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From: "Steve Harris" <>
Subject: Re: Five Questions for Steve Harris
Date: Mon, 11 Mar 2002 21:36:31 -0700
Message-ID: <a6k0np$508$>

Matti Narkia

> After that there has been the following prospective, double-blind,
> randomized trial, published Nov 12, 2001 by Schnyder et al. in NEJM:
> Schnyder G, Roffi M, Pin R, Flammer Y, Lange H, Eberli FR, Meier B,
> Turi ZG, Hess OM.
> Decreased rate of coronary restenosis after lowering of plasma
> homocysteine levels.
> N Engl J Med. 2001 Nov 29;345(22):1593-600.
> PMID: 11757505
>     "... CONCLUSIONS: Treatment with a combination of folic acid,
>     vitamin B12, and pyridoxine significantly reduces homocysteine
>     levels and decreases the rate of restenosis and the need for
>     revascularization of the target lesion after coronary angioplasty.
>     This inexpensive treatment, which has minimal side effects, should
>     be considered as adjunctive therapy for patients undergoing
>     coronary angioplasty."


Thanks. You beat me to posting this last one, which of course I'd read
because it was in the Big Wig Journal.  But I had thought it was the first
of its kind, and thank you for pointing out the previous study, of which I
was unaware.

Yes, intervention studies on homocysteine in humans are coming right along.
Since homocysteine levels have recently been found to correlate nicely with
prospective probability of developing dementia (another NEJM study just a
few months old), a major question now to be answered is if intervention
makes any difference there also.

Homocysteine levels rise with age, BTW, probably for multifactorial reasons.
And sicker patients have higher ones. I did a small study in my own
geriatric outpatient clinic and found that fully a third of my newly
referred ambulatory geriatric patients had severely elevated levels ( > 15).
The classically trained nutritionist who always tut-tutted when I
automatically put everybody on a multivitamin quit complaining as much after
that. I still can't tell you if I did anybody any good in that, but I can
tell you that I sure fixed a lot of lab numbers for a few cents a day. <g>

BTW, I just found at the grocery store a betaine+pepsin supplement
(Thompson) which is basically 30 grams of betaine for $5. So at 6 grams a
day, that's basically the $1 a day that Marty quoted. This is more expensive
than vitamins, but still pretty cheap compared with the $3 to $6 a day that
statin treatment will cost you.  Not that I'm suggesting it as an
alternative, of course.  Just putting things in perspective. Even
second-level treatment of homocysteine is cheap compared with cholesterol

There is at least one paper on medline suggesting that if homocysteine
intervention really does turn out to track the epidemiologic
homocysteine-disease correlations, then folate and B12 fortification of
foods may be among the best public health money we can spend.  By contrast,
statin treatment surely saves lives, but the cost is somewhere between
$5,000 to $100,000 per year of quality-adjusted-life (QALY), depending on
how carefully you pick your treatment risk groups.  That compares favorably
with the cost of coronary bypass for heart patients and nursing homes for
stroke victims, so HMOs will probably continue to shell it out. But it's
still a LOT of money.  If I was an HMO I'd be handing out free vitamins.
Kaiser Permanente should be sending every member a couple hundred Twinlab
Daily One's every year.


From: "Steve Harris" <>
Subject: Re: "smart" foods
Date: Mon, 22 Apr 2002 22:11:43 -0600
Message-ID: <aa2mu8$3ih$>

"Gym Bob" <> wrote in message
> I'm with you except homocysteine is not an amino acid. L-cysteine is.

Of course homocysteine is an amino acid. Not all amino acids are used to
synthesize proteins. Consider citruline.

FYI: Anything that looks like


Is an amino acid. See the amino?  See the acid?


From: David Rind <>
Subject: Re: stroke, homocysteine and B 12
Date: Tue, 01 Mar 2005 22:14:55 -0500
Message-ID: <d03avs$jrb$>

Zee wrote:
> I was hoping you would comment. I am being told I *must* lower my
> homocysteine. It has not responded to folate. I am also told my
> physcians are "very worried" about my ldl cholesterol. These comments
> are usually followed by my getting a  "non-compliant patient" talk
> followed by a sign-off as patient letter cc'd to my general
> practitioner.
> Did you see the recent post about pantethine to lower cholesterol? Do
> you have any thoughts on that? I would welcome your opinion.
> Zee

I'm not sure my comments will be too helpful for a couple of reasons:

First, it's hard for me to make useful comments about for an individual
over the Net -- it's just not similar to the information available when
seeing a patient.

Second, my approach to high risk cardiac situations is the one you like
least. If I were really worried that someone's homocysteine level (plus
some number of other risk factors) placed them at too high a risk for
cardiovascular disease, my approach would be to have them take a statin.

High homocysteine levels do seem to correlate some with cardiovascular
risk, but we really don't know that lowering those levels with folate
(or with folate plus other vitamins) really has any important impact on
that risk. I don't know of any evidence that anyone "must" lower their
homocysteine level, since we don't actually know that doing so has any
beneficial effect. In contrast, statins clearly lower cardiovascular risk.

I didn't notice the post on pantethine (is this pantothenic acid?), but
in the absence of any specific information my take would be similar to
what I posted a while ago about ezetimibe (and also similar to what I
wrote about lowering homocysteine levels above). Knowing that something
lowers cholesterol levels in and of itself isn't that convincing to me
that it will show clinical benefit. It is really not at all clear that
the benefit of statins doesn't have a lot to do with effects separate
from lowering cholesterol levels. I believe we really need trials with
clinical endpoints for any drug intended to treat hypercholesterolemia.

David Rind

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