Management of Hyperhomocysteinemia

Hyperhomocysteinemia is an established risk factor for cardiovascular disease. The modification of traditional cardiovascular risk factors has resulted in better morbidity and mortality outcomes, so the treatment of hyperhomocysteinemia is explored for a similar benefit. Vitamin B-6, vitamin B-12 and folate, as co-factors in the metabolism of homosyteine, are used in the treatment of hyperhomocysteinemia. Betaine, a methyl-donor in a separate homocysteine metabolism pathway, is also used to treat hyperhomocysteinemia. These supplements have been used in various doses and combinations for different periods of time, with favorable outcomes. There is still no concensus whether hyperhomocysteinemia can be treated with folic acid alone, or in combination with vitamin B-6 and vitamin B-12. The dose of the supplements required to normalize fasting homocysteine remains to be determined, especially in diabetic nephropathy, hemodialysis and renal transplant patients. The benefits from lowering homocysteine levels have mainly been demonstrated in surrogate cardiovascular outcomes. The treatment of hyperhomocysteinemia cannot be firmly advocated until there are trials that demonstrate a beneficial clinical endpoint. In patients who have cardiovascular disease in the absence of more established risk factors, investigation and treatment of hyperhomocysteinemia should be considered.