Table 10 SUGGESTEDTREATMENT GUIDELINES FOR HHcy
Fasting plasma total Hcy (tHcy) levels: | ||
The prevalence of HHcy in the general population is between five and ten percent (using a threshold set at the 90th to 95th percentile of 15 micromol / liter). Keep in mind that this figure may escalate to, as high as, 30% to 40 % in the elderly. | ||
Normal: 5–15 micromol/L (Based on table below 5 – 9 micromol/L) | ||
Moderate: 15–30 micromol/L | ||
Intermediate: 31–100 micromol/L | ||
Severe: >100 micromol/L | ||
Goal of Treatment: 9 micromol / Liter or less. (Based on table below) | ||
HYPERHOMOCYSTEINEMIA | ||
Check for secondary causes: | ||
Renal dysfunction | ||
Folate B12 B6 deficiency * Significant to exclude Pernicious Anemia | ||
Hypothyroidism and others (table 2) | ||
GLOBAL RISK REDUCTION (table 9) | ||
1. Diet rich in B vitamins and folate [IF NOT TO GOAL] | ||
2. Advance to multivitamin therapy 400 microgram folic acid, 2 mg B6, and 6 mg B12. [IF NOT TO GOAL] | ||
3. Advance to prescription strength 1 mg folic acid, 25 mg B6, and 500 microgram B12. [IF NOT TO GOAL] | ||
4. Advance to 2–5 mg folic acid, B12 to 1,000 microgram, and B6 25 – 100 mg. | ||
5. Sublingual and injectable B12 may be used if necessary, as well as, a trial of Betaine hydrocloride in intractable cases. Higher doses of up to 15 mg of folic acid may be required in hemodialysis patients. | ||
6. Global Risk Reduction (table 9) | ||
Consider: Total Hcy is associated with a graded mortality risk. Patients with known CAD have the following graded risk [95, 97]: | ||
tHCY in micromol/liter | Relative risk of all cause death. | Relative risk of CAD death |
< 9 | 1.0 | 1.0 |
9 – 14.9 | 1.9 (0.7 – 5.1) | 2.3 (0.7 – 7.7) |
15 – 19.9 | 2.8 (0.9 – 9.0) | 2.5 (0.6 – 10.5) |
> 20 | 4.5 (1.2 – 16.6) | 7.8 (1.7 – 35.1) |