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Because it doesnt require conversion, Methyl B12 is more effective for many people especially those with genetic variations in methylation enzymes (like MTHFR)

The Wilderness Medical Society (WMS) 2024 update and its JAMA synopsis emphasize gradual ascent as first-line prevention and recommend acetazolamide (and dexamethasone in selected circumstances) for pharmacologic prophylaxis

bretylium-like effect It can produce an initial pressor effect (due to tyramine & cocaine like actions), but later results in sympathoplegia (due to reserpine & bretylium like effects)