Homocysteine Reduction for Stroke Prevention: Regarding the Recent AHA/ASA 2021 Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack.

IF 1.8 4区 医学 Q3 PHARMACOLOGY & PHARMACY Pharmacogenomics & Personalized Medicine Pub Date : 2023-10-03 eCollection Date: 2023-01-01 DOI:10.2147/PGPM.S426421
Craig Brown, Jianhua Wang, Hong Jiang, Merrill F Elias
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Abstract

Reduction of secondary ischemic stroke risk following an initial stroke is an important goal. The 2021 Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack assembles opportunities for up to 80% secondary stroke reduction. Homocysteine reduction was not included in the recommendations. The reduction of homocysteine with low doses of folic acid has been shown to reduce ischemic stroke and all stroke. This has been obscured by studies using high doses of folic acid and cyanocobalamin in patients with renal failure and Methylenetetrahydrofolate reductase (MTHFR) polymorphisms. The confounding impacts of high dose folic acid and cyanocobalamin toxicity in renal failure and MTHFR C677T subgroups are discussed. New studies show that their toxicity is due to non-bioequivalence to the natural dietary forms, L-methylfolate and methylcobalamin. Low doses of folic acid and cyanocobalamin are safer than high doses for these subpopulations. Even lower toxicity with greater effectiveness for reducing homocysteine is seen with L-methylfolate and methylcobalamin, which are safe at high doses. Retinal vascular imaging is a noninvasive method for evaluating central nervous system (CNS) microangiopathy. A formulation containing l-methylfolate and methylcobalamin has been shown to reduce homocysteine and increase perfusion in diabetic retinopathy. This supports homocysteine intervention for CNS ischemia. Future ischemic stroke intervention studies could benefit from monitoring retinal perfusion to estimate the impact of risk reduction strategies. The omission of a recommendation for homocysteine and secondary stroke reduction through the use of B vitamins should be reconsidered in light of re-analysis of major B vitamin intervention studies and new technologies for monitoring CNS perfusion. We recommend revision of the 2021 Guideline to include homocysteine reduction with low doses of folic acid and cyanocobalamin, or better yet, L-methylfolate and methylcobalamin, making a good clinical guideline better.

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减少同型半胱氨酸预防中风:关于近期AHA/ASA 2021预防中风和短暂性脑缺血发作患者的中风。
降低初次中风后继发性缺血性中风的风险是一个重要目标。2021年预防中风和短暂性脑缺血发作患者的中风为高达80%的继发性中风减少提供了机会。同型半胱氨酸减少不包括在建议中。低剂量叶酸降低同型半胱氨酸已被证明可以减少缺血性中风和所有中风。在肾功能衰竭和亚甲基四氢叶酸还原酶(MTHFR)多态性患者中使用高剂量叶酸和氰钴胺的研究掩盖了这一点。讨论了高剂量叶酸和氰钴胺毒性对肾功能衰竭和MTHFR C677T亚组的混杂影响。新的研究表明,它们的毒性是由于与天然膳食形式L-甲基叶酸和甲基钴胺不具有生物等效性。对于这些亚群来说,低剂量的叶酸和氰钴胺比高剂量的更安全。L-甲基叶酸和甲基钴胺在高剂量下是安全的,毒性更低,降低同型半胱氨酸的效果更大。视网膜血管成像是评价中枢神经系统(CNS)微血管病变的一种非侵入性方法。一种含有l-甲基叶酸和甲基钴胺的制剂已被证明可以降低同型半胱氨酸并增加糖尿病视网膜病变的灌注。这支持同型半胱氨酸对中枢神经系统缺血的干预。未来的缺血性中风干预研究可能受益于监测视网膜灌注,以评估风险降低策略的影响。应根据对主要B族维生素干预研究的重新分析和监测中枢神经系统灌注的新技术,重新考虑通过使用B族维生素来减少同型半胱氨酸和继发性中风的建议的遗漏。我们建议修订2021年指南,将低剂量叶酸和氰钴胺或更好的L-甲基叶酸和甲基钴胺降低同型半胱氨酸纳入其中,使良好的临床指南变得更好。
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来源期刊
Pharmacogenomics & Personalized Medicine
Pharmacogenomics & Personalized Medicine Biochemistry, Genetics and Molecular Biology-Molecular Medicine
CiteScore
3.30
自引率
5.30%
发文量
110
审稿时长
16 weeks
期刊介绍: Pharmacogenomics and Personalized Medicine is an international, peer-reviewed, open-access journal characterizing the influence of genotype on pharmacology leading to the development of personalized treatment programs and individualized drug selection for improved safety, efficacy and sustainability. In particular, emphasis will be given to: Genomic and proteomic profiling Genetics and drug metabolism Targeted drug identification and discovery Optimizing drug selection & dosage based on patient''s genetic profile Drug related morbidity & mortality intervention Advanced disease screening and targeted therapeutic intervention Genetic based vaccine development Patient satisfaction and preference Health economic evaluations Practical and organizational issues in the development and implementation of personalized medicine programs.
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