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doi: 10.1074/jbc.274.6.3734

Specifically, circulating ALCAR was found to be reduced in patients with severe osteoarthritis pain that did not improve after a total joint replacement (Costello et al., 2020)

The starting dose should be reduced in these patients, and dosage reductions or discontinuation should be considered in patients with excessive somnolence [see DOSAGE AND ADMINISTRATION ]