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Table 10 SUGGESTEDTREATMENT GUIDELINES FOR HHcy

From: Homocysteine and reactive oxygen species in metabolic syndrome, type 2 diabetes mellitus, and atheroscleropathy: The pleiotropic effects of folate supplementation

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)
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