What You Need To Know About and How To Get Started

Copyright© 2016, Kurt N. Woeller, D.O. and Educational Resource Association. This material may not be reprinted, distributed or used without permission.

1 Content Disclaimer

The material contained within this document/presentation is not intended to replace the services and/or medical advice of a licensed health care practitioner, nor is it meant to encourage diagnosis and treatment of disease. It is for educational purposes only. Kurt N. Woeller, D.O. (or associates) does not accept legal responsibility for any problems arising from experimentation with the information described herein. Any application of suggestions set forth in the following portions of this document/presentation is at the reader's discretion and sole risk. Implementation or experimentation with any supplements, herbs, dietary changes, medications, and/or lifestyle changes, etc., is done so at your sole risk and responsibility and should be discussed with your (or your child’s) personal physician first.

2 Lecture Overview

• What is Methylation? • Methylation Problems and • Testing Options For Methylation Assessment • Treatment Options for Methylation

YOUR LOGO 3 Support Documents for Module #6

• Methyl-B12 Injection Prescription Form (must be signed by licensed physician). • Methyl-B12 Subcutaneous Injection Information Sheet. • Dr. Woeller’s Methyl-B12 for Autism eBook (pdf) • Lecture slides for Methylation and Autism (pdf) • Lecture slides for Methylation and Autism: note taking (pdf).

YOUR LOGO 4 Between The Wheels

YOUR LOGO 5 What Is Methylation?

YOUR LOGO 6 A methyl group contains one carbon (C) atom and three hydrogen (H) atoms. The process of methylation is transferring this ‘methyl’ group for the purpose of modifying a variety of chemical reactions throughout the body.

YOUR LOGO 7 Why Is Methylation So Important? • Key biochemical process commonly altered in many neurodevelopmental disorders like Autism, and neurological diseases such as Alzheimer’s. • The chemistry of methylation, and its impairment, explains a lot with regards to altered brain and cellular function seen in autism: • Memory retention and recall • Poor language development • Diminished environmental awareness • Multiple neurochemistry imbalances • Detoxification problems • Immune dysfunction

YOUR LOGO 8 Methylation Cycle Diagram

Methionine The cycle constantly spins from DMG to . Methyl- SAMe Methyl-B12 B12 has the greatest (Methionine influence through the TMG Synthase) enzyme complex called Methionine Synthase.

Homocysteine

P5P

Glutathione (Potent Antioxidant)

The overall effect of methylation is to regulate gene activity for proper cell function, as well as activate various enzymes in their role for biochemical conversions. 9 YOUR LOGO Methylation

• Proper immune response to i.e. TB DNA synthesis

• New blood cell formation • Helps control gene expression mutations, i.e. mental retardation, Schizophrenia • T cells • Supports detoxification Involved in DNA regulation and Immune Function • Membrane fluidity & phospholipid methylation – attention issue Myelination and pruning • Multiple enzymatic reactions requiring production methylation: Prevents homocysteine trapping, i.e. • Melatonin cardiovascular implications • Neurotransmitter levels : dopamine Supports intestinal mucosa and norepinephrine • Tryptophan methylation: serotonin

YOUR LOGO 10 Methylation is involved in cell membrane function

YOUR LOGO 11 Regulation of neurotransmitter conversion such as Norepinephrine to Epinephrine is dependent on methylation.

YOUR LOGO 12 The Role of Histamine • Inflammatory response • Sleep-wake cycle • Increases capillary • Body temperature permeability to white regulation. blood cells and various • Appetite immune proteins. • Erections • Gastric acid secretion • Learning and memory • Regulates various neurochemicals such as serotonin, norepinephrine and acetylcholine.

YOUR LOGO 13 DNA methylation is a process in which methyl groups are added to DNA. In humans, we can methylate two nucleotides – Cytosine and Adenine. Methylation’s primary role is to modify DNA activity by suppression of DNA transcription.

YOUR LOGO 14 YOUR LOGO 15 Melatonin Issues In Autism

• The Pineal Gland produces Acetyl Serotonin Methyl-Transferase (ASMT) which converts serotonin to melatonin. • Dating back to the 60s, studies in autism have reported elevated levels of serotonin in the blood. • In the past 15+ years, various reports have shown abnormally low levels of melatonin in the blood or urine of people with autism. • Some children with autism obtain restful sleep after taking over-the- counter melatonin. • In 2008, a study analyzed ASMT and melatonin and found autism individuals tend to carry certain mutations in ASMT, and have significantly less melatonin and less ASMT in their blood compared with controls (Melke J. et al. Mol. Psychiatry, 90-98). • ASMT gene - there are two identical copies, one of which resides on the X chromosome and the other on the Y chromosome.

YOUR LOGO 16 Methylation Problems In Autism

YOUR LOGO 17 Methylation Cycle Diagram

Methionine The cycle constantly spins from homocysteine DMG to methionine. Methyl- SAMe Methyl-B12 B12 has the greatest (Methionine influence through the TMG Synthase) enzyme complex called Methionine Synthase.

Homocysteine

P5P

Glutathione (Potent Antioxidant)

The overall effect of methylation is to regulate gene activity for proper cell function, as well as activate various enzymes in their role for biochemical conversions. 18 YOUR LOGO Jill James, Ph.D Research on Methylation Problems in Autism Metabolic biomarkers of increased oxidative stress and impaired methylation capacity in children with autism1,2 S Jill James, Paul Cutler, Stepan Melnyk, Stefanie Jernigan, Laurette Janak, David W Gaylor and James A Neubrander From the Department of Pediatrics, University of Arkansas for Medical Sciences, and the Arkansas Children's Hospital Research Institute, Little Rock, AR (SJJ, SM, and SJ); Niagara Falls, NY (PC); Colden, NY (LJ); Gaylor and Associates, LLC, Eureka Springs, AR (DWG); and Edison, NJ (JAN) Results: Relative to the control children, the children with autism had significantly lower baseline plasma concentrations of methionine, SAM, homocysteine, cystathionine, cysteine, and total glutathione and significantly higher concentrations of SAH, adenosine, and oxidized glutathione. This metabolic profile is consistent with impaired capacity for methylation (significantly lower ratio of SAM to SAH) and increased oxidative stress (significantly lower redox ratio of reduced glutathione to oxidized glutathione) in children with autism. The intervention trial was effective in normalizing the metabolic imbalance in the autistic children. “An increased vulnerability to oxidative stress and a decreased capacity for methylation may contribute to the development and clinical manifestation of autism.”

YOUR LOGO 19 Methylation Altered By Environmental Toxins

Neurodevelopmental Toxins Deplete Glutathione and Inhibit and - Dependent Methionine Synthase Activity: A Link between Oxidative Stress and Autism MOSTAFA IBRAHIM-AHMED WALY and RICHARD DETH PHARMACEUTICAL SCIENCES, NORTHEASTERN UNIVERSITY, BOSTON, MA Ethanol, arsenic, lead, mercury, aluminum and the vaccine preservative thimerosal are suspected to be etiological factors for neurodegenerative and neurodevelopmental disorders. Autism is a neurodevelopmental disorder characterized by oxidative stress and impaired methylation status, including decreased activity of the folate and vitamin B12-dependent enzyme methionine synthase (MS). MS-mediated conversion of homocysteine to methionine is crucial for neurons and all mammalian cells to sustain normal methylation status, involving more than 100 different reactions. Glutathione (GSH) protects MS from oxidative inactivation by reactive oxygen species, while MS inactivation increases GSH synthesis by augmenting transsulfuration. Utilizing SH-SY5Y cultured human neural cells, we found that a 1 hour pre-incubation of cells with arsenic, lead, mercury, aluminum and thimerosal potently decreased both hydroxycobalamin (OHCbl) and (MeCbl)-based MS activity, although OHCbl exhibited greater sensitivity than MeCbl. At a concentration of 100 nmol, each of these neurodevelopmental toxins caused a 60–70% reduction of intracellular GSH levels. 22 mM (0.1%) ethanol caused a similar inhibition of OHCbl- and MeCbl-based MS activity and a similar decrease in GSH levels. “Our findings suggest that heavy metals and ethanol may contribute to the occurrence of neurodevelopmental disorders such as autism via a mechanism that involves oxidative stress and inhibition of Methionine Synthase activity.”

YOUR LOGO 20 Thimerosal Blocks GSH-dependent Synthesis of Methyl-B12

Hydroxycobalamin Cyanocobalamin

GSH GSH

Thimerosal Thimerosal Glutathionylcobalamin S-adenosyl methionine 5-MethylTHF Methylcobalamin Methionine Homocysteine Methionine Synthase

D4RMET D4RHCY

YOUR LOGO 21 Testing Options For Methylation Assessment

YOUR LOGO 22 The Methylation Pathway: Health Diagnostics and Research Institute www.hdri-usa.com

YOUR LOGO 23 YOUR LOGO 24 Single Nucleotide Polymorphism SNP (aka. SNiP)

YOUR LOGO 25 YOUR LOGO 26 YOUR LOGO 27 • Adenine • Thymine • Cytosine • Guanine

YOUR LOGO 28 DNA is double stranded: two polynucleotides twisted into a double helix • Consists of four types of nucleotides: – Adenine pairs to Thymine – Cytosine pairs with Guanine

Base pair The sequence of nitrogenous Nitrogenous bases carries genetic base (A) information.

Figure 3.20C YOUR LOGO 29 The Flow of Genetic Information

DNA RNA PROTEINS - 2 3 the machinery 1 of the cells DNA

1. REPLICATION – DNA Synthesis 2. TRANSCRIPTION – RNA Synthesis 3. TRANSLATION – Protein Synthesis

Methylation

YOUR LOGO 30 Single Nucleotide Polymorphism (SNP)

Difference of one base at specific base pair position.

Cytosine → Thymine Adenine → Guanine

5-30 million SNPs in the Human genome

YOUR LOGO 31 Role of SNPs in Disease Predisposition

• Change < 1% population = mutation • Change > 1% population = polymorphism

Common diseases are multifactorial

The genetic differences between human populations make one population more susceptible to a particular disease than another.

YOUR LOGO 32 Journal of American Physicians and Surgeons Volume 9:106-108, 2004

Located on chromosome 1 (1p36.3)

YOUR LOGO 33 MTHFR gene SNPs C677T, A1298C • MTHFR = MethyleneTetraHydroFolate Reductase • Enzyme that methylates folic acid as 5,10 methylene- THF to 5-Methyl-THF (bioactive form) – this then leads to homocysteine to methionine conversion to support the methylation cycle. • Two mutations – C677T and A1298C • 677 – related more to folate • 1298 – dopamine and serotonin, ammonia, tyrosine & tryptophan metabolism - some folate influence as well. • Each can be - -, + -, or + +

YOUR LOGO 34 COMT polymorphism

COMT – Catechol-o-methyl-transferase • Deactivates neurotransmitters like dopamine, norepinephrine, and epinephrine. • Deactivates certain estrogens. • Deactivates environmental chemicals with a catechol structure.

YOUR LOGO 35 Neurotransmitter Metabolites

Adrenal gland epinephrine COMT Vanillylmandelic acid (VMA) Periperal nerves norepinephrine CNS

COMT Homovanillic acid CNS dopamine HVA MAO-A GI tract serotonin 5-hydroxyindoleacetic platelets acid (5-HIAA) Will be discussed in Module #15 36 YOUR LOGO Critical Effect of Intestinal Bacteria on Brain and Nervous System

Organic acids test Organic Acids Test

COMT Organic acid test COMT

37 YOUR LOGO Whole Blood Histamine (and Basophils)

• Advocated by William Walsh, Ph.D. – Walsh Research Institute – www.latitudes.org. • Helps to assess ‘functionality’ of the methylation. • Histamine and methylation are inversely related to each other. • If whole blood histamine is low, the individual will be over-methylated and if it is high, they will be under-methylated.

YOUR LOGO 38 Under-Methylation: Some suspected symptoms and traits • Addictiveness • High libido • Calm demeanor, but high inner tension • Illness denial • Chronic depression • Frequent headaches • Perfectionism • Family history of high accomplishment • Seasonal allergies • Dietary inflexibility • Self-motivated • Slenderness • Sparse body hair • Suicidal tendencies • Sports competitiveness • Phobias • Strong willed • Adverse reaction to benzodiazepines and folic acid. • Oppositional defiance • Positive response to SSRI’s and anti- • Obsessive compulsive tendencies histamines.

YOUR LOGO 39 Over-Methylation: Some suspected symptoms and traits

• Absence of seasonal allergies • Sleep disorder, tinnitus, • Copper overload hirsutism, food/chemical sensitivities, artistic or musical • Depression ability. • Dry eyes and mouth • High anxiety/panic, hyperactivity • Estrogen and antihistamine • Rapid speech intolerance. • Religiosity • Low libido • Tendency to be overweight • low motivation during school years. • Nervous legs, pacing, etc. • Self-mutilation • Adverse reaction to SSRI’s and SAMe, improvement with benzodiazepines.

YOUR LOGO 40 Methylation Supplement Support

YOUR LOGO 41 How Do We Resolve These Issues With Methylation Cycle Support

• High dose (4mg to 8mg/lbs. – max. 1000mg) with ½ as much magnesium (2mg to 4mg/lbs.). • SAMe – 200mg to 400mg daily • Dimethylglycine (DMG) or Trimethylglycine (TMG) • Folinic Acid or L-Methyl-Folate - helps support folate chemistry for methylcobalamin methylation. • Methyl-B12 therapy – subcutaneous injection, nasal spray, transdermal, lollipop, oral liquid, sublingual.

YOUR LOGO 42 Methylation Cycle Diagram

Methionine The cycle constantly spins from homocysteine DMG to methionine. Methyl- SAMe Methyl-B12 B12 has the greatest (Methionine influence through the TMG Synthase) enzyme complex called Methionine Synthase.

Homocysteine

P5P

Glutathione (Potent Antioxidant)

The overall effect of methylation is to regulate gene activity for proper cell function, as well as activate various enzymes in their role for biochemical conversions. 43 YOUR LOGO Dimethylglycine (DMG)

DMG at 125mg – 1 to 6+ tablets daily. On average is 2 to 3 tablets per day. No specific dosage for age or weight. www.nbnus.com

YOUR LOGO 44 DMG (Dimethylglycine) • Derived from Trimethylglycine (TMG) • Has influence over folate metabolism • DMG Influences: • Folate (THF, 5, 10-methyleneTHF, 10-formylTHF) to influence purines (AMP, ATP, GTP) and pyrimidine (genetic influence) = cellular response and perception. • Methylation of cobalamin within the Methionine Synthase complex • Activation of D4 receptor leading to improved attention • Benefits of DMG: • Improved language, attention, and focusing • Less self- stimulatory behavior • Reduced hyperactivity and mood issues Dosing = 125mg to 900mg plus - average range for a 40 to 50 lbs. child about 250mg to 750mg. Need to adjust dosing according to clinical response of individual.

YOUR LOGO 45 Trimethylglycine (TMG)

TMG 125mg to 500mg+ daily www.nbnus.com

YOUR LOGO 46 TMG (Trimethylglycine)

• Helps convert homocysteine into methionine through the Betaine homocysteine-methyl-transferase enzyme (BHMT). • TMG becomes DMG after donating methyl group to homocysteine. • General recommendations before use: • Start with lower dose • Consider having taurine supplemented prior, i.e. 250mg to 500mg. • Main Reason: TMG causes hcy to become met. If cysteine is low, the process of taurine & glutathione production can be compromised. Dosing = 125mg to 500mg+. An average range for a 40 to 50 lbs. child about 250mg to 800mg works well.

YOUR LOGO 47 Folate

• – derived from plants (green leafy veggies), grains, beans, as well as certain forms of yeast and bacteria. • Folate provides methyl groups to cobalamin within the Methionine Synthase enzyme complex. • It also provides assembly information of purines and pyrimidines. • Folinic Acid (5-formyltetrahydrofolate) is a versatile form. • There are many different forms of folate that need a variety of biochemical manipulation.

YOUR LOGO 48 Folinic Acid & L-Methyl-Folate

400mcg capsule 1000mcg capsule

YOUR LOGO www.nbnus.com Methyl-B12

5 drops is approx = 1000mcg One tablet = 1000mcg

YOUR LOGO 50 www.revitapop.com

3.6 mg of Methylcobalamin per lollipop

YOUR LOGO 51 Methyl-Mate (New Beginnings Nutritional – www.nbnus.com) Liquid ultra-concentrated methylcobalamin

• Pharmaceutical grade MB12 • 250 mcg per drop • Each spray is approx. 500 mcg • Adults: 1 to 3 sprays each nostril 1 to 2x per day. • Children: 1 to 2 sprays daily Sold as a sublingual. Need to request nasal spray applicator when ordering.

YOUR LOGO 52

Effect of method of administration on

methyl B-12 absorption 1600

12 subcutaneous 5500 mcg 1200 Nasal Nasal 1000 mcg 1000 mcg itamin B 800

lood v Oral 400 5000 mcg

Oral pg/ml b 0 2400 mcg 0 1 4 8 24

YOUR LOGO Time- hours after administration 53 Methyl-B12 for Autism-Spectrum Disorders

YOUR LOGO 54 Compounded and Pre-Filled

YOUR LOGO 55 Methyl-B12 Injections

YOUR LOGO 56 Upper Outer Quadrant

YOUR LOGO 57 30 Degree Angle or Less

YOUR LOGO 58 Numbing Cream Option

YOUR LOGO 59 Methylcobalamin (B12) Many Individuals Improve in 3 Major Areas:

Cerebral Cortex Function (90%) Speech and Language Function (80%) Emotion and Socialization Function (70%)

YOUR LOGO 60 Methylcobalamin (B12) Injections • All forms of Methyl-B12 can be helpful, i.e. sublingual tablets, nasal spray, but: • Subcutaneous injection is “gold standard” • Ideally, no other ‘biomedical’ changes are made during 1st 6 weeks of Methyl-B12 implementation. • At the end of 6 weeks can add other support supplements such as L-methyl-folate, folinic acid, DMG, etc. • Need to watch for too much methylation support: • TMG – if currently taking, it is suggested to discontinue before starting Methyl-B12. • Hyperness, overstimulated, sleeping problems…aggression.

YOUR LOGO 61 Methylcobalamin (B12) Injections

• 75 to 85% plus - have positive changes that are noticeable in 1st 6 weeks. • Less than 10% show no benefit, less than 5% need to stop because of intolerable side effects.

YOUR LOGO 62 Hyperactivity – 60% of time

YOUR LOGO 63 Sleeping Disturbance – 40% of time

YOUR LOGO 64 Mouthing – 30% of time

YOUR LOGO 65 Methylcobalamin (B12) Main Side Effects: • Hyperactivity – most common • Sleep disturbance • Mouthing of objects – fingers, chewing on knuckles. • More easily frustrated: • This can indicate a greater awareness of surroundings, more willingness to engage and participate which in certain situations can manifest as frustration because of child’s limited skills and abilities.

YOUR LOGO 66 Methylcobalamin (B12)

• Side effects will usually last 2 to 6 weeks. Average = 4 weeks. • Tolerable versus Intolerable – “positive- negative scenario.” • If child becomes aggressive or self- injurious this is a concern and should not be viewed as a positive or tolerable reaction.

YOUR LOGO 67 Methyl-B12 – Improving Positive Outcomes

• Watch for 72 hour consistency between shots: • Consider increasing frequency to every 48 hours after making sure injection angle is accurate. • Quick onset hyperness – may need smaller dose, injection too deep. • Immediate positives, i.e. eye contact, attention that is quickly lost – usually injection depth is to deep.

YOUR LOGO 68 Methyl-B12 - Improving Positive Outcomes

• Red urine – injection depth to deep • Child may also lack a lot of subcutaneous fat so B12 is naturally absorbed quicker. • Do not pucker skin when injecting because it leads to ineffective dosing. • If injection angle is accurate and still see 36 to 48 hour benefit with a 24 hour drop- off before the next injection is due – will likely benefit from every other day dosing.

YOUR LOGO 69 Methyl-B12 – Adding Other Nutrients To The Syringe • Adding Folinic Acid to the syringe (100mcg to 400mcg) – may help at times with hyperactivity & overstimulation. • However, anytime you add an ingredient to the Methyl-B12 syringe the base concentration (25mg/ml) will change, i.e. 12.5mg/ml, 6.25mg/ml). I personally prefer to dose Folinic Acid orally. • Some doctors add N-acetyl-cysteine (NAC) – a promoter of glutathione. It will change the base concentration of Methyl-B12 too.

YOUR LOGO 70 Other Forms of B12

• Hydroxycobalamin – another form of B12 that seems to help some kids on the autism- spectrum. • Consider using if Methyl-B12 is not tolerated or a plateau effect has occurred and child is not responsive to Methyl-B12 dosing changes. • Injection dosage for Hydroxy-B12 – dose the same as Methyl-B12 – 64.5mcg/kg every 3 days.

YOUR LOGO 71 Final Thoughts of Methyl-B12

• Despite all the lab testing for methylation status that is available, the best lab is the child’s body. • Laboratory testing certainly helps to fine tune the process of methylation support, particularly if the clinical response is not initially favorable from a trial of Methyl- B12. • Laboratory testing can help isolate potential conflicts in prescribing various supplements. • Methyl-B12 injections (and other forms of Methyl-B12 therapy) has been one of the most consistently beneficial therapies for individuals on the autism-spectrum.

YOUR LOGO 72 Thank You Kurt N. Woeller, D.O. www.AutismRecovery101.com [email protected]

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