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The metabolism and elimination of NAD+ (and its by-products) could be altered in advanced hepatic or renal dysfunction, and high-dose NAD+ might theoretically affect cardiovascular dynamics, so practitioners generally avoid or closely supervise NAD+ use in such settings

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Those most at risk include vegans and vegetarians, people with digestive conditions such as Crohn's disease, coeliac disease or IBS, those taking long-term metformin or proton pump inhibitors, older adults whose ability to absorb B12 through the gut declines naturally with age, those with pernicious anaemia, and anyone with a history of chronic alcohol use