From the Guidelines
Homocysteine levels should be managed through dietary changes and supplementation with B vitamins, particularly folate and cobalamin, when moderate homocysteinaemia is present, as this can help reduce the risk of cardiovascular disease and other health problems. To manage elevated homocysteine levels, it is essential to understand the underlying cause, as treatment should focus on reversing this cause 1. Moderate homocysteinaemia, defined as fasting plasma total homocysteine levels between 15-30 mmol/L, can often be due to poor diet, mild folate or cobalamin deficiency, or other factors such as hypothyroidism or impaired renal function 1. When the cause of moderate homocysteinaemia is established, the best treatment approach is to address this underlying cause. For instance, if the elevated homocysteine levels are due to a poor diet, increasing consumption of foods rich in B vitamins such as leafy greens, legumes, fruits, whole grains, and animal proteins can help lower homocysteine levels 1. Additionally, supplementation with folic acid at a dose of 400 mg/day can lead to a 25-30% reduction in plasma homocysteine levels, and co-administration of cobalamin (0.02-1 mg/day) can achieve an additional 7% reduction 1. In cases where elevated homocysteine levels are due to the presence of the MTHFR 677TT genotype, oral 5-MTHF treatment should be considered 1. It is crucial to note that while pharmacological treatment with folic acid and B vitamins may not be recommended for the general population, it should be considered for individuals with homocysteinaemia 1. Key points to consider in managing homocysteine levels include:
- Identifying and addressing the underlying cause of elevated homocysteine levels
- Dietary changes to increase B vitamin intake
- Supplementation with folic acid and cobalamin as necessary
- Regular monitoring of homocysteine levels, especially for those with known elevations or risk factors
- Supervision by a healthcare provider for treatment and management.
From the Research
Homocysteine Overview
- Homocysteine is an amino acid in the blood that, when elevated, is linked to a higher risk of cardiovascular disease and stroke 2, 3, 4.
- Hyperhomocysteinemia can be caused by genetic defects, deficiencies in folic acid and/or vitamin B12, renal failure, and certain medications or metabolic alterations 3.
Reduction of Homocysteine Levels
- Folic acid supplementation has been shown to effectively lower plasma homocysteine concentrations in healthy older adults, with a daily dose of approximately 400 micrograms being the minimum required for adequate reduction 2.
- Vitamin B12 and, to a lesser extent, vitamin B6 are also effective at lowering plasma homocysteine, especially after homocysteine lowering by folic acid in individuals with raised plasma homocysteine 4.
- Supplementation with vitamins B6, B12, and/or folic acid has been found to reduce homocysteine levels in patients with mild cognitive impairment, with a mean decline of 31.9% in homocysteine concentration observed in the intervention arms 5.
Homocysteine and Chronic Kidney Disease
- Hyperhomocysteinemia is commonly found in patients with chronic kidney disease (CKD) due to impaired renal metabolism and reduced renal excretion 6.
- Folic acid and vitamin B12 supplementation may be considered as adjunctive therapy in patients with CKD to reduce hyperhomocysteinemia and potentially lower cardiovascular risk 6.
Key Findings
- The minimum dose of folic acid required for maximal reduction of homocysteine concentrations is estimated to be 392 micrograms per day 2.
- A combination of pyridoxine and folic acid may be effective in treating primary hyperhomocysteinemia, with a recommended dose of 50 mg pyridoxine and 5 mg folic acid per day 3.
- Riboflavin supplementation may be effective at lowering plasma homocysteine only in individuals homozygous for the T allele of the C677T polymorphism of the methylenetetrahydrofolate reductase (MTHFR) gene 4.