment during an acute attack (time-sensitive response to high-dose vitamins). PMC
Inadequate dosing (some patients need higher thiamine doses during crises). NCBI+1

Symptoms

Subacute confusion or drowsiness—a brain “fog” that worsens over days after a trigger. NCBI
Seizures (often controllable with standard anti-seizure drugs). NCBI
Ataxia (unsteady gait, clumsy movements). NCBI
Dystonia (painful twisting postures) and rigidity (stiffness) that are very common. NCBI
Dysarthria (slurred or strained speech). NCBI
Dysphagia (trouble swallowing), sometimes with choking. NCBI
Eye movement problems—supranuclear facial palsy, ophthalmoplegia, nystagmus, diplopia. NCBI
Pyramidal signs—hyperreflexia, ankle clonus, up-going toes (Babinski). NCBI
Weakness—hemiparesis or quadriparesis in severe attacks. NCBI
Headache and signs of raised intracranial pressure in some episodes. NCBI
Coma in untreated, severe attacks. NCBI
Feeding difficulty, vomiting, hypotonia, respiratory failure in the early-infantile form. NCBI
Rapid improvement after starting therapy (a helpful clue). NCBI
Recurrent pattern—similar episodes over years if not treated or if treatment lapses. NCBI
Long-term issues if treatment is late—persistent dystonia, weakness, epilepsy, or mild intellectual disability. NCBI

Diagnostic tests

A) Physical examination (bedside)

General neurologic exam: The clinician checks alertness, orientation, memory, and behavior; BTBGD often shows subacute encephalopathy (confusion) after a trigger. NCBI
Motor tone and posture exam: Dystonia and rigidity are looked for directly because they are hallmarks of the childhood form. NCBI
Pyramidal signs exam: Reflex hammer testing may reveal brisk reflexes, ankle clonus, and Babinski signs, showing corticospinal tract involvement. NCBI
Cranial nerve/eye movement exam: Doctors assess gaze, nystagmus, double vision, facial movement, and swallowing—common problem areas in BTBGD. NCBI
Gait and balance exam: Heel-toe walking and general stance can show ataxia; this often improves with proper vitamin therapy. NCBI

B) “Manual” bedside tests (simple functional checks)

Finger-to-nose / heel-to-shin tests: These highlight ataxia and incoordination typical of encephalopathic attacks. NCBI
Rapid alternating movements (dysdiadochokinesia): Slowed or irregular movements point to cerebellar/basal ganglia dysfunction. NCBI
Romberg test: Closing eyes while standing reveals balance problems due to central dysfunction. NCBI
Swallow screen / cough test: Quick bedside checks for dysphagia and aspiration risk during attacks. NCBI
Speech articulation test: Listening for slurred, strained, or hypophonic speech supports involvement of basal ganglia and brainstem pathways. NCBI

C) Laboratory & pathological investigations

Basic blood work during an attack: May be fairly non-specific; lactate or acidosis can be present (especially in the infantile type), but normal results do not exclude BTBGD. NCBI
CSF studies (if performed): Often non-specific; BTBGD is not diagnosed by CSF but other causes can be ruled out. NCBI
Genetic testing for SLC19A3 (gold standard): Confirms the diagnosis by finding two disease-causing variants; this is the key test for certainty. NCBI
Expanded “energy disorder” panels / differential workup: Used to distinguish BTBGD from mitochondrial or organic acid disorders when the picture is unclear. NCBI
Thiamine or thiamine-diphosphate levels: May be normal and are not reliable to rule in/out BTBGD because the problem is transport into the brain, not always a systemic deficiency. NCBI

D) Electrodiagnostic tests

EEG (electroencephalogram): Helpful when seizures or status epilepticus occur; shows seizure patterns and guides anti-seizure therapy. NCBI
Evoked potentials (selected cases): Sometimes used to gauge central pathway function during recovery; supportive rather than diagnostic. PMC

E) Imaging tests

MRI brain—acute stage: Classic finding is bilateral, symmetric swelling and bright signal in the caudate and putamen (basal ganglia) on T2/FLAIR, often with diffusion restriction; this pattern strongly suggests BTBGD in the right clinical setting. BioMed Central+1
MRI brain—other regions: Thalami, brainstem, cerebellum, and cerebral cortex can also be involved; repeat MRIs track recovery after treatment. BioMed Central
MR spectroscopy (when available): May show a lactate peak during an acute crisis, reflecting impaired energy metabolism. BioMed Central

Core treatment

Start immediately (don’t wait for genetic confirmation) in any patient suspected of BTBGD:
Thiamine high dose + Biotin high dose. Typical starting ranges used in reports and reviews: Thiamine 10–40 mg/kg/day divided doses; Biotin 5–10 mg/kg/day divided doses (exact dose individualized by specialist; some patients need even higher thiamine). Taylor & Francis Online+3NCBI+3PMC+3
Acute crisis (fever, new confusion, seizures, dystonia): urgent hospital care, IV thiamine if oral intake is not reliable, treat seizures, correct dehydration, treat infection, and continue biotin. NCBI
Never stop vitamins abruptly; relapses can occur if treatment is missed. NCBI

Non-pharmacological treatments (therapies & other measures)

Emergency illness plan. Families should carry a clear letter that instructs ER teams to give high-dose thiamine promptly during fever or acute neurologic change, plus standard sepsis/encephalitis work-up. This prevents delays that risk permanent injury. NCBI
Rapid fever and infection control. Early evaluation and treatment of infections reduce metabolic stress that can trigger relapses in BTBGD. Maintain hydration and antipyretic use as advised. NCBI
Nutrition optimization. Regular meals with adequate calories to avoid fasting stress; consider dietitian support to ensure balanced macronutrients and micronutrients alongside prescribed high-dose vitamins. NCBI
Sick-day rules. During vomiting or poor intake, switch to hospital-supervised IV thiamine, maintain fluids, and monitor electrolytes and glucose; resume full oral dosing ASAP. NCBI
Physiotherapy. Target dystonia, spasticity, and gait issues with stretching, strengthening, and task-specific training to regain function after crises. Lippincott Journals
Occupational therapy. Fine-motor retraining, adaptive utensils, and assistive technology can restore daily independence after acute episodes. Lippincott Journals
Speech-language therapy. For dysarthria, dysphagia, and language deficits; includes safe-swallow strategies to reduce aspiration risk. Lippincott Journals
Neuropsychology & school supports. Cognitive rehab, individualized education plans, and pacing to manage fatigue and processing speed after encephalopathy. Lippincott Journals
Avoid prolonged fasting. Practical steps: small bedtime snack, sick-day glucose monitoring as instructed, and peri-procedural fasting minimization. NCBI
Peri-anesthesia precautions. Coordinate with anesthesia to minimize fasting and stress; continue vitamins; ensure IV thiamine coverage if NPO. NCBI
Vaccinations. Keep routine immunizations current to prevent infections that can trigger decompensation; there is no disease-specific contraindication to routine vaccines. NCBI
Fever plan at home. Early antipyretics, oral fluids, and low threshold to seek care if neurologic symptoms appear. NCBI
Genetic counseling. Autosomal recessive inheritance; discuss carrier testing, options for future pregnancy, and testing at-risk siblings. NCBI
Medical alert ID. Identifies the condition and directs urgent thiamine dosing in emergencies. NCBI
MRI & follow-up imaging. Basal ganglia lesions (especially caudate and putamen) during crises; follow-up helps assess recovery and guide therapy. NCBI
Regular neurology/metabolic clinic visits. Monitor growth, development, movement symptoms, breakthrough events, and adherence to vitamins. NCBI
Dysphagia management. Modified textures or temporary tube feeding in severe episodes to ensure safe nutrition while continuing treatment. NCBI
Mental health support. Counseling for anxiety/depression around relapses; caregiver support reduces burnout and improves adherence. Lippincott Journals
Community rehabilitation programs. Intensive therapy blocks after hospitalizations to speed functional recovery and reduce long-term disability. Lippincott Journals
Adherence tools. Pill organizers, phone reminders, and pharmacy blister packs help ensure lifelong daily dosing without gaps. NCBI

Drug treatments

Important: Only high-dose thiamine and biotin are disease-modifying in SLC19A3 deficiency; the remaining medicines are supportive/symptomatic (e.g., seizures, dystonia, nausea). Doses below are typical ranges; final choices and exact dosing must be individualized by a specialist.

Thiamine (Vitamin B1).
Class: vitamin. Purpose: core therapy to bypass impaired transport and restore energy metabolism. Typical dose: 10–40 mg/kg/day PO divided (some patients require higher); IV in acute crisis when oral is not reliable. Mechanism: cofactor for pyruvate dehydrogenase and other enzymes; improves neuronal ATP generation. Key safety: rare IV hypersensitivity; monitor if parenteral. FDA labeling for thiamine injection describes indications, warnings (including rare anaphylactoid reactions). NCBI+2FDA Access Data+2
Biotin (Vitamin B7).
Class: vitamin. Purpose: adjunct core therapy; improves energetics via carboxylase enzymes. Typical dose: 5–10 mg/kg/day PO divided; lifelong. Mechanism: cofactor for carboxylases. Safety: generally well tolerated. FDA recognizes biotin as a nutrient; in parenteral multivitamins it is included per label specifications. NCBI+2FDA Access Data+2
Levetiracetam (for seizures/status prevention).
Class: antiseizure (SV2A modulator). Typical adult starting dose 500 mg BID (pediatric weight-based); IV option in acute care. Purpose: control acute and chronic seizures common during decompensation. Key adverse effects: irritability, somnolence. FDA labeling provides dosing and safety. FDA Label Search
Diazepam rectal gel (rescue for prolonged seizures).
Class: benzodiazepine (GABA-A modulator). Dose: weight-based per FDA label for seizure clusters. Purpose: home/ER rescue to stop clusters. AEs: drowsiness, respiratory depression if combined with other CNS depressants. FDA label (Diastat) details dosing/safety. FDA Label Search
Midazolam nasal (rescue).
Class: benzodiazepine. Dose: fixed unit doses per FDA label for seizure clusters. AEs: sedation, respiratory depression. FDA labeling available. FDA Label Search
Valproate (maintenance antiseizure, specialist decision).
Class: broad-spectrum antiseizure. Dose: individualized mg/kg/day; monitor liver function and ammonia. AEs: hepatotoxicity risk (especially in younger children), thrombocytopenia, teratogenicity; use only with careful specialist oversight. FDA labeling provides guidance. FDA Label Search
Topiramate (maintenance antiseizure).
Class: carbonic anhydrase–modulating antiseizure. Dose: titrated mg/kg/day. AEs: paresthesias, cognitive slowing, kidney stones. FDA labeling provides dosing/safety. FDA Label Search
Lacosamide (adjunctive focal-seizure control).
Class: sodium-channel modulator. Dose: weight-based; IV/PO forms. AEs: dizziness, PR-interval prolongation. FDA label is authoritative. FDA Label Search
Clonazepam (adjunct for myoclonus/dystonia).
Class: benzodiazepine. Dose: individualized; caution sedation. FDA labeling available. FDA Label Search
Phenobarbital (neonatal/infantile seizures).
Class: barbiturate antiseizure. Dose: weight-based loading/maintenance; monitor sedation and breathing. FDA labeling available. FDA Label Search
Baclofen (spasticity/dystonia relief).
Class: GABA-B agonist antispasmodic. Dose: gradual titration; watch sedation/weakness. FDA label provides warnings. FDA Label Search
Trihexyphenidyl (dystonia).
Class: anticholinergic. Dose: careful titration; AEs: dry mouth, blurry vision. FDA labeling via DailyMed/labels database. FDA Label Search
Botulinum toxin injections (focal dystonia/sialorrhea).
Class: neuromuscular blocking biologic. Dose: per muscle by specialist. AEs: local weakness. FDA labeling covers indications and safety. FDA Label Search
Ondansetron (antiemetic during crises to maintain oral therapy).
Class: 5-HT3 antagonist. Dose: weight-based. AEs: constipation, QT prolongation. FDA labeling is reference. FDA Label Search
Proton-pump inhibitor (e.g., omeprazole) during prolonged illness if gastritis or reflux threatens oral intake; use shortest necessary duration. FDA labeling available. FDA Label Search
Acetaminophen for fever per weight-based dosing to reduce metabolic stress; avoid overdosing; heed liver warnings per FDA label. FDA Label Search
Ibuprofen for fever/inflammation if not contraindicated; renal/GI cautions per FDA labeling. FDA Label Search
Amoxicillin-clavulanate (representative antibiotic) when bacterial infection is diagnosed; choice guided by local guidelines—goal is rapid control of infection stress. FDA labeling provides dosing/safety. FDA Label Search
Inpatient IV fluids with dextrose (medical order, not OTC drug) during acute decompensation to prevent catabolism while IV thiamine is given. Standard acute encephalopathy care principles apply. NCBI
Parenteral multivitamin (e.g., M.V.I./Infuvite) when NPO to ensure biotin and thiamine coverage alongside additional high-dose thiamine per protocol. FDA labels detail composition and warnings. FDA Access Data+1

Note: The only proven disease-modifying therapy is high-dose thiamine ± biotin. Antiseizure and other drugs are supportive; they do not replace vitamins. Early, adequate thiamine is crucial; some patients require above 40 mg/kg/day to achieve remission, per recent reports. Always individualize with a metabolic/neurology specialist. PubMed+1

Dietary molecular supplements

These are adjuncts with general mitochondrial/neurologic rationale; none substitute for thiamine/biotin. Discuss with your clinician.

Riboflavin (B2): cofactor for electron transport enzymes; typical 10–50 mg/day in children (higher in adults). May support cellular energy. NCBI
Coenzyme Q10: component of respiratory chain; 2–10 mg/kg/day divided; sometimes used in mitochondrial support. NCBI
L-carnitine: shuttles fatty acids into mitochondria; ~50–100 mg/kg/day; consider if poor intake/illness. NCBI
Alpha-lipoic acid: antioxidant/cofactor; adult 300–600 mg/day; theoretical support for redox balance. NCBI
Magnesium: cofactor for many enzymes including thiamine-dependent steps; dose per age/renal function. NCBI
Vitamin D3: bone/immune support; supplement to reach normal serum 25-OH D. NCBI
Omega-3 fatty acids (EPA/DHA): membrane and anti-inflammatory effects; typical pediatric 20–50 mg/kg/day combined EPA+DHA. NCBI
Folate (B9): DNA/mitochondrial function; dose per age; avoid excess without indication. NCBI
Vitamin B6 (pyridoxine): neurotransmitter synthesis; low-dose adjunct if deficient; high doses risk neuropathy. NCBI
Multivitamin with minerals: Insurance against gaps; does not replace high-dose thiamine/biotin. FDA Access Data

Drugs (immunity booster / regenerative / stem-cell category)

There are no approved immune “boosters,” regenerative, or stem-cell drugs for BTBGD. Management relies on vitamins plus supportive care. The items below are contextual and used for other indications; they are not disease-modifying for BTBGD and should not be started without specialist advice.

Vaccines (routine schedule). Not a “drug” for BTBGD itself, but essential preventive immunotherapy to reduce infection-triggered crises. NCBI
IV immunoglobulin (IVIG). Only if a separate, proven immunodeficiency exists—not standard for BTBGD. NCBI
Erythropoietin or G-CSF. Not for BTBGD; listed only to clarify lack of indication. NCBI
Stem-cell therapies. No evidence or approval in BTBGD; avoid outside trials with rigorous oversight. NCBI
Neuromodulation (e.g., DBS) for refractory dystonia. Extremely rare, case-by-case after maximal vitamin therapy; not first-line. NCBI
Experimental metabolic cofactors (e.g., dichloroacetate). Not recommended; no BTBGD evidence; risks can outweigh benefits. NCBI

Surgeries (why and when)

Surgery is not routine for BTBGD. Rare situations:

Gastrostomy tube if severe, persistent dysphagia or poor intake threatens nutrition/medication adherence. Goal: safe, reliable delivery of vitamins and calories. NCBI
Tracheostomy only for chronic airway protection in profound, unresolving dysphagia. NCBI
Orthopedic procedures for fixed contractures after long-standing spasticity; combined with rehab and baclofen/botulinum toxin. Lippincott Journals
Deep brain stimulation (DBS) for severe, refractory dystonia after full vitamin optimization (very uncommon). NCBI
Feeding tube revision or antireflux surgery if recurrent aspiration persists despite medical therapy. NCBI

Preventions (practical)

Never miss thiamine/biotin doses; set reminders. NCBI
Treat fevers/infections early; seek care promptly for neurologic change. NCBI
Avoid fasting; plan for procedures to minimize NPO time and give IV thiamine. NCBI
Keep vaccinations current. NCBI
Carry an emergency letter/ID detailing the thiamine protocol. NCBI
Maintain regular follow-up with neurology/metabolic clinic. NCBI
Have home rescue meds for seizures (e.g., diazepam or midazolam) with training. FDA Label Search
Hydrate well during illness; use oral rehydration and seek IV fluids early if needed. NCBI
School/work plans for rest breaks and quick access to care. Lippincott Journals
Family screening to identify affected siblings early. NCBI

When to see a doctor (or go to the ER)

Immediately (ER): new confusion, seizures, abnormal movements, severe headache, high fever, trouble swallowing or breathing, inability to take oral vitamins. These can signal an acute metabolic crisis and need urgent thiamine. NCBI
Soon (clinic): increasing fatigue, behavior or school decline, subtle movement changes, frequent vomiting, medication access problems, or any dose interruptions. Early adjustment prevents relapse. NCBI

What to eat and what to avoid

Eat: (1) regular meals/snacks with balanced carbs, protein, fat; (2) adequate calories during growth/illness; (3) foods naturally containing B-vitamins (whole grains, legumes, eggs, dairy, meat) in addition to prescribed high-dose vitamins; (4) plenty of fluids; (5) easy-to-swallow textures during recovery. NCBI
Avoid/limit: (6) prolonged fasting or “skipping meals”; (7) dehydration; (8) unnecessary restrictive fad diets; (9) alcohol in adolescents/adults (can worsen thiamine status); (10) stopping vitamins because “symptoms improved.” NCBI

FAQs

Is this condition curable? It is treatable. Many people do very well if high-dose thiamine and biotin start early and continue for life. Stopping can cause relapse. NCBI
How fast do vitamins work? Often within days to weeks; MRI changes may take longer. Early treatment gives the best outcomes. NCBI
What dose do I need? Doses are individualized; some need >40 mg/kg/day thiamine to control symptoms. Your team will adjust. PubMed+1
Do I need biotin if thiamine helps? Yes—standard care uses both, unless your specialist advises otherwise. NCBI
Will my child outgrow it? No; lifelong therapy is recommended to prevent relapses. NCBI
Can infections trigger attacks? Yes; fever/illness increases metabolic stress—follow your emergency plan. NCBI
Is genetic testing necessary? It confirms the diagnosis (SLC19A3 variants) and helps family planning, but treatment should not wait for results if BTBGD is suspected. NCBI
Are antiseizure medicines permanent? Not always; some patients taper after stabilization, guided by EEG/clinical course. Vitamins remain lifelong. NCBI
Any special anesthesia concerns? Avoid prolonged fasting; ensure peri-operative IV thiamine and resume oral dosing promptly. NCBI
Are there approved stem-cell or gene therapies? No approved therapies yet for BTBGD. NCBI
What does the MRI show? Reversible lesions in the basal ganglia (caudate/putamen) during crises; changes improve with treatment. NCBI
Can adults present for the first time? Rarely, yes—spectrum includes infantile, childhood, and occasional adult-onset forms. NCBI
Is diet alone enough? No. A healthy diet helps, but pharmacologic-dose vitamins are essential. NCBI
Is IV thiamine safe? Generally yes, especially in emergencies; rare hypersensitivity reactions are described in FDA labeling—teams monitor closely. FDA Access Data
Where can clinicians read more? GeneReviews and recent reviews summarize diagnosis, dosing ranges, and outcomes; FDA labels cover vitamin and adjunct medication safety. NCBI+2BioMed Central+2

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