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 90^th to 95^th 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)