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NICE Clinical Knowledge Summaries recommend B12 injections for: Pernicious anaemia an autoimmune condition affecting intrinsic factor production Malabsorption syndromes including coeliac disease and inflammatory bowel disease Post-surgical states particularly following gastrectomy or ileal resection Strict vegan diets when oral supplementation proves inadequate, though oral cyanocobalamin is usually sufficient for dietary deficiency Clinical trials demonstrate that B12 injections rapidly improve haematological parameters and neurological symptoms when deficiency is confirmed through blood tests

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instead, they arise spontaneously during cell division (similar to cancer mutations)

doi: 10.1186/s11658-018-0130-0 222 LiGQiuZ

Because these pens deliver fixed doses, using them for microdosing wastes medication (if you use a single pen across multiple weeks, you risk contamination, and the remaining medication goes to waste)