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Homocysteine: a Risk Factor Worth Treating

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Homocysteine: a Risk Factor Worth Treating Volume 6, No.1 2004 A CONCISE UPDATE OF IMPORTANT ISSUES CONCERNING NATURAL HEALTH INGREDIENTS Thomas G. Guilliams Ph.D. HOMOCYSTEINE: A RISK FACTOR WORTH TREATING As an emerging independent risk factor for cardiovascular disease and other aging diseases such as Alzheimer’s, homocysteine related research has generated a vast amount of literature and sparked a vigorous debate over the past decade. In fact, a comprehensive textbook is now available describing the role of homocysteine in health and disease (3). This review will survey the history of homocysteine research, the rationale for considering homocysteine as a causative agent, rather than just a marker for vascular diseases; and review the intervention trials for lowering homocysteine in patients. Homocysteine is a sulfur amino acid and a normal intermediate lesions in these individuals and he further postulated that in methionine metabolism. When excess homocysteine is made and moderately elevated homocysteine due to heterozygous mutations not readily converted into methionine or cysteine, it is excreted out of in homocysteine related genes or poor vitamin status would also lead the tightly regulated cell environment into the blood. It is the role of to increased risk of cardiovascular disease (4). the liver and kidney to remove excess homocysteine from the blood. By the early 1990’s, elevated homocysteine was being In many individuals with in-born errors of homocysteine considered an independent risk factor for cardiovascular disease metabolism, kidney or liver disease, nutrient deficiencies or (along with cholesterol and other lipid markers, age, gender, smoking concomitant ingestion of certain pharmaceuticals, homocysteine status, obesity, hypertension and diabetes). A prospective study of levels can rise beyond normal levels and lead to adverse health male physicians in 1992 found that acute myocardial infarction (MI) outcomes. or death due to coronary disease was statistically related to increased The role of elevated blood homocysteine homocysteine levels, after adjusting for other levels in clinical practice is still being debated. Figure 1 risk factors (5). In 1995, a key meta-analysis The central question is whether it is clinically was published by JAMA in which 27 studies beneficial to measure for and treat elevated levels involving over 4,000 subjects concluded that of homocysteine (1-2). While some consider homocysteine was an independent risk factor homocysteine as simply a marker but not a for cardiovascular disease (CVD) and treatable causative agent, or ignore homocysteine estimated that 10% of the population’s CVD as an innocuous metabolite that is coincidental risk is attributable to elevated homocysteine to other treatable risk factors; the weight of the (6). In total there are nearly 100 retrospective scientific evidence suggests otherwise. and prospective clinical studies linking homocysteine levels and increase risk of Brief Historical Perspective cardiovascular outcomes and numerous In the early 1960’s several inborn errors of reviews of the literature available (7-11). homocysteine metabolism were described in According to a recent meta-analysis of young children leading to extremely high levels of the data, a causal relationship between homocysteine— resulting in mental retardation and early death, homocysteine and cardiovascular disease is highly likely (12). The caused usually by some cardiovascular event. After examining many authors conclude that lowering homocysteine 3 µmol/L would cases and performing autopsies on several young people, Kilmer reduce the risk of ischemic heart disease by 16%, deep vein McCully concluded, as did others, that the severely elevated levels of thrombosis by 25% and stroke by 24%. homocysteine were directly responsible for the various vascular Volume 6, No.1 (continued from page 1) Homocysteine Metabolism Figure 2 (p.6) shows the basic metabolic pathways concerning IN MY OPINION homocysteine. Homocysteine is an intermediate in methionine metabolism, the latter being derived primarily from dietary protein. Saw palmetto extracts lower urinary This pathway involves the formation of S-adenosylmethionine (SAM) symptoms in patients diagnosed with benign which subsequently transfers a methyl group to any number of several prostatic hyperplasia (BPH). This is a truthful methyl acceptor molecules (DNA, proteins, neurotransmitters) and statement and can be shown by reliable clinical forms adenosylhomocysteine, which is subsequently converted to trials published in peer-reviewed journals. And homocysteine. even though saw palmetto extracts are classified as Homocysteine is then either converted back to methionine by dietary supplements if a manufacturer were to remethylation or further metabolized to cysteine via the produce a product with the above statement on transsulfuration pathway. Remethylation primarily occurs when a the label (or in other point of purchase literature) methyl group is transferred from methyltetrahydrofolate (MTHF), the the FDA would consider this an unapproved drug. active form of the folic acid/folate cycle, by a methyltransferase Why? Because for FDA, a drug is not the substance enzyme requiring cobalamin (vitamin B12) as a necessary cofactor. A per se, but what can be said about the substance. secondary remethylation pathway, active primarily in liver and kidney If the substance is intended to diagnose, prevent cells, uses trimethylglycine (a.k.a. betaine) as the methyl donor. The or cure a known disease, then it is a drug and transsulfuration pathway requires two enzymatic reactions, both of requires FDA drug approval. This is why which require the cofactor pyridoxal-5-phospate- the active form of pharmaceutical companies spend as much time vitamin B6. inventing new diseases as they do new drugs. That said, dietary supplements (nutraceuticals as they Measuring Homocysteine Levels might be called) are substances, we are told, not Homocysteine (Hcy) levels can easily be measured in most intended to diagnose, prevent or cure any known laboratories which test for other blood chemicals. It is important to disease. Apparently saw palmetto is fine when it is follow the instructions provided by the lab to ensure consistent 2 being used by persons without BPH, or for those homocysteine measurements. Often, incorrect values are a result of who treat BPH unintentionally. With this type of poor collection, poor post-collection procedures (not centrifuging or logic water is fine when used “to support normal storing on ice soon enough), or non-fasting conditions. Average hydration” but becomes an unapproved drug fasting plasma total homocysteine for “healthy” subjects in the when recommended to hydrate persons with current folic acid fortified U.S. population is between 6 and 12 diarrhea. µmol/L (or µM). In normal subjects, 75% of total plasma Hcy (tHcy) As it turns out, this may be one of the is bound to various proteins (primarily albumen) via disulfide bonds. big issues facing the use of nutraceuticals in the The remaining 25% free Hcy is found mostly as oxidized future and it involves the First Amendment to the homocysteine dimers (homocystine) or as homocysteine-cysteine Constitution. The question is whether FDA has the heterodimers; while only about 1-2% is in the reduced state. Because right to curtail free speech of certain words (those of the many forms of homocysteine, tHcy was often termed involving diseases) when they are used truthfully “Homocyst(e)ine” in the literature to account for these multiple regardless of the substance’s FDA approval status. forms. Currently, most of the studies concerning Hcy levels have This is one of the major stumbling blocks primarily focused on tHcy levels and not on free Hcy or free/bound preventing research of proprietary dietary ratios. Some advocate for the use of free Hcy as a marker rather than supplement products. Who wants to do a multi- tHcy or even intracellular levels rather than plasma levels, although center, double-blind study showing their product more research in humans needs to be conducted as other species such significantly lowers BPH symptoms when all they as rats have 65-75% of tHcy as free Hcy. can legally say is “Supports normal prostate function- not intended to cure.....etc.” This is not Hyperhomocysteinemia- Risk Factor Assessment only false, but ludicrous. FDA must be called to Increased Mortality task for this double standard and allow claims to Elevated plasma tHcy is an independent risk factor for be made which reflect the real benefit of products cardiovascular as well as non-cardiovascular mortality (31, 13). In a being sold, independent of whether those claims prospective cohort study following 2127 men and 2639 women for over include a disease. Until then, we will be at the 4 years, increasing levels of plasma tHcy was directly related with mercy of looming new diseases invented to sell us increasing mortality. The population was divided into quintiles based more pharmaceuticals.* on initial plasma tHcy (5.1-8.9, 9.0-11.9, 12.0-14.9, 15.0-19.9, >20 µmol/L) and followed for survival. After adjusting for other cardiovascular risk * These comments are not intended to diagnose, factors the overall mortality ratio was 1, 1.33, 2.02, 2.48, and 3.56 for cure, or treat the overwhelming conflict of interest the 5 quintiles. The authors conclude that after multivariate adjustment, between the FDA approval process and Big a 5 µmol/L increase in tHcy increased all cause mortality by 49%, Pharma. cardiovascular mortality 50%, cancer mortality 26% and non-cancer, 2004 (continued from page 2) non-cardiovascular mortality 104%. This data suggests that the level of lowering blood pressure as well as homocysteine (28). This diet is homocysteine which is likely to result in a low risk for mortality is high in fruit and vegetable consumption and recommends low dairy below 9 and perhaps even lower. Figure 1 shows a graph of increasing and meat fat intake. Physicians should note that thiazide diuretics, coronary artery disease (CAD) risk (both fatal and non-fatal) some of the first medications given to hypertensive patients, summarized from the various prospective trials available.
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