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When a person with Down syndrome has vitamin B12 and/or folate deficiency, the increase in the homocysteine level may not be great enough to overcome this starting low value of homocysteine
/Paris/, 1993, 87, 313327
Patients taking long-term medications that reduce stomach acid, including proton pump inhibitors (omeprazole, lansoprazole) or H2-receptor antagonists (famotidine), may also develop deficiency after several years of use
Trace elements that have the potential to limit this efficiency include cobalt (converted to vitamin B12 in the lamb) and selenium
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