Simplified Methylation Protocol Revised as of Today

[LaurieL]

Hi, tealady.

Lecithin (or alternatively, phos. serine complex) is included to support repair of damaged membranes, particularly in the mitochondria. The oxidative stress in ME/CFS can be quite severe, and the lipid membranes are the most vulnerable parts of the cells to damage from this cause.

Best regards,

Rich

I thought it was lecithin for the nerves, and omega 3's for the fluidity of cell membranes? I also bought PS, which is for something else, but I am having a rough day, and can't remember it off the top of my head. I am confused?

Laurie

 

[Freddd]

RICH - One thing that has steadily improved on your protocol is skin rashes. My oldest daughter (29) has a variety of skin issues that have been worsening over the years, despite dietary and contact-allergen interventions. I'm wondering if she might benefit from b12 or from your whole protocol. She has very high energy and exercises regularly, so she doesn't have CFS. I would buy her the b12 drops, since there's no way she'd keep a sublingual under her tongue for 45 minutes.

What's your opinion? Worth a try?

Hi Madie,

At 63 my skin is the best in my entire life. All the bumps, irritations, infected follicles, roughness,dandruff, acne etc is gone and the acne scars are disappearing and smoothing out. I still have some bouts of skin problems, always timed with folate deficiency for one reason or another.

 

[Freddd]

QUESTION FOR RICH--

Will the protocol help with MCS and with histamine reactions to pollen and other allergens?

You haven't talked much about MCS, and I'm curiouswhat your experinece has been with that...?

Hi Dreambirdie,

My experience with methylb12 and Metafolin in regards to these things are excellent. MCS - GONE. Seasonal Allergies - 99% gone. Asthma - GONE.

Since starting these I am now able to use any detergents and fabric softeners that I might cvopme across. I don't have to avoid that aisle in the supermarket. I haven't left any movies, concerts etc because of overwhelming perfume on some woman.

I have 100% discontinued Albuterol, theophylline, antihistamines, pseudoephedrine, ephedrine, etc. I take absolutely NONE of these any more at any time with the exception of when I was having the induced folate deficiency from the glutathione precursors. I don't even carry all those things with me for emergency usage. I used to have a gadget bag of emergency medications I carried with me at all times.

Many other people have similarly gotten rid of these things with the active b12 protocol.

 

[Freddd]

Hi Rich--

Does glutathione cause fatigue sometimes? This is now happening to me, if I take it on a daily basis.

It does by causing an induced b12 and folate deficiencies.

 

[maddietod]

Freddd- Thanks for this information. Kate started the protocol about a week ago, and we'll see how it works just for skin issues. It's helpful to know that for you, it's not just the b12 that helps. I'm just starting my 3rd month on Rich's protocol, and I'm still having some detox days (nausea, overheating/sweating). I'm hoping that that will stop at some point, and then I'll evaluate my overall progress and probably start asking questions again.

 

[Dreambirdie]

It does by causing an induced b12 and folate deficiencies.

Fredddd, That question was for Rich. And so was my other one.


Hi Rich--

Does glutathione cause fatigue sometimes?

 

[richvank]

Fredddd, That question was for Rich. And so was my other one.


Hi Rich--

Does glutathione cause fatigue sometimes?

Hi, Dreambirdie.

In some people, yes. From about 1999 through 2004, I encouraged PWCs to try to build up their glutathione directly and by use of the precursor amino acids, in a variety of ways. I would say that most who reported trying it (on the CFSFMExperimental group) found that it was beneficial in terms of decreasing the severity of their symptoms, but there were also some who reported that boosting glutathione directly made their symptoms worse. And for those who were helped by it, the benefits were temporary, in that they were lost if the person stopped boosting glutathione. In late 2004 I learned that a problem in the methyation cycle, which is upstream of glutathione synthesis in the sulfur metabolism, was associated with glutathione depletion in autism. Treating to support the methylation cycle caused glutathione to come up automatically. We found by lab testing in ME/CFS that this is true in this disorder, also. So I stopped encouraging people to boost glutathione directly, and instead to focus on supporting the methylation cycle.

I don't know for sure the reason for the unfavorable response that some PWCs have to boosting glutathione directly. One possibility is that when glutathione (GSH) is oxidized (to become GSSG) in responding to the oxidative stress that is present in ME/CFS, these PWCs are not able to reduce it back to be used over, so that the result is a decrease in the ratio of GSH to GSSG. This ratio normally controls the redox potential in the cells, and this potential affects many biochemical reactions there.

The reaction that normally recycles GSSG to GSH is the glutathione reductase reaction, and it requires vitamin B2 and NADPH, which is made from vitamin B3, and is recycled by a side chain on the glycolysis pathway, called the pentose phosphate shunt. So, basically, glucose (blood sugar) is used to power the recycling of glutathione, using B2 and B3 as necessary cofactors. Some PWCs have been found to be low in NADH, and thus are likely also to be low in NADPH.

As you've no doubt noted, Freddd has emphasized that taking glutathione or its precursor amino acids is very deleterious to him, and he has also reported that some others have responded this same way. Freddd also notes that he has a very unfavorable response to folic acid and folinic acid. Folic acid and folinic acid also place demands on NADPH for their conversion to 5,10-methylene tetrahydrofolate, which is the form of folate needed to produce 5L-methyl tetrahydrofolate, which is the form of folate needed as a reactant by the methionine synthase reaction. Furthermore, the MTHFR reaction, which does this conversion, requires NADPH, as does the methionine synthase reductase reaction, which normally refreshes the methylcobalamin coenzyme that supports the methionine synthase enzyme. It may be that Freddd's unfavorable response to all of these supplements is due to their demand for NADPH, which may be in short supply in his case and in some others, and which is needed for these other two important reactions in the folate metabolism and the methylation cycle.

Best regards,

Rich

 

[richvank]

I thought it was lecithin for the nerves, and omega 3's for the fluidity of cell membranes? I also bought PS, which is for something else, but I am having a rough day, and can't remember it off the top of my head. I am confused?

Laurie

Hi, Laurie.

Lecithin contains several phospholipids, which in turn contain fatty acids. Some of the fatty acids in lecithin are omega-3 fatty acids.Lecithin supports cell membranes in general. It is particularly important to have healthy membranes on the neurons, including the neuronal membranes and the myelin surrounding the axons of the neurons. It's true that the unsaturated fatty acids, especially omega-3 fatty acids, help to make the membranes more fluid. This is important for helping the function of the proteins that are in the membranes, which serve as transporters and receptors.

Rich

 

[Dreambirdie]

Thanks Rich for your very thorough explanation.

I am currently having mixed feelings about using the glutathione on a regular basis. On the one hand it is helping me tolerate the methylation supp's much better, probably because it is aiding my liver in processing the toxins that are being released by taking those supp's. Without the glutathione, I think it would take me a very very long time to build up beyond the the most minimal specks of doses. It also helps my MCS reactions A LOT.

On the other hand, the glutathione is sometimes making me very sluggish and dragged out, and I am not too thrilled with that. Less fatigue, not more, would be my preference. Low NADH might be an explanation for that.

SO I guess I will have to play it by ear, and figure it out as I go.

Thanks again for your input.

 

[biophile]

A question for richvank

Hi richvank,

I have to ask, would a partial block in the methylation cycle help explain why I responded negatively to SAM-e, vitamin E, and vitamin C? (the last 2 often recommended due to being anti-oxidants).

SAM-e: horrible bilious and strong malaise feeling all over, especially in the liver area, tingling in right arm.

Vitamin E: unusual nausea and weird "scratchy" headache.

Vitamin C: dull headache.

The response to SAM-e was bad and prolonged enough that you couldn't pay me to try it again. I would be reluctant to try vitamin E again, but the effects only lasted 48 hours. The effect from vitamin C isn't bad enough to fear it but I wouldn't take it regularly. These reactions only occurred when illness reached a certain phase of severity, a few years after trying numerous medications and treatments using recommended dosages (not all at once or together).

Until then the above listed supplements had no noticeable effect at all. Something strange occurred during the worsening of illness and ever since then, tolerance to medications and supplements in general took a nose dive and post-exertional symptoms have become much worse.

It has been a long time since I have read anything which may help to explain what happened and why it still mostly seems stuck there without sign of further improvement. I think your hypothesis on the partial block in the methylation cycle is a good candidate, and I would appreciate your opinion.

Last year I tried 1/4 dose FolaPro and 1/4 dose hydroxy-B12 for roughly 2 months. I couldn't sustain or tolerate a higher dosage. I stopped altogether, perhaps because I got impatient or just forgot 3 months is the suggested minimum. That was about 12 months ago and I regret not staying on it because I have recently become interested in trying it again due to the 23andme results. I ordered more FolaPro as the last bottle was out of date. The hydroxy-B12 bottle I have is still within date. I also ordered folinic acid and methyl-B12 drops. I am reluctant to get other peripheral cofactors, due to cost and potential tolerance issues.

Apparently I am "(+/+)" for several of the relevant SNP's according to 23andme testing, so I guess this may point towards an increased susceptibility to a functional issue within the methylation cycle? I also wonder if it would be possible for me to fine-tune the protocol by looking at personal differences in my 23andme profile and do research on the mechanisms behind these processes?

http://www.knowyourgenetics.com/The Methylation Pathway_files/diagram-1.jpg

http://www.knowyourgenetics.com/The Methylation Pathway_files/supplmentation-1.jpg

Another option I am considering for later is mitochondria related supplements.

EDIT: Looks like LaurieL is attempting a personalised 23andme analysis as well.

 

[sandralee]

Hi Rich,

Do you think that taking a diamine oxidase supplement could impact negatively on the methylation cycle in any way?

Best wishes,

Sandra

 

[aquariusgirl]

Hi Rich

I thought your response to dreambiride & her reaction to glutathione were very interesting.

Based on what you said, I am thinking that a person deficieint in B2 &3 and with poor blood sugar control might not respond all that well to gluthatione supplementation.

I just took a tspn of the liposomal stuff & now I have to go to bed...but like dreambirdie I have found it helpful to ease liver congestion in the past.

 

[leela]

Without the glutathione, I think it would take me a very very long time to build up beyond the the most minimal specks of doses. It also helps my MCS reactions A LOT.

On the other hand, the glutathione is sometimes making me very sluggish and dragged out, and I am not too thrilled with that. Less fatigue, not more, would be my preference. Low NADH might be an explanation for that.

SO I guess I will have to play it by ear, and figure it out as I go.

THis is maybe a really dumb question, but have you played with the dose? As you already know I am one of the people for whom glutathione TD has been a godsend, and I admit to having adjusted the dose according to whether I was actively chelating, feeling generally detoxy or what have you. I can't say I noticed it making me feel extra tired, but I tend to use it mostly when I am doing those sorts of things that wipe me out, so hard to tell.

Especially since I am doing a modified simplified methylation protocol right now, I tend to reserve use of GSH to when I am really overwhelmed with toxicity. I wonder if you used it less often, or at lower doses, if you'd still feel the benefits without the drags?

 

[Dreambirdie]

I thought your response to dreambiride & her reaction to glutathione were very interesting.

Based on what you said, I am thinking that a person deficieint in B2 &3 and with poor blood sugar control might not respond all that well to gluthatione supplementation.

I just took a tspn of the liposomal stuff & now I have to go to bed...but like dreambirdie I have found it helpful to ease liver congestion in the past.

I have noticed that I am craving carbs a lot more since I started using the glutathione. I RARELY EVER have this level of carb craving, so I think it is affecting my blood sugar. I will increase my B-complex and see if that helps.

Thanks for the insight.

 

[Dreambirdie]

THis is maybe a really dumb question, but have you played with the dose? As you already know I am one of the people for whom glutathione TD has been a godsend, and I admit to having adjusted the dose according to whether I was actively chelating, feeling generally detoxy or what have you. I can't say I noticed it making me feel extra tired, but I tend to use it mostly when I am doing those sorts of things that wipe me out, so hard to tell.

Especially since I am doing a modified simplified methylation protocol right now, I tend to reserve use of GSH to when I am really overwhelmed with toxicity. I wonder if you used it less often, or at lower doses, if you'd still feel the benefits without the drags?

Hi Leela--

Thanks for your input.

I have played with the dose of glutathione, and I have played even more with the dose of mB12 I've taken.

The last 2 days I took both the mB12 (half tab--250 mcg) and adB12 (whole tab), with the folapro, and it ended up making me very wired and toxic. No sluggishness with that! I had also spent some considerable time in the sun, so that probably accelerated the detox even more. I had to use 3 doses of glutathione to help unburden my liver.

I am going to skip a few days of the mB12 and order more hydroxoB12, which is a whole lot easier for me to tolerate. Then I will (theoretically) only have to use the glutathione when I am dealing with overt toxins... like at the dentist's office.

At least that is my plan for the moment... liable to change at any moment depending on the level of discomfort/distress I'm in.

 

[maddietod]

Rich-

I'm at day 84 on your protocol, and I've run out of Methylmate. This means I'm using it up at almost twice the expected rate.

(1) Have I created problems for myself by nearly doubling the dose of Methylmate?

(2) How can I get a more accurate measure?

(3) I've used about 3/4 of my Hydroxy B12, so I'm having a similar, but less drastic, problem regulating that as well.

(4) If I decide I need to measure in, say, quarter teaspoons, can I mix these products (individually) with water and keep them in the fridge? I have glass amber bottles that I can wrap in dark paper.

Thanks, as always, for your help

Madie

Edit: With this new bottle, I'm measuring the drops into a small spoon (away from sunlight).

 

[lucyhem]

Hi Rich
I finally got the supplements for the protocol and did the blood draw for the Methylation Pathways test. I am slowly starting to add the supplements. I noticed that I bought the HYdroxy B12 sublingual tablets rather than drops. They are 1000mcg. Will that be OK? I opened the bottle before realizing the mistake.
I also notice that people are playing around with many forms of B12. is that fine to do w this protocol. Could you explain the parameters with that. I know Fredd was offering a B12 protocol. Are people drawing from both?

Lucy

 

[maddietod]

3 months on protocol

I'm at 3 months, and can't find much improvement. In fact, some cognitive functions are worse. My psoriasis improved steadily until a month ago, and it's now back to where it was when I started. My other, milder skin rashes have disappeared. That's my only gain.

I had waves of detox-type reactions, ending about 2 weeks ago. I got sudden drenching sweats, nausea continuing for days, and splitting headaches. So something happened.

I've followed the protocol exactly (using lecithin), adding magnesium to tolerance. I take no drugs or other supplements.

What now?

Madie

 

[Freddd]

I'm at 3 months, and can't find much improvement. In fact, some cognitive functions are worse. My psoriasis improved steadily until a month ago, and it's now back to where it was when I started. My other, milder skin rashes have disappeared. That's my only gain.

I had waves of detox-type reactions, ending about 2 weeks ago. I got sudden drenching sweats, nausea continuing for days, and splitting headaches. So something happened.

I've followed the protocol exactly (using lecithin), adding magnesium to tolerance. I take no drugs or other supplements.

What now?

Madie

Hi Madie,

I would suggest that it is time to do the "B" part of the A-B trial. A switch to the active b12 protocol will tell you much. You may have gone about as far as the simplified protocol can take you. There are no guarantees but generally the active protocol is a great deal more effective.

Also, your skin rashes improving indicates you have made some headway in the methylation department and you may be suffering from low potassium. Your body seems to be hitting some limits. Also, depending upon what you are taking in the folic acid/folinic acid/glutathione/NAC department you may be having folate deficiency with those symptoms.

 

[richvank]

I'm at 3 months, and can't find much improvement. In fact, some cognitive functions are worse. My psoriasis improved steadily until a month ago, and it's now back to where it was when I started. My other, milder skin rashes have disappeared. That's my only gain.

I had waves of detox-type reactions, ending about 2 weeks ago. I got sudden drenching sweats, nausea continuing for days, and splitting headaches. So something happened.

I've followed the protocol exactly (using lecithin), adding magnesium to tolerance. I take no drugs or other supplements.

What now?

Madie

Hi, Madie.

It sounds as though the simplified protocol has helped to lift a partial methylation cycle block enough that your body has been able to excrete some toxins.

I think that 3 months is long enough to find out what your response is to this protocol. If you would like to try switching to the protocol Freddd recommends, I would be very interested to find out how it goes for you on that protocol.

I don't know if it is feasible for you to run the methylation pathways panel and the Metametrix plasma amino acids panel before you change protocols, but if you were able to do that, I think we could learn a lot from it, both in terms of what the effects of the simplified protocol have been, and also in terms of getting baseline data to see what the effects of Freddd's protocol will be, if you choose to try it.

The contact information for the methylation pathways panel is pasted below, as are interpretive comments for it. It requires an order from a physician or a chiropracter.

The plasma amino acids panel can be obtained without a doctor's order from--

https://www.directlabs.com/OrderTests/tabid/55/language/en-US/Default.aspx

It's the "Amino Acids, 40 plasma-Metametrix KIT."

I want to emphasize that my interest is in finding out what will work the best for you and for other PWCs, and to try to understand why. I very much appreciate your willingness to do this testing on yourself.

Best regards,

Rich


Methylation Pathways Panel

This panel will indicate whether a person has a partial methylation cycle block and/or glutathione depletion. I recommend that this panel be run before deciding whether to consider treatment for lifting the methylation cycle block. I am not associated with the lab that offers this panel.

The panel requires an order from a physician or a chiropractor. The best way to order the panel is by fax, on a clinicians letterhead.


Available from:

Health Diagnostics and Research Institute
540 Bordentown Avenue, Suite 2300
South Amboy, NJ 08879
USA
Phone: (732) 721-1234
Fax: (732) 525-3288

Lab Director: Elizabeth Valentine, M.D.

Dr. Tapan Audhya, Ph.D., is willing to help clinicians with interpretation of the panel by phone, or you can use the comments below:


May 19, 2011


Interpretation of Results of the Methylation Pathways Panel

by
Richard A. Van Konynenburg, Ph.D.
Independent Researcher
(richvank@aol.com)


Disclaimer: The Methylation Pathways Panel is offered by the European Laboratory of Nutrients in the Netherlands and the Health Diagnostics and Research Institute in New Jersey, USA. I am not affiliated with these laboratories, but have been a user of this panel, and have written these suggestions at the request of Tapan Audhya, Ph.D., Director of Research for the Health Diagnostics lab, for the benefit of physicians who may not be familiar with this panel. My suggestions for the interpretation of results of the panel are based on my study of the biochemistry involved, on my own experience with interpreting panel results as part of the analysis of a fairly large number of cases of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) over the past four years, and on discussion of some of the issues with Dr. Audhya. I am a researcher, not a licensed physician. Treatment decisions based on the results of applying this panel and its interpretation to individual cases are the responsibility of the treating physician.

Application: In addition to being useful in analyzing cases of ME/CFS, this panel can also be usefully applied to cases of autism and other disorders that involve abnormalities in glutathione, methylation and the folate metabolism.

The panel includes measurement of two forms of glutathione (reduced and oxidized), S-adenosylmethionine (SAMe), S-adenosylhomocysteine (SAH), adenosine, and seven folate derivatives.

According to Dr. Audhya (personal communication), the reference ranges shown on the lab reports for each of these metabolites were derived from measurements on at least 120 healthy male and female volunteer medical students from ages 20 to 40, non-smoking, and with no known chronic diseases. The reference ranges extend to plus and minus two standard deviations from the mean of these measurements.

Glutathione (reduced): This is a measurement of the concentration of the
chemically reduced (active) form of glutathione (abbreviated GSH) in the blood
plasma. The reference range is 3.8 to 5.5 micromoles per liter.

Glutathione plays many important roles in the biochemistry of the body, including serving as the basis of the antioxidant enzyme system, participating in the detoxication system, and supporting the cell-mediated immune response, all of which exhibit deficits in CFS. The level of GSH in the plasma is likely to be more reflective of tissue intracellular glutathione status than the more commonly and more easily measured red blood cell or (essentially equivalent) whole blood glutathione level, which is about three orders of magnitude greater, because red blood cells are normally net producers of glutathione. Also, knowledge of the level of the reduced form, as distinguished from total (reduced plus oxidized) glutathione, which is more commonly measured, is more diagnostic of the status of glutathione function.

In order to be able to approximate the in vivo level of reduced glutathione when blood samples must be shipped to a lab, it is necessary to include special enzyme inhibitors in the sample vials, and these are included in the test kit supplied by these two laboratories.

Most people with chronic fatigue syndrome (PWCs), but not all, are found to have values of GSH that are below the reference range*. This means that they are suffering from glutathione depletion. As they undergo treatment to lift the partial methylation cycle block, this value usually rises into the normal range over a period of a few months. I believe that this is very important, because
glutathione normally participates in the intracellular metabolism of vitamin B12, and if it is low, a functional deficiency of vitamin B12 results, and insufficient methylcobalamin is produced to support methionine synthase in the methylation cycle. In my view, this is the mechanism that causes the onset of ME/CFS. This functional deficiency is not detected in a conventional serum B12 test, but will produce elevated methylmalonate in a urine organic acids test. In my opinion, many of the abnormalities and symptoms in ME/CFS can be traced directly to glutathione depletion.

Anecdotal evidence suggests that PWCs who do not have glutathione depletion do have abnormalities in the function of one or more of the enzymes that make use of glutathione, i.e. the glutathione peroxidases and/or glutathione transferases. This may be due to genetic polymorphisms or DNA adducts on the genes that code for these enzymes, or in the case of some of the glutathione peroxidases, to a low selenium status.

Glutathione (oxidized): This is a measurement of the concentration
of the oxidized form of glutathione (abbreviated GSSG) in the blood
plasma. The reference range is 0.16 to 0.50 micromoles per liter.

Normally, oxidized glutathione in the cells is recycled back to reduced glutathione by glutathione reductase, an enzyme that requires vitamin B2 and NADPH. If this reaction is overwhelmed by oxidative stress, the cells export excess GSSG to the plasma. In some (but not all) PWCs, GSSG is elevated above the normal
range, and this represents oxidative stress. It is more common in CFS to see this level in the high-normal range. This value may increase slightly under initial treatment of a partial methylation cycle block.*

Ratio of Glutatione (reduced) to Glutathione (oxidized): This is not shown explicitly on the panel results, but can be calculated from them. It is a measure of the redox potential in the plasma, and reflects the state of the antioxidant system in the cells. The normal mean value is 14. PWCs often have a value slightly more than half this amount, indicating a state of glutathione depletion and oxidative stress. This ratio has been found to increase during treatment of a partial methylation cycle block.*

S-adenosymethionine (RBC): This is a measure of the concentration of S-adenosylmethionine (SAMe) in the red blood cells. The reference range is 221 to 256 micromoles per deciliter.

SAMe is produced in the methylation cycle and is the main supplier of methyl (CH3) groups for a large number of methylation reactions in the body, including the methylation of DNA and the biosynthesis of creatine, carnitine, coenzyme Q10, melatonin and epinephrine. This measurement is made in the red blood cells because the level there reflects an average over a longer time and is less vulnerable to fluctuations than is the plasma level of SAMe.

Most PWCs have values below the reference range, and treatment raises the value.* A low value for SAMe represents a low methylation capacity, and
in CFS, it usually appears to result from an inhibition or partial block of the enzyme methionine synthase in the methylation cycle. Many of the abnormalities in CFS can be tied to lack of sufficient methylation capacity.

S-adenosylhomocysteine (RBC): This is a measure of the
concentration of S-adenosylhomocysteine (SAH) in the red blood cells. The reference range is 38.0 to 49.0 micromoles per deciliter.

SAH is the product of the many methyltransferase reactions that utilize SAMe as a source of methyl groups. In CFS, its value ranges from below the reference range to above the reference range. Values appear to be converging toward the reference range with treatment.

Sum of SAM and SAH: When the sum of SAM and SAH is below about 268
micromoles per deciliter, it appears to suggest the presence of
upregulating polymorphisms in the cystathionine beta synthase (CBS)
enzyme, though this may not be true in every case. For those considering following the Yasko treatment program, this may be useful information.

Ratio of SAM to SAH: A ratio less than about 4.5 represents low
methylation capacity. Both the concentration of SAM and the ratio of
concentrations of SAM to SAH are important in determining the
methylation capacity, because they affect the rates of the methyltransferase reactions.

Adenosine: This is a measure of the concentration of adenosine in the
blood plasma. The reference range is 16.8 to 21.4 x 10(-8) molar.

Adenosine is a product of the reaction that converts SAH to homocysteine. It is also exported to the plasma when mitochondria develop a low energy charge, so that ATP drops down to ADP, AMP, and eventually, adenosine. Adenosine in the plasma is normally broken down to inosine by the enzyme adenosine deaminase.

In some PWCs adenosine is found to be high, in some it is low, and in some it is in the reference range. I don't yet understand what controls the adenosine level in these patients, and I suspect that there is more than one factor involved. In most PWCs who started with abnormal values, the adenosine level appears to be moving into the reference range with methylation cycle treatment, but more data are needed.

5-CH3-THF: This is a measure of the concentration of 5L-methyl
tetrahydrofolate in the blood plasma. The reference range is 8.4 to 72.6 nanomoles per liter.

This form of folate is present in natural foods, and is normally the most abundant form of folate in the blood plasma. It is the form that serves as a reactant for the enzyme methionine synthase, and is thus the important form for the methylation cycle. It is also the only form of folate that normally can enter the brain. Its only known reactions are the methionine synthase reaction and reaction with the oxidant peroxynitrite.

When there is a partial block in methionine synthase, 5L-CH3-THF drains from the cells into the blood plasma by the so-called methyl trap mechanism. As other forms of folate are converted to 5L-CH3-MTF, this mechanism depletes the cells of folates in general.

Many PWCs have a low value of 5L-CH3-MTF, consistent with a partial block in the methylation cycle. Most methylation treatment protocols include supplementation with 5L-CH3-MTF, which is sold over-the-counter as Metafolin, FolaPro, or MethylMate B (trademarks), and in the prescription medical foods supplied by PamLab, including Deplin, CerefolinNAC and Metanx. There are some others on the market that include both racemic forms (5L and 5R) of this folate.

When methylation treatment is used, the level of 5-CH3-THF rises in nearly every PWC. If the concentration of 5-CH3-THF is within the reference range, but either SAM or the ratio of SAM to SAH is below the reference values, it suggests that there is a partial methylation cycle block and that it is caused by inavailability of sufficient bioactive B12, rather than inavailability of sufficient folate. A urine organic acids panel will show elevated methylmalonate if there is a functional deficiency of B12. I have seen this combination frequently, and I think it demonstrates that the functional deficiency of B12 is the immediate root cause of most cases of partial methylation cycle block. Usually glutathione is low in these cases, which is consistent with such a functional deficiency. As the activity of the methylation cycle becomes more normal, the demand for 5-CH3-THF will likely increase, so including it in the treatment protocol, even if not initially low, will likely be beneficial.

10-Formyl-THF: This is a measure of the concentration of 10-formyl
tetrahydrofolate in the blood plasma. The reference range is 1.5 to 8.2 nanomoles per liter.

This form of folate is involved in reactions to form purines, which form part of RNA and DNA as well as ATP. It is usually on the low side in PWCs, likely as a result of the methyl trap mechanism mentioned above. This deficiency is likely the reason for some elevation of mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) often seen in PWCs. This deficit may also impact replacement of cells lining the gut, as well as white blood cells.

5-Formyl-THF: This is a measure of the concentration of 5-formyl
tetrahydrofolate (also called folinic acid) in the blood plasma. The reference range is 1.2 to 11.7 nanomoles per liter.

This form is not used directly as a substrate in one-carbon transfer reactions, but it can be converted into other forms of folate, and may serve as a buffer form of folate. Most but not all PWCs have a value on the low side. It is one of the
supplements in some methylation protocols. It can be converted to 5L-CH3-THF in the body by a series of three reactions, one of which requires NADPH, and it may also help to supply other forms of folate until the methionine synthase reaction comes up to more normal activity.

THF: This is a measure of the concentration of tetrahydrofolate in
the blood plasma. The reference range is 0.6 to 6.8 nanomoles per liter.

This is the fundamental chemically reduced form of folate from which several other reduced folate forms are synthesized, and thus serves as the hub of the folate metabolism. THF is also a product of the methionine synthase reaction, and participates in the reaction that converts formiminoglutamate (figlu) into glutamate in the metabolism of histidine. If figlu is found to be elevated in a urine organic acids panel, it usually indicates that THF is low. In PWCs it is lower than the mean normal value of 3.7 nanomoles per liter in most but not all PWCs.

Folic acid: This is a measure of the concentration of folic acid in
the blood plasma. The reference range is 8.9 to 24.6 nanomoles per liter.

Folic acid is a synthetic form of folate, not found in nature. It is added to food grains in the U.S. and some other countries in order to lower the incidence of neural tube birth defects, including spina bifida. It is the oxidized form of folate, and therefore has a long shelf life and is the most common commercial folate supplement. It is normally converted into THF by two sequential reactions catalyzed by dihydrofolate reductase (DHFR), using NADPH as the reductant. However, some people are not able to carry out this reaction well for genetic reasons, and PWCs may be depleted in NADPH, so folic acid is not the best supplemental form of folate for these people.

Low values suggest folic acid deficiency in the current diet. High values, especially in the presence of low values for THF, may be associated with inability to convert folic acid into reduced folate readily, such as because of a genetic polymorphism in the DHFR enzyme. They may also be due to high supplementation of folic acid.

Folinic acid (WB): This is a measure of the concentration of folinic acid in the whole blood. The reference range is 9.0 to 35.5 nanomoles per liter.

See comments on 5-formyl-THF above. Whole blood folinic acid usually tracks with the plasma 5-formyl-THF concentration.

Folic acid (RBC): This is a measure of the concentration of folic acid in the red blood cells. The reference range is 400 to 1500 nanomoles per liter.

The red blood cells import folic acid when they are initially being formed, but during most of their lifetime, they do not normally import, export, or use it. They simply serve as reservoirs for it, giving it up when they are broken down.

Many PWCs have low values of this parameter. This can be caused by a low folic acid status in the diet over the previous few months, since the population of RBCs at any time has ages ranging from zero to about four months. However, in CFS it can also be caused by oxidative damage to the cell membranes, which allows folic acid to leak out of the cells. Dr. Audhya reports that treatment with omega-3 fatty acids has been found to raise this value over time in one cohort.

If anyone finds errors in the above suggestions, I would appreciate being notified at richvank@aol.com.

* Nathan, N., and Van Konynenburg, R.A., Treatment Study of Methylation Cycle Support in Patients with Chronic Fatigue Syndrome and Fibromyalgia, poster paper, 9th International IACFS/ME Conference, Reno, Nevada, March 12-15, 2009. (http://www.mecfs-vic.org.au/sites/w...Article-2009VanKonynenburg-TrtMethylStudy.pdf)