B12 and Homocysteine
In brief
Section titled “In brief”- Test B12 and homocysteine only on indication
- B12 below 300 pmol/L: suspected functional deficiency
- Homocysteine above 10 µmol/L: suboptimal, consider treatment
- H-cocktail: folate, B12, B6, B2 and optionally TMG
- Treatment aimed at functional optimization, not hard endpoint prevention
Indications for testing
Section titled “Indications for testing”Test B12 and homocysteine for:
| Indication | Explanation |
|---|---|
| Cognitive complaints | MCI, memory problems |
| Polyneuropathy | Tingling, balance disorders |
| Fatigue | Unexplained tiredness |
| Depressive complaints | Mood problems |
| Macrocytosis or anemia | Large red blood cells |
| Vegan/vegetarian | No or few animal products |
| Malabsorption | IBD, metformin, PPI use |
| Vascular problems | Unexplained vascular issues |
| Functional deficiency | Normal B12 but high homocysteine |
Threshold values
Section titled “Threshold values”Vitamin B12
Section titled “Vitamin B12”| Value | Assessment |
|---|---|
| Below 250 pmol/L | Likely deficiency |
| Below 300 pmol/L | Suspected functional deficiency |
| Above 300 pmol/L | Likely sufficient |
Homocysteine
Section titled “Homocysteine”| Value | Assessment |
|---|---|
| Below 8 µmol/L | Ideal |
| Below 10 µmol/L | Target value |
| 10-12 µmol/L | Suboptimal |
| Above 12-15 µmol/L | Clinically significantly elevated |
Therapy for B12 below 300 pmol/L
Section titled “Therapy for B12 below 300 pmol/L”Nutrition
Section titled “Nutrition”Increase intake of animal proteins:
- Meat
- Fish
- Eggs
- Dairy
Supplementation
Section titled “Supplementation”| Option | Dosage |
|---|---|
| Daily | Methylcobalamin 1000 mcg per day |
| Intermittent | 1000-5000 mcg, 2-3x per week |
Therapy for homocysteine above 10 µmol/L
Section titled “Therapy for homocysteine above 10 µmol/L”Nutrition
Section titled “Nutrition”| Nutrient | Food sources |
|---|---|
| Folate | Green leafy vegetables |
| B12 | Animal products |
| B6/B2 | Fish, eggs, nuts |
| TMG/betaine | Beetroot, quinoa, spinach |
H-cocktail (biochemical optimization)
Section titled “H-cocktail (biochemical optimization)”The H-cocktail is a combination of supplements for homocysteine optimization:
| Supplement | Dosage |
|---|---|
| Folate (5-MTHF) | 200-800 mcg |
| Vitamin B12 | 1000 mcg |
| Vitamin B6 (P5P) | 20-30 mg |
| Vitamin B2 | 10 mg |
| TMG/betaine | 500-1000 mg (optional) |
Goal of treatment
Section titled “Goal of treatment”Treatment aims at:
- Optimizing methylation — Improved biochemical processes
- Supporting neurological function — Nerve protection
- Supporting cognitive function — Memory and concentration
- Normalizing homocysteine — Target value below 10 µmol/L
What is not proven
Section titled “What is not proven”Clinical summary
Section titled “Clinical summary”Veelgestelde vragen
When should I have B12 and homocysteine tested?
For cognitive complaints, polyneuropathy, tingling, fatigue, depressive complaints, macrocytosis, vegan/vegetarian eating, use of metformin or PPIs, or unexplained vascular problems.
What are the target values for B12 and homocysteine?
B12: above 300 pmol/L (below 300 is suspected functional deficiency). Homocysteine: below 10 µmol/L, ideally below 8 µmol/L. Above 12-15 µmol/L is clinically significantly elevated.
What is the H-cocktail?
The H-cocktail is a combination for biochemical optimization of homocysteine: folate (5-MTHF) 200-800 mcg, B12 1000 mcg, B6 (P5P) 20-30 mg, B2 10 mg, and optionally TMG 500-1000 mg.
Does homocysteine treatment reduce heart attack risk?
Large RCTs have shown no reduction in heart attack, stroke or mortality from homocysteine lowering. Treatment aims at functional optimization (energy, cognition, methylation), not hard endpoint prevention.
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