Hydroxocobalamin is suited for the treatment of all cobalamin (vitamin B₁₂) deficiency states. It is most significant for pernicious anemia which occurs frequently in the elderly and is dependent on autoimmune-induced gastric atrophy with intrinsic factor deficiency. The vitamin is also used for the diagnosis of this disease (shilling test).

Other causes for vitamin B₁₂ deficiencies are operations (gastrectomy, ileal resection), infections (e.g. fish tape worm), and different malabsorption syndromes. Since the supply of vitamin B₁₂ is usually covered by dairy products vegetarians do not normally have a deficiency.

Different studies seem to suggest that a relatively large group of elderly people could have a form of vitamin B₁₂ deficiency. However, the benefit of an administration of therapeutic doses of vitamin B₁₂ has not been demonstrated either for the said disease nor for e.g. multiple sclerosis, neuralgias or other nervous disorders.

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