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If a patient was new to a health system where the medication was prescribed, they may be misclassified
Since D2HG and L2HG are indistinguishable in standard LC-MS, to determine which 2HG enantiomer(s) is affected, we adapted a chiral N-(p-toluenesulfonyl)-L-phenylalanyl chloride (TSPC) derivation followed by liquid chromatography with tandem mass spectrometry (LC-MS/MS) analysis 24,40
Figure 3: Stepwise treatment result evolution
The current formulary-driven switch, in contrast, represents a payer-initiated formulary shift rather than a supply-side limitation
