Sustaining The Brain
With Antioxidant ProtectionThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
From The November 2003 Issue of Functional Foods & Nutraceuticals
David Perlmutter, MD
David Perlmutter, MD, explains how a range of antioxidants may hold the keys to better cognitive function. Also includes intellectual property filings and the rap on phosphatidylserine.
There still is no cure for debilitating cognitive conditions such as Alzheimer’s and Parkinson’s. But natural agents hold promise for supporting brain health and at least delaying the onset of many of these diseases. David Perlmutter, MD, researches the field
The end of the 1990s marked the completion of the so-called Decade of the Brain, a title bestowed upon this period by researchers and clinicians in the neurosciences. Their intent was both to enhance awareness of the various neurodegenerative diseases and to encourage research into the diverse genetic, infectious, environmental, traumatic and lifestyle influences on their development. But despite the commendable advances in our understanding of the causes of these maladies, lack of significant progress from a therapeutic perspective may mean that we will leave the Decade of the Brain to usher in the Century of Brain Dysfunction.
For example, our understanding of the possible underlying causes of Alzheimer’s disease—including genetic predisposition, educational level, electromagnetic radiation, aluminum exposure and oestrogen insufficiency—has advanced dramatically. But despite the encouraging claims in medical journal advertisements, none of the currently marketed Alzheimer’s drugs offers any significant benefit for this disease. Indeed, as the highly respected Journal of the American Medical Association recently reported in a comprehensive review of the effectiveness of tacrine (Cognex), one of the most aggressively marketed drugs for Alzheimer’s disease, “Despite being licensed in several countries, the efficacy of tacrine in treating the symptoms of Alzheimer’s disease remains controversial, and government approval for its use has been refused in several countries.” [1]
These are sobering comments from a journal looked upon as the sounding board of American medicine, especially in light of the fact that there are an estimated 4.5 million Alzheimer’s patients in the United States today, and caring for these individuals costs the nation more than $60 billion annually. But these statistics pale when confronting projections for the next 30 years. Alzheimer’s, being primarily a disease of the aged, will have an ever-increasing negative impact on societies, because the elderly represent the most rapidly growing segment of the population. As seen in the chart to the right, by 2030 more than 9 million Alzheimer’s patients will be in America, with close to half the population over 85 years old carrying the diagnosis. [2]
The situation is much the same with other degenerative diseases of the nervous system. Between 1955 and 1986, the mortality from Parkinson’s disease in the US rose 411 per cent, while deaths from Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease) increased 328 per cent in only the nine-year period from 1977 to 1986. [3]
But is the rapid increase in incidence of these diseases simply a reflection of the fact that we are now living longer and not succumbing to other processes? Or are there other influential factors in our society that have a bearing on these degenerative conditions? An attempt to answer these questions appeared in a 1993 editorial in The Lancet in which the author stated, “Modern civilisation is not the cause of our chronic diseases, it merely unveiled what our genes had lurking in store for us for centuries, if not millennia, as we now live long enough to see these genes massively expressing themselves.” [4]
The idea that our health is entirely determined by our genes suggests that our fate with respect to neurodegenerative conditions is predetermined at the time of our conception. In this perspective, environmental, nutritional and emotional aspects of our lives have little influence. Progression of disease is inherent in this plan, allowing perhaps only a role for treating symptoms—paying attention only to the smoke and not the underlying fire.
But in the past several years, the vigorous explorations of the fundamental biochemical events involved in the progressive deterioration of the nervous system characteristic of the neurodegenerative diseases have revealed that these conditions do not simply represent a linear predetermined progression. The unbending rules of genetic determinism have been replaced by the paradigm of genetic predisposition—a concept that recognises inherited risk as only one of many factors that influences an individual’s ability to resist the entropic nature of the tenuous personal capacities that maintain nervous system integrity.
Underlying Oxidative Stress
The molecular mechanism underlying nervous system decay that is characteristic of these disorders shares a final common pathway with the ageing process. The key players mediating this degeneration belong to a group of chemicals commonly known as free radicals, or more generally, pro-oxidants.
Despite the negativity associated with these molecules in popular health texts, free radicals mediate processes central to the perpetuation of life itself. In humans, these pro-oxidants direct the formation of our various body parts, initiate and modulate immune activity, ‘kill’ invading bacteria, and destroy cancer cells.
Pro-oxidants are generated during the normal processes of cellular metabolism and are produced in increased amounts when physiologic systems are stressed. Stressors associated with increased pro-oxidant production may be intrinsic, as occurs for example when emotion induces the production of ‘stress hormones,’ or when blood supply is compromised. Extrinsic influences known to stimulate pro-oxidant production include such diverse events as infection, trauma and exposure to toxins.
It is when the controlling mechanisms that normally limit the ‘life span’ or activity of pro-oxidants become inadequate that the destructive nature of these short-lived molecules becomes manifest. This occurs when excessive pro-oxidants either overwhelm the body’s protective antioxidant chemicals, or antioxidant insufficiency prevents adequate protection from even the ‘normal’ level of pro-oxidant production.
Within each living cell in the human body there exist microscopic particles whose sole purpose is energy production. These inclusions, the mitochondria, are responsible for utilising fuel to provide power for all of the cell’s various activities. But despite their critical role in maintaining the life of the cell, mitochondria are unusually susceptible to being damaged by pro-oxidants. When damaged, mitochondrial energy production suffers, rendering the entire cell, including the mitochondria themselves, even more susceptible to oxidative damage. And to make matters worse, this entire process becomes self-perpetuating: Damaged mitochondria produce excessive amounts of pro-oxidants.
The process may be initiated by any number of factors, but ultimately culminates in cell death. Alzheimer’s disease is characterised by an inherent defect in mitochondrial energy production, an inflammatory response to one or more brain proteins, increased amounts of brain iron, and ineffective antioxidant activity. [5, 6] All of these factors contribute to a hostile environment for delicate brain neurons by enhancing pro-oxidant-mediated damage.
Parkinson’s disease has much the same etiology, also featuring a primary flaw in mitochondrial energy production, plus increased concentrations of brain iron, a catalyst for oxidative stress. [7, 8] Inflammation is less of a factor, but unique to this disease are defects in the ability of the liver to detoxify various environmental toxins. These flaws allow accumulation of diverse chemical agents that directly compromise mitochondrial function and enhance the destructive potential of pro-oxidants.
Multiple sclerosis also is marked by the hallmark excessive pro-oxidant activity, in this case as a consequence of inflammation induced by an uninhibited immune reaction directed at myelin, the fragile protective insulation surrounding brain neurons. [9] The damaging effects of this misdirected immune response are compounded by antioxidant inadequacies characteristic of this disease as well. [10]
ALS fundamentals remain somewhat more obscure. Increased incidence in individuals with a history of pesticide exposure suggests abnormalities of liver detoxification, as is seen in Parkinson’s disease. [11] Although the focus of intensive research during the 1980s, the idea that ALS may represent a misdirected immune reaction is now less popular, while excessive pro-oxidant production from damaged mitochondria is now well accepted. [12]
Antioxidant Protection
While each of the many neurodegenerative disorders is characterised by a unique set of symptoms, two biochemical flaws underlie the process of brain destruction in all of these disorders: defective antioxidant protection and reduced mitochondrial energy production.
Thus, therapeutic strategies targeting these fundamental elements are applicable to all the neurodegenerative conditions. These strategies have yielded intriguing results.
Vitamin E, for instance, is the subject of two promising studies. In a prominent 1997 study published in the New England Journal of Medicine, 1,000IU of all-rac [dl]-alpha-tocopherol, twice daily for two years, was reported to be equally effective to the amphetamine precursor drug selegiline in delaying the progression of Alzheimer’s. [13] In the study, vitamin E was shown to delay the onset of certain end points such as requiring assistance with activities of daily living and nursing home placement. While these are not specific measures of cognitive function, they are meaningful parameters nonetheless.
In addition, as part of the Nurses’ Health Study, researchers tested the cognitive function of almost 15,000 women, ages 70-79. The tests included memory, immediate and delayed recall of lists of words, and tests of verbal fluency. For example, one of the tests asked women to name as many animals as they could in one minute (responses ranged from two to 38 animal names). Test scores were compared with the subjects’ use of vitamin C and E supplements. Women who had been taking both supplements for at least ten years had significantly better cognitive performance than women who had never taken those supplements. The benefits were less consistent among women who had taken vitamin E alone, and no benefits were associated with vitamin C alone. [14]
Alpha-lipoic acid may revolutionise the treatment of neurodegenerative diseases because it has the unique attributes of being rapidly absorbed from the gut, readily crosses the blood-brain barrier, and has free radical-scavenging activity.
In addition to its own antioxidant activity, alpha-lipoic acid also facilitates the regeneration of all the other major brain antioxidants including vitamins C and E and glutathione. Lipoic acid acts as a heavy metal chelator, enhancing the excretion of brain toxic metals including lead, cadmium and mercury. [15] It is no wonder that this sulfur-containing antioxidant is the subject of intensive scientific evaluation. [16, 17]
Glutathione is one of the fundamental players in the entire process of mitochondrial energy production. There is currently a great deal of debate as to whether oral administration of glutathione has any significant effect on raising blood levels of glutathione, [18, 19] but clearly the production of glutathione can be dramatically enhanced by providing the nutritional supplement N-acetyl-cysteine (NAC). [20]
NAC has the ability to increase availability of glutathione, an ability that is enhanced by the presence of adequate amounts of vitamins C and E. [21] In addition, NAC itself is an antioxidant that has been demonstrated to reduce the formation of the free radical nitric oxide (NO) in vitro in cultured rat brain cells. [22] NO has been implicated as having a causative role in Parkinson’s disease, multiple sclerosis, Alzheimer’s disease and other neurodegenerative conditions.22, 23, 24, 25 These research studies clearly support the causative role of NO in these diseases, and strategies to decrease NO are being studied worldwide with the goal of having an impact on these diseases.
Co-enzyme Q10, present in all living plant and animal cells, is another important player in energy production. The brain is dependent upon adequate energy availability for such processes as the production of neurotransmitters, the brain’s chemical messengers. Interestingly, M Flint Beal, MD, and colleagues at the Massachusetts General Hospital have found that Parkinson’s patients demonstrate a profound deficiency of coenzyme Q10 in plasma, which may explain why their brains produce an inadequate supply of the neurotransmitter dopamine. [26] Beal’s laboratory further revealed in a pilot study of 15 Parkinson’s patients that 200mg Co-Q10, formulated as a chewable wafer, administered two, three or four times daily for one month, is readily absorbed, is well tolerated and measurably increases cellular energy production. [27]
These qualities, coupled with its antioxidant properties, prompted what has become a landmark study published in October 2002 in which Beal and principal investigator Cliff Shults, MD, demonstrated that the rate of worsening of 80 early-stage Parkinson’s patients could be slowed by more than 40 per cent with the addition of oral Co-Q10. [28] The multi-centre, randomised, parallel-group, placebo-controlled, double-blind trial compared placebo with 300mg/day, 600mg/day or 1,200mg/day, for 32 months.
Although Co-Q10 appeared to slow the progressive deterioration in Parkinson’s cases, it should be noted that the best response was with the highest dosage—and 1,200mg/day Co-Q10 can fairly be called a cost-intolerable dose for most consumers.
Finally, recognising the importance of Co-Q10 makes it critical to identify any factors that may suppress its de novo synthesis. Unfortunately, two of the most commonly prescribed cholesterol-lowering drugs, pravastatin (Pravachol) and lovastatin (Mevacor), dramatically lower serum Co-Q10 levels. [29] What remains to be seen is whether and how much exogenous Co-Q10 can compensate for this effect as well as increase intracellular concentrations of Co-Q10. While there is no direct evidence so far, in our centre, patients taking statin drugs are provided Co-Q10 at a dosage of 100mg per day.
Mevacor is dwarfed by the sales of simvastatin (Zocor)—one 12-week study found simvastatin to elicit significant reductions in both alpha-tocopherol and Co-Q10 concentrations in serum. [30] However, an open-label study involving six months of simvastatin therapy found no change in muscle Co-Q10 concentrations—muscle indicators of energy production—and no change in LDL Co-Q10 or LDL antioxidant contents, when expressed as a function of plasma LDL concentrations. [31] Still, many researchers and raw materials marketers are starting to think of working with pharmaceutical interests to incorporate Co-Q10 into statins.
Acetyl-L-carnitine serves a critical role in brain energetics by acting as a co-factor in the process by which mitochondria convert fatty acids into energy. This has important implications in the neurodegenerative diseases, as deficient energy production is the hallmark of these conditions.
In a 1995 study, researchers demonstrated the ability of acetyl-L-carnitine to completely prevent Parkinsonism in laboratory animals. When laboratory animals are exposed to the brain toxin MPTP, they immediately develop full-blown Parkinsonism as a consequence of enhanced production of destructive free radicals specifically in the brain area that produces dopamine. Pre-treating the animals with acetyl-L-carnitine prior to MPTP exposure offered complete protection—none of the animals developed Parkinsonism. This study suggested the therapeutic potential of acetyl-L-carnitine as a brain protectant specifically useful in Parkinson’s disease. [32]
Acetyl-L-carnitine functions primarily as a shuttle, transporting critical fuel sources into the mitochondria, the energy-producing machinery of the neuron. Its second task is to facilitate the removal of the toxic by-products of brain metabolism. Because of these functions, acetyl-L-carnitine has a pivotal role in facilitating the fundamental processes necessary for brain cell survival.
In addition, acetyl-L-carnitine is readily converted into an important neurotransmitter known as acetylcholine, which is known to be profoundly deficient in the brains of Alzheimer’s patients.
It is for these reasons that acetyl-L-carnitine has been evaluated in dementia studies. Researchers at the University of California, San Diego, found a striking reduction in the rate of mental decline in younger Alzheimer’s patients taking 3g/day acetyl-L-carnitine hydrochloride over the one-year evaluation. [33] However, late-onset Alzheimer’s patients tended to progress more rapidly.
These differing results have confounded researchers. Two separate 2003 meta-analyses from London had different conclusions regarding acetyl-L-carnitine’s efficacy for dementia, particularly for Alzheimer’s patients. In one, researchers analysed double-blind, placebo-controlled, prospective, parallel group comparison studies of at least three months’ duration for mild cognitive impairment and mild (early) Alzheimer’s disease. Doses of alpha-lipoic acid ranged from 1.5–3g/day. A significant advantage was seen compared to placebo at three months on both the clinical scales and the psychometric tests. [34]
Conversely, the second recent meta-analysis of 11 trials concluded that “the evidence does not suggest that ALC is likely to prove an important therapeutic agent.” [35]
Ginkgo biloba has been used for centuries and is described in a traditional Chinese pharmacopoeia. In France, extracts of Ginkgo biloba are administered orally and intravenously and are among the most commonly prescribed pharmaceutical drugs. This also holds in Germany, where ginkgo is licensed for the treatment of a variety of brain disorders including headache, tinnitus, vertigo and memory disorders.
Perhaps the most convincing validation of the effectiveness of Ginkgo biloba comes from a 1997 study published in the Journal of the American Medical Association. In this placebo-controlled study, the progress of 309 Alzheimer’s patients was evaluated over a one-year period. At the completion of the study, the placebo group showed a progressive decline in mental function on a standardised psychological test, whilst the group receiving ginkgo, on average, actually improved. Similar results were also noted in independent evaluations of social skills. The authors concluded that Ginkgo biloba is “safe and appears capable of stabilising and, in a substantial number of cases, improving for six months to one year the cognitive performance and the social functioning of demented patients.” [36]
The effectiveness of Ginkgo biloba may be explained by several mechanisms including enhancement of mitochondrial energy production, increasing blood flow and perhaps most importantly, its ability to reduce the damaging activity of free radicals. [36]
However, two more recent trials found no benefit for ginkgo for age-associated memory loss. A 2000 study—since criticised for its design flaws—was a 24-week, double-blind, placebo-controlled trial of 214 participants and found no benefit with a dose of 160mg or 240mg/day. [37] The second, in 2002, was a six-week study of 230 healthy individuals older than 60 who took 120mg/day with no significant improvement in mental function. [38]
Docosahexaenoic acid (DHA) is a primary component of the mitochondrial membrane, site of cellular energy production. It’s therefore not surprising that levels of this omega-3 fatty acid are markedly increased in more metabolically active areas of the brain. DHA makes up an impressive 25 per cent of total human brain fat, and deficiencies of DHA have been linked to behavioural problems, visual dysfunction, and a variety of other neurological disorders including Alzheimer’s disease. [39]
While synthesis of DHA from precursors does take place in humans, deficiencies of the enzymes required for this process may cause inefficiency, resulting in low levels of this critical brain fat. Fortunately, the consumption of fish or fish oils provides adequate amounts of preformed DHA. In July 2003, a highly publicised study was published in the Archives of Neurology demonstrating that the key reason consuming fish at least once a week lowered Alzheimer’s disease risk was DHA. In fact, it was shown that of the 815 subjects studied, those consuming the most DHA had a remarkable 60 per cent reduction in Alzheimer’s risk. [40]
But the idea of simply increasing fish consumption to reap the benefits of DHA is now being scrutinised. A recent study reported by the Associated Press has had a profound effect on the public awareness of the potential hazards of fish consumption. The report summarised research demonstrating that having as little as two servings of fish monthly led to toxic levels of mercury in 89 per cent of the 116 subjects studied. [41,42] This strengthens the case for the use of supplements of highly refined fish oils free of mercury and other heavy metals as well as PCBs.
As we are now firmly entrenched in the ‘information age,’ the knowledge we so desperately need to maintain health and meet the challenges of disease is now within our grasp. Our dependence upon a system in which standard of care is dictated by pharmaceutical advertising is giving way to a new standard of care—one that recognises the utility of a wide spectrum of well-studied, scientifically validated interventions not solely disseminated by the prescription pad.
It has been said that knowledge is power, and clearly in this context, knowledge is health.
David Perlmutter, MD, is a board-certified neurologist. He is author of BrainRecovery.com and medical advisor for Nordic Naturals.
Supply Issues
Does Source Matter: Bovine vs Soy PS?Phosphatidylserine (PS) has a star-crossed history. In February 2003, the US Food and Drug Administration (FDA) granted it two qualified health claims for reducing the risk of cognitive dysfunction and dementia in the elderly. Yet while the FDA ruled on the body of evidence, most of that was based on bovine cortex-derived PS—and global concerns about bovine spongiform encephalopathy, or mad cow disease, have eliminated bovine-sourced PS from commercial sources. Instead, today all PS is derived from soy. Currently, the evidence is more equivocal from soy PS than bovine-derived PS.
PS is one of the major building blocks for the mitochondrial membrane—the site of neuronal energy production. In addition, PS provides structural integrity to the neuronal membrane, enhancing the ability of neurons to communicate with each other. Abnormalities of the neuronal membrane have been linked to age-related functional changes in brain performance. These important functions of phosphatidylserine have prompted research into its therapeutic potential in dementia. While PS may reduce symptoms in the short term, PS probably only slows the rate of deterioration rather than halting the progression altogether.
It is notable that FDA granted only a ‘qualified’ health claim and not an outright health claim. A 2001 study in the Netherlands found no effect of soy-derived PS on any mental or memory function test in 120 memory-impaired subjects receiving high- or low-dose soy-derived PS for three weeks. [1]
[But the search for technical advances to modify soy-sourced PS continues. Researchers hope one day to develop a molecular profile of soy PS that is not only more closely aligned with bovine material, but is indeed superior. ]
—Todd RunestadReferences
1. Jorissen BL, et al. The influence of soy-derived phophatidylserine on cognition in age-associated memory impairment. Nutr Neurosci 2001;4(2):121-34
Intellectual Property
Natural Bioactives Target Neuronal BioenergeticsThe biopharma world has invested prodigious amounts of human and financial capital toward developing drugs for neurodegenerative diseases (NDD). Similarly, numerous inventors have identified natural bioactive agents that have promise in NDD. A common thematic platform of pursuit has been neuronal bioenergetics—the capacity of nerve cells to efficiently and reliably produce cellular energy.
Creatine: One branch of the energetics tree has been creatine, a metabolic intermediate non-protein amino acid with a ‘muscular’ heritage. Patents based upon some elegant animal studies by Drs Flint Beal at Columbia University and Rima Kaddurah-Daouk of Avicena Corporation (co-inventors on several patents: US 20020161049; WO 9951097; EP0804183) claim creatine and its analogs for treating Huntington’s, ALS, Parkinson’s and even stroke. The results of ongoing long-term clinical trials with creatine in ALS are eagerly awaited, as shorter-term studies have offered only equivocal results. The claim for creatine, a method-of-use claim, would seem to be significantly more legally challenging to enforce, given the overabundance of creatine supplements.
Ketones: The metabolic axis of low/no carbohydrate diets, ketones can be formed endogenously or provided in a precursor form. British Technology Group’s BTH International Ltd Division has a few patents claiming the use of beta-hydroxybutyric acid or acetoacetate, or metabolic precursors thereof, for treating NDD (US 6323237; WO 0015216).
Accera, based in Colorado, has patents pending (US 2003/ 059824; WO 0302861) related to the use of specific medium-chain triglycerides as natural lipids (with or without additional L-carnitine) that can elevate circulating ketones in the blood, and presumably the brain. This ‘almost food’ approach may merit a functional foods consideration.
Huperzine A, an alkaloid found in Huperzia serrata, and in several dietary supplements in the US, has been an NDD target for both academic and commercial IP development. The Mayo Foundation for Medical Education and Research has been assigned a European patent (EP 1167354) by its inventors, Alan Kozikowski and Yan Xia, that claim the composition of racemic huperzine A (two isomers) and its use for inhibiting cholinesterase. The patent describes nearly equal inhibitory activity of the racemate compared to the naturally occurring single isomer. The same inventors assigned a nearly identical patent to the University of Pittsburgh (US 5106979).
Kozikowski and colleague Ken Kellar, both at Georgetown University in Washington, DC, also have assigned patents (US 6369052; WO 0211712; AU 0181006) describing compositions containing a huperzine (A or B; single isomer or racemate) and a nicotine (single isomer or racemate), and their use in treating, preventing or mitigating NDD.
Pfizer has a number of patent filings claiming a composition containing a gamma aminobutyric acid (GABA) agonist, which mimics the action of GABA, and a cholinesterase inhibitor, the latter including huperzine A.
Lastly, scientists from Wake Forest University, North Carolina, have assigned a patent (US 6524616) describing a composition of huperzine A and plant isoflavones as a method to improve memory. It will be interesting to see the huperzine intellectual property landscape unfold, given the various industries and parties involved.
—Anthony Almada/IMAGINutrition
Emerging Research
Methylation’s Neuropsychiatric ConnectionMethylation is an important reaction in the human brain, which has a high demand for both S-adenosylmethionine (SAMe) and choline. Methylation is involved, for example, in the production of neurotransmitters like serotonin or in the maintenance of the myelin sheath. Therefore, hypomethylation affects neuropsychiatric health. In addition, homocysteine, which accumulates when the enzyme activity of the single-carbon cycle is decreased, or when methylation factors like folate, vitamin B12 or betaine are lacking, has demonstrated neurotoxic effects.
Both inborn errors of monocarbon transfer as well as conditions of methyl group deficiency—such as those caused by a deficiency of folate or vitamin B12—can result in a variety of neuropsychiatric symptoms. Three distinguishable inborn errors of the single-carbon cycle have been reported, all of which relate to defects in the enzymes MTHFR, MS or MAT and which can lead to a deficiency of SAM-e, the universal methyl donor in the body:
- Deficiency of 5-methyltetrahydrofolate, which can be caused by methylenetetrahydrofolate reductase (MTHFR) deficiency or congenital folate malabsorption.
- Deficiency of methylcobalamin and consequently a functional deficiency of MS. This deficiency is caused by inborn errors of cobalamin metabolism, the so-called cbl C, cbl D, cbl E, cbl F and cbl G mutations.
- Deficiency of methionine adenosyltransferase (MAT), the enzyme needed for the transfer of ATP to methionine to yield SAM-e.
Humans with defects of the enzymes MTHFR, MS or MAT suffer from neurological symptoms. Depending on the age of the onset and the kind of enzyme defect and/or deficiency, the following disturbances have been described:
- In early infancy, acute neurological distress is characteristic. It occurs with progressive deterioration, feeding difficulties, hypotonia and lethargy. Finally, the patients may go into coma or develop abnormal movements—even seizures.
- In childhood, progressive encephalopathy is the most characteristic symptom. Usually a period of normal development (four to 18 months) is followed by a period of developmental deceleration or arrest with poor head growth and acquired microcephaly, which may take one to several years to manifest.
Depending on the kind of enzyme defect, inborn errors of monocarbon transfer can be treated by administration of the following methylation factors:
- Vitamin B12 (hydroxocobalamin), taken parenterally, is applied in cobalamin-defective patients.
- Folate supplementation has been successfully used in patients with MTHFR deficiency.
- Betaine supplementation allows physiological improvements in CblC and CblE/G patients.
Furthermore, betaine is clearly beneficial for improving the overall prognosis in MTHFR-deficient patients. In infants, mortality rate is decreased by betaine supplementation and comparably good development is achieved. In children and adults, further neurological deterioration is prevented by oral supplementation with betaine. In MTHFR deficiency, the application of betaine could reverse myelin abnormalities.
—Dr Christine Kraus, Dr Robert Faurie, Dr Lutz Thomas/AMINO GmbH
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