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Why One Therapy Alone May Not Be Enough Many patients start TRT and experience significant improvements in energy, libido, and strength, but still report: Persistent poor sleep quality Slower-than-expected recovery Incomplete body composition changes Plateau in fat loss despite improved muscle mass These residual symptoms often reflect concurrent GH deficiency that TRT protocols alone cannot address

So, during DR, NAD + -dependent PDC and citric acid cycle dehydrogenases IDH3, -ketoglutarate dehydrogenase (OGDH), and MDH2 may be slightly inhibited, leading to decreased flux through the MAS, even though MDH2 is not the rate-limiting step of the MAS, contributing to the reduction in the brain cytoplasmic [NAD + ]/[NADH] observed during DR

10.1111/acel.12768 91 LiX.GengJ.ZhaoJ.NiQ.ZhaoC.ZhengY.et al (2019)

The fifty-three-year-old physician whose shoulder finally starts cooperating