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Serum MMA of 100 to 750 nmol/L, urine MMA of 1 to 4 nmol/L, and serum homocysteine of 6 to 29 mol/L are the reference ranges for most methods.10 If the normalisation of elevated serum homocysteine and MMA levels in response to vitamin B 12 replacement therapy is used as a diagnosis of deficiency, up to 50% of patients may be missed when the diagnosis is based on low vitamin B 12 level (150 pmol/L) alone.18 19 Rise in homocysteine level before increase in MMA is an early indicator of vitamin B 12 deficiency