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Rarely, adverse effects can be serious and include: NHS Vitamin B12 deficiency: NHS Vitamin B12 injections:

A lack of response may indicate that the bottleneck is downstream, such as -oxidation enzyme activity, tricarboxylic acid cycle capacity, electron transport chain function, substrate delivery, or cell viability

ORF3a of the COVID-19 virus SARS-CoV-2 blocks HOPS complex-mediated assembly of the SNARE complex required for autolysosome formation

Heightened Sensation and Pleasure : Patients with ED, particularly those with underlying conditions such as diabetes, may experience diminished sensation and pleasure during sexual activity