MTHFR Mutations AND Thiamine-Responsive Megaloblastic Anemia

[managing]

So, what advice, thoughts, suggestions would you have for somebody who recently discovered they have mutations of MTHFR (both common mutations) genes AND SLC19A2 (which leads to Thiamine responsive Megaloblastic Anemia). 45 yr old male. Been PUFA depleting for years. Active: cycling, skiing, weight lifting, but also suffer from various CFS type effects cyclically.

The TRMA manifests itself most strongly in progressive sensorineural hearing loss. Less so as diabetes. Defintely some insulin resistance issues and 10% overweight. But blood glucose well under control.

The MTHFR mutations manifest mainly as IBS, Migraine, gut permeability, autoimmune/inflammatory.

Supplements/Therapies
Thiamine, obviously. How much and how often? As a water soluble, it should be 2-3 x day to keep levels up? Can it be overdone? Doesn't seem to have any toxicity per se.

Methylcobalamin and Folate supplementation are controversial and RP seems to be cautionary about over methylation

Niacinamide--even small doses put me straight to sleep. Yes, with sugar. Am I missing something?

Pansterone--no, I don't expect it to be therapeutic here, but any concerns?

Weight Loss
Seems I could benefit from weight loss. Supplements dietary strategy suggested as adaptation to these mutations? Low fat has never dropped one ounce from me. Low carb was very effective, but I am hesitant to make insulin resistance worse on purpose. Have recovered a lot of insulin sensitivity since low carb days. Paging @tyw on many levels . . .

Children
Children haven't been tested yet. Wife's mother has Parkinson's which some associate with MTHFR mutations, so a chance they got it from both sides. Any reason NOT to supplement them at least with Thiamine?

 

[tyw]

I am going to list generalisations from the problems regarding Methylation treatment that I gleaned from one of the doctors I am in contact with. I won't be revealing patient details obviously, and any protocol below should be seen as a hypothetical protocol meant for informational purposes only (I am certainly not a doctor).

I will also state some facts without proof, and I do not have much proof, other than the results I saw in clinical practice. I will not provide much references, and leave it up to the reader to do their own research on various points made. The purpose is to give an overview as briefly as possible. This post will probably still be too long anyway ....

As always, I would recommend people have a knowledgeable doctor deal with their ongoing methylation issues, with the proper monitoring tools in place.

----

First off, methylation is a big topic, and there are many sites on which this topic is discussed, with various people trying out various B vitamin and methyl donor supplementation strategies (one can go search for these forums on their own time). The common theme is that supplementing with an isolated B vitamin is not a good strategy, and tends to lead to imbalances in the rest of the B vitamins.

In clinical practice, I see this to be true, and do not think it wise to do something like pure Thiamine (B1), Riboflavin (B2), or pyridoxal 5-phosphate (active B6) supplementation.

I state this without proof: Most methylation problems are either due to a lack of Methyl Donors, or insufficient FAD.

I will start with FAD.

FAD is derived from a 2-step enzymatic reaction from Riboflavin / Vit B2. Thiamine balance is implicated here, and again I do not give recommendations on the doses. I will say that both must be present, and supplemented in together for a prolonged period (at least several weeks) for there to be substantial effect.

As to why FAD is the bottleneck, if the reader looks up diagrams on the Folate cycle, the Biopterin cycle, and the Transsulfuration cycles, you will see what I mean. All the common bottlenecks require FAD as an electron acceptor to work. MAO needs FAD, GSSG -> GSH recycling needs FAD to work, 5-methylenetetrahydrofolate -> 5-methyltetrahydrofolate requires FAD to work, MTHR requires FAD to work, MTRR requires FAD to work, etc, etc .....

SIDENOTE: I do not worry as much about Vitamin B12 supplementation. In most clinical cases, this is often sufficient, or too high. High B12 is a likely symptom that FAD is in insufficient levels. Again, the reader can look up all the enzymes which require B12 as a co-factor, they almost all require FAD (and sometimes NADPH as well).

B6 follows a similar pattern, though since B6 supplementation produces less downsides, I am not too worried about overdose of this compound.​

FAD recycling is huge issue which I think is not properly addressed in methylation. It is clear that so many things require FAD as an electron acceptor (and creating FADH or FADH2 or some FAD free radical as a result), and that this now-more-energetic FAD-derivative itself requires another electron acceptor to get you back down to FAD, and then that FAD can be reused again in reactions.

Traditionally, the idea was that Oxygen was needed as an electron acceptor for higher-energy derivatives of FAD, in order to regenerate FAD. Based on the clinical models that I've seen, those with SNPs that produce excess SOD (superoxide dismutase) have more "methylation problems". ie: These people have chronically low superoxide (which is the case in diabetes BTW -- Hyperlipid: The Crabtree Effect and superoxide in diabetes).

I have hypothesised therefore that superoxide production is a key ingredient to maintaining fast and efficient FAD regeneration (in addition to ample O2 of course). This article is complex, but does describe the various redox states of FAD, and how transfers can occur -- Cryptochrome and Magnetic Sensing

I do not know if this is true, but it may explain why those who are capable of producing physiologically relevant levels of superoxide, while maintaining good cell level oxygenation, are able to stave of methylation-type issues despite having "poor methylation SNPs".

In any case, a compromise in these systems require exogenous supplementation. Oftentimes, this needs to be done in a synergistic manner, and usually must first include sufficient B1 and B2. The B2 is required to provide for the lacking FAD.

After balance has been achieved (use blood markers), a combo of :

- some NAD or NADH source at decent doses (see note below on COMT)
- B6 as Pyridoxal-5-phosphate, typically at least 50mg a day (but again, dosages need to be adjusted)
- Lysine, usually low dose (<1,000mg a day)
- Zinc, moderate dose (10-30mg)
- Magnesium source, but not glycinate or aspartate (see note below)

All of these are co-factors that seem to need to work together. Best if taken just before bed, since lysine tends to be best absorbed with little food (this assumes that dinner is not too heavy). B6 and lysine seems to be a synergistic combo that both need to be present to work (again, reader can do their research). Lysine tends to be de-acetylated and therefore be ineffective if there is insufficient Magnesium, and these reactions are often NAD-dependent.

Regarding NAD, I have no idea why this is the case, but clinically speaking, those with a COMT V158M AA +/+ SNP tend to do better with direct NAD+ supplementation (eg: niacin or niacinamide), and those with the -/- SNP tend to do better with NADH supplementation. No clue why, but mental symptoms like depression and sluggishness become obvious when giving a COMT V158M -/- NAD supplementation. The +/- SNP seems to have less issues overall, and responds to NAD supplementation as well. Again, I have not properly thought through the mechanics of this, and cannot explain why this is the case. It is just a weird pattern noticed in practice.

The note regarding Magnesium in a non glycinate or aspartate form is based on the observation that many people who have such "methylation issues" often come with a dysfunctional Glycine Cleavage System (which itself is NAD+ dependent, and thus requires a high NAD+/NADH ratio) -- Glycine cleavage system - Wikipedia . Usually this comes with an unfavourable GAD SNP, which does affect GABA levels in the brain.

Back all the way to methyl donors. In general, overdosing on methyl donors is very difficult IMO. Even cases where you give 10mg of 5-MTHF in multiple doses a day doesn't seem to create issues. IMO, methyl donors are behaviour exactly according to their name -- they donate methyl groups only when called to donate them; there is no risk of over-methylation due to having too many methyl donors lying around; over-methylation is a process that is upstream of the methyl donor, if methylation needs to happen and there are no methyl donors, bad things happen (enzyme systems do not work).

Clinically speaking, I rarely see issues with something like 5-MTHF supplementation, however, it also do not see it to be effective unless all the upstream issues with FAD are fixed first. Everything above is usually done synergistically with 5-MTHF supplementation. Again, if we look at the diagrams illustrating methylation processes, you will often find 5-MTHF as a donor only in far-downstream processes, which need all prior steps to succeed before that is useful.

The same caveat for 5-MTHF applies to B-12 -- this is a downstream cofactor which needs FAD levels to be adequate before further supplementation is added. As for type of B-12 supplementation, I am in general agreement with Amy Yasko's recommendations (based on COMT V158M and VDR taq SNPs) -- https://www.knowyourgenetics.com/media/pdf/Simplified Protocol.pdf

Yasko is big on Lithium supplementation. I generally would like to only use this is cases of particular COMT SNPs, and that should be worked out with a good practitioner.

Often times, moderate dose Molybdnum (500mcg x 3 a day) and Manganese (10mg x 2 a day) are beneficial. Again, this requires practitioner monitoring.

Some people implicate Gut issues as being caused by under-Methylation. Example article showing the Oxalate and Methylation connection -- Oxalates and MTHFR: Understanding the Gut-Kidney Axis . I have no recommendations here. Some doctors seem to like to use Fecal Calprotectin as a measure of GI inflammation, but honestly I think it is a very blunt marker that doesn't say much other than "yeah, u r inflammed".

I do like the Genova NutrEval Plasma tests though -- Clinician Services | Genova Diagnositcs . That would tell you if stuff like Lysine is too low, or magnesium is too low, as well as the status of all the markers of balance for the B vitamins that I mentioned above. Fatty acid analysis is available too. The problem as usual is cost of the test, and the requirement for frequent re-testing.

----

Regarding diet, Fatty acid metabolism technically requires more FAD than carbohydrate based metabolism. (see wiki article for details -- Beta oxidation - Wikipedia) Well, carbohydrate metabolism still needs FMN (pre-cursor to FAD, and formed from Riboflavin), but there are no conclusions to be made IMO.

Some people claim that thyroid needs to be good in order for the conversion of Riboflavin to FMN and FAD. While this is theoretically true, in practice, I rarely see any issues here unless in cases of hardcore ketogenesis. Mild carb intake (100g a day) seems to fix any issues. If in doubt, one can always check their thyroid status. I am not opposed to thyroid supplementation if needed, but that is for a doctor to determine.

I have no hard evidence for this whatsoever, but higher fat diets, especially saturated fat, do not seem to fit well with people who have methylation issues. Common symptoms include anxiety, shivering, cold hands and feet, and general histamine-overdose like symptoms. There is no doubt that the methylation cycles need to be more active during fatty acid processing, but I have yet to pin down an actual mechanic.

The same applies for excess protein consumption. Again, dunno why, but it's just something that we see in practice (even when controlled for purely protein without fat, eg: chicken breasts, shrimp with fat-free condiments).

In general, Molybdenum and Manganese in the doses listed above seem to be the fix, though again, I have not nailed down the exact mechanics, and therefore do not make any recommendations.

This of course doesn't mean that one should go extreme low fat and high carb though. Experiment accordingly, and find a diet that doesn't cause symptoms to flare up.

After a non-stressful diet has been achieved, all the remaining issues above still need to be addressed. This is a case where a bad diet will make things worse, but a good diet is not a sufficient fix. Directed supplementation is usually necessary.

----

As usual, a lot of this sort of work requires supervised diagnosis and monitoring by a doctor , and that is what I'd recommend. This post is just here to present some ideas which I don't normally see covered on this topic, and maybe some people will find that interesting.

.....

 

[managing]

I am going to list generalisations from the problems regarding Methylation treatment that I gleaned from one of the doctors I am in contact with. I won't be revealing patient details obviously, and any protocol below should be seen as a hypothetical protocol meant for informational purposes only (I am certainly not a doctor).

I will also state some facts without proof, and I do not have much proof, other than the results I saw in clinical practice. I will not provide much references, and leave it up to the reader to do their own research on various points made. The purpose is to give an overview as briefly as possible. This post will probably still be too long anyway ....

As always, I would recommend people have a knowledgeable doctor deal with their ongoing methylation issues, with the proper monitoring tools in place.

----

First off, methylation is a big topic, and there are many sites on which this topic is discussed, with various people trying out various B vitamin and methyl donor supplementation strategies (one can go search for these forums on their own time). The common theme is that supplementing with an isolated B vitamin is not a good strategy, and tends to lead to imbalances in the rest of the B vitamins.

In clinical practice, I see this to be true, and do not think it wise to do something like pure Thiamine (B1), Riboflavin (B2), or pyridoxal 5-phosphate (active B6) supplementation.

I state this without proof: Most methylation problems are either due to a lack of Methyl Donors, or insufficient FAD.

I will start with FAD.

FAD is derived from a 2-step enzymatic reaction from Riboflavin / Vit B2. Thiamine balance is implicated here, and again I do not give recommendations on the doses. I will say that both must be present, and supplemented in together for a prolonged period (at least several weeks) for there to be substantial effect.

As to why FAD is the bottleneck, if the reader looks up diagrams on the Folate cycle, the Biopterin cycle, and the Transsulfuration cycles, you will see what I mean. All the common bottlenecks require FAD as an electron acceptor to work. MAO needs FAD, GSSG -> GSH recycling needs FAD to work, 5-methylenetetrahydrofolate -> 5-methyltetrahydrofolate requires FAD to work, MTHR requires FAD to work, MTRR requires FAD to work, etc, etc .....

SIDENOTE: I do not worry as much about Vitamin B12 supplementation. In most clinical cases, this is often sufficient, or too high. High B12 is a likely symptom that FAD is in insufficient levels. Again, the reader can look up all the enzymes which require B12 as a co-factor, they almost all require FAD (and sometimes NADPH as well).

B6 follows a similar pattern, though since B6 supplementation produces less downsides, I am not too worried about overdose of this compound.​

FAD recycling is huge issue which I think is not properly addressed in methylation. It is clear that so many things require FAD as an electron acceptor (and creating FADH or FADH2 or some FAD free radical as a result), and that this now-more-energetic FAD-derivative itself requires another electron acceptor to get you back down to FAD, and then that FAD can be reused again in reactions.

Traditionally, the idea was that Oxygen was needed as an electron acceptor for higher-energy derivatives of FAD, in order to regenerate FAD. Based on the clinical models that I've seen, those with SNPs that produce excess SOD (superoxide dismutase) have more "methylation problems". ie: These people have chronically low superoxide (which is the case in diabetes BTW -- Hyperlipid: The Crabtree Effect and superoxide in diabetes).

I have hypothesised therefore that superoxide production is a key ingredient to maintaining fast and efficient FAD regeneration (in addition to ample O2 of course). This article is complex, but does describe the various redox states of FAD, and how transfers can occur -- Cryptochrome and Magnetic Sensing

I do not know if this is true, but it may explain why those who are capable of producing physiologically relevant levels of superoxide, while maintaining good cell level oxygenation, are able to stave of methylation-type issues despite having "poor methylation SNPs".

In any case, a compromise in these systems require exogenous supplementation. Oftentimes, this needs to be done in a synergistic manner, and usually must first include sufficient B1 and B2. The B2 is required to provide for the lacking FAD.

After balance has been achieved (use blood markers), a combo of :

- some NAD or NADH source at decent doses (see note below on COMT)
- B6 as Pyridoxal-5-phosphate, typically at least 50mg a day (but again, dosages need to be adjusted)
- Lysine, usually low dose (<1,000mg a day)
- Zinc, moderate dose (10-30mg)
- Magnesium source, but not glycinate or aspartate (see note below)

All of these are co-factors that seem to need to work together. Best if taken just before bed, since lysine tends to be best absorbed with little food (this assumes that dinner is not too heavy). B6 and lysine seems to be a synergistic combo that both need to be present to work (again, reader can do their research). Lysine tends to be de-acetylated and therefore be ineffective if there is insufficient Magnesium, and these reactions are often NAD-dependent.

Regarding NAD, I have no idea why this is the case, but clinically speaking, those with a COMT V158M AA +/+ SNP tend to do better with direct NAD+ supplementation (eg: niacin or niacinamide), and those with the -/- SNP tend to do better with NADH supplementation. No clue why, but mental symptoms like depression and sluggishness become obvious when giving a COMT V158M -/- NAD supplementation. The +/- SNP seems to have less issues overall, and responds to NAD supplementation as well. Again, I have not properly thought through the mechanics of this, and cannot explain why this is the case. It is just a weird pattern noticed in practice.

The note regarding Magnesium in a non glycinate or aspartate form is based on the observation that many people who have such "methylation issues" often come with a dysfunctional Glycine Cleavage System (which itself is NAD+ dependent, and thus requires a high NAD+/NADH ratio) -- Glycine cleavage system - Wikipedia . Usually this comes with an unfavourable GAD SNP, which does affect GABA levels in the brain.

Back all the way to methyl donors. In general, overdosing on methyl donors is very difficult IMO. Even cases where you give 10mg of 5-MTHF in multiple doses a day doesn't seem to create issues. IMO, methyl donors are behaviour exactly according to their name -- they donate methyl groups only when called to donate them; there is no risk of over-methylation due to having too many methyl donors lying around; over-methylation is a process that is upstream of the methyl donor, if methylation needs to happen and there are no methyl donors, bad things happen (enzyme systems do not work).

Clinically speaking, I rarely see issues with something like 5-MTHF supplementation, however, it also do not see it to be effective unless all the upstream issues with FAD are fixed first. Everything above is usually done synergistically with 5-MTHF supplementation. Again, if we look at the diagrams illustrating methylation processes, you will often find 5-MTHF as a donor only in far-downstream processes, which need all prior steps to succeed before that is useful.

The same caveat for 5-MTHF applies to B-12 -- this is a downstream cofactor which needs FAD levels to be adequate before further supplementation is added. As for type of B-12 supplementation, I am in general agreement with Amy Yasko's recommendations (based on COMT V158M and VDR taq SNPs) -- https://www.knowyourgenetics.com/media/pdf/Simplified Protocol.pdf

Yasko is big on Lithium supplementation. I generally would like to only use this is cases of particular COMT SNPs, and that should be worked out with a good practitioner.

Often times, moderate dose Molybdnum (500mcg x 3 a day) and Manganese (10mg x 2 a day) are beneficial. Again, this requires practitioner monitoring.

Some people implicate Gut issues as being caused by under-Methylation. Example article showing the Oxalate and Methylation connection -- Oxalates and MTHFR: Understanding the Gut-Kidney Axis . I have no recommendations here. Some doctors seem to like to use Fecal Calprotectin as a measure of GI inflammation, but honestly I think it is a very blunt marker that doesn't say much other than "yeah, u r inflammed".

I do like the Genova NutrEval Plasma tests though -- Clinician Services | Genova Diagnositcs . That would tell you if stuff like Lysine is too low, or magnesium is too low, as well as the status of all the markers of balance for the B vitamins that I mentioned above. Fatty acid analysis is available too. The problem as usual is cost of the test, and the requirement for frequent re-testing.

----

Regarding diet, Fatty acid metabolism technically requires more FAD than carbohydrate based metabolism. (see wiki article for details -- Beta oxidation - Wikipedia) Well, carbohydrate metabolism still needs FMN (pre-cursor to FAD, and formed from Riboflavin), but there are no conclusions to be made IMO.

Some people claim that thyroid needs to be good in order for the conversion of Riboflavin to FMN and FAD. While this is theoretically true, in practice, I rarely see any issues here unless in cases of hardcore ketogenesis. Mild carb intake (100g a day) seems to fix any issues. If in doubt, one can always check their thyroid status. I am not opposed to thyroid supplementation if needed, but that is for a doctor to determine.

I have no hard evidence for this whatsoever, but higher fat diets, especially saturated fat, do not seem to fit well with people who have methylation issues. Common symptoms include anxiety, shivering, cold hands and feet, and general histamine-overdose like symptoms. There is no doubt that the methylation cycles need to be more active during fatty acid processing, but I have yet to pin down an actual mechanic.

The same applies for excess protein consumption. Again, dunno why, but it's just something that we see in practice (even when controlled for purely protein without fat, eg: chicken breasts, shrimp with fat-free condiments).

In general, Molybdenum and Manganese in the doses listed above seem to be the fix, though again, I have not nailed down the exact mechanics, and therefore do not make any recommendations.

This of course doesn't mean that one should go extreme low fat and high carb though. Experiment accordingly, and find a diet that doesn't cause symptoms to flare up.

After a non-stressful diet has been achieved, all the remaining issues above still need to be addressed. This is a case where a bad diet will make things worse, but a good diet is not a sufficient fix. Directed supplementation is usually necessary.

----

As usual, a lot of this sort of work requires supervised diagnosis and monitoring by a doctor , and that is what I'd recommend. This post is just here to present some ideas which I don't normally see covered on this topic, and maybe some people will find that interesting.

.....

Wow. That. Was. Amazing. Thank you. It will take days to reread this and fully process, along with the resources provided.

 

[Trix]

Very Nice tyw, Thank you for taking the time to explain your understanding!

 

[Koveras]

I have no hard evidence for this whatsoever, but higher fat diets, especially saturated fat, do not seem to fit well with people who have methylation issues. Common symptoms include anxiety, shivering, cold hands and feet, and general histamine-overdose like symptoms. There is no doubt that the methylation cycles need to be more active during fatty acid processing, but I have yet to pin down an actual mechanic.

Saturated fats have a higher choline requirement then other fats, but higher fat diets in general will have high choline requirements - and there is some interplay between high fat diets, the microbiome, genetics, and choline requirements

In other words, potentially acting as a methyl sink / requiring a higher intake of methyl donors.

https://chrismasterjohnphd.com/2010/11/23/sweet-truth-about-liver-and-egg-yolks/

Gut Microbiota and Nonalcoholic Fatty Liver Disease: Insights on Mechanism and Application of Metabolomics

 

[johnwester130]

MTHFKR

 

[managing]

MTHFKR

Right? Every time I say it in my head, that is what I call it . . .

 

[managing]

The note regarding Magnesium in a non glycinate or aspartate form is based on the observation that many people who have such "methylation issues" often come with a dysfunctional Glycine Cleavage System (which itself is NAD+ dependent, and thus requires a high NAD+/NADH ratio) -- Glycine cleavage system - Wikipedia . Usually this comes with an unfavourable GAD SNP, which does affect GABA levels in the brain.

.....

As I process this considerable bite, my first thought (random order) is, does the above bit about glycine cleavage system suggest that gelatin/bone broth might be problematic for those affected? If so, what effects might be expected?

 

[tyw]

@Koveras Good info. I shall dig further!

As I process this considerable bite, my first thought (random order) is, does the above bit about glycine cleavage system suggest that gelatin/bone broth might be problematic for those affected? If so, what effects might be expected?

Possible if glycine overdose has been achieved. Overdoing bone broth could potentially lead to issues.

The Glycine cleavage system is likely the most significant glycine disposal pathway in the body, and if it is not working, one can get a mild version of Glycine encephalopathy, with all the associated nervous system issues -- Glycine encephalopathy - Wikipedia

Note that the forward reaction, which catabolises glycine, requires both NAD+ and 5-MTHF to work. Not having enough of either is going to be a problem with those who are slightly compromised on this pathway (hence the recommendation to supplement both in my first post).

.....

 

[managing]

@Koveras Good info. I shall dig further!



Possible if glycine overdose has been achieved. Overdoing bone broth could potentially lead to issues.

The Glycine cleavage system is likely the most significant glycine disposal pathway in the body, and if it is not working, one can get a mild version of Glycine encephalopathy, with all the associated nervous system issues -- Glycine encephalopathy - Wikipedia

Note that the forward reaction, which catabolises glycine, requires both NAD+ and 5-MTHF to work. Not having enough of either is going to be a problem with those who are slightly compromised on this pathway (hence the recommendation to supplement both in my first post).

.....

Thanks. I've often found that for awhile gelatin/broth consumption makes me feel good. Then if I keep it up, it makes me feel worse. Anecdotal of course, but FWIW.

I didn't say in my original post, but I've begun taking Thiamine and can see that it makes me feel better already. I've been taking 50-100mg 2-3x day. It seems excessive, but you seem to suggest front-loading and then cutting back, which is my intent. After your original response I have some riboflavin on order and will arrive in a few days.

If I understand you correctly, you are saying start with thse two together and by confirm with lab, you mean confirm that RBC are "normal", ie, not megaloblastic, yes? How long will it take to turn over entirely? Or will they simply shrink and not require apoptosis for resolution?

And that is when I start with the rest of listed in your original response. Have I got it?

 

[tyw]

Thanks. I've often found that for awhile gelatin/broth consumption makes me feel good. Then if I keep it up, it makes me feel worse. Anecdotal of course, but FWIW.

I didn't say in my original post, but I've begun taking Thiamine and can see that it makes me feel better already. I've been taking 50-100mg 2-3x day. It seems excessive, but you seem to suggest front-loading and then cutting back, which is my intent. After your original response I have some riboflavin on order and will arrive in a few days.

If I understand you correctly, you are saying start with thse two together and by confirm with lab, you mean confirm that RBC are "normal", ie, not megaloblastic, yes? How long will it take to turn over entirely? Or will they simply shrink and not require apoptosis for resolution?

And that is when I start with the rest of listed in your original response. Have I got it?

Serum tests for B1 and B2 should suffice, as would all the B vitamins. Some people will use a Pyroluria Urine Test to determine if stress factors in your life are causing excessive B6 turnover, but getting serum markers to a decent state should suffice. IME, with proper supplementation, this should not take longer than a month.

There are less common cases where B1 levels only went up with either Benfotiamine or IV thiamine, but again, those are not common, and if oral supplementation of thiamine is not successful, then a trained medical practitioner is required to administer these compounds. Benfotiamine typically requires concurrent Thiamine supplementation.

RBC structural analysis would be good too, but IMO those changes take longer (like 3 months), and the serum marker is a better bet to determine further supplementation requirements. RBC changes probably require the rest of the B-vitamins to be present as well, hence why we see serum B1 and B2 levels recover first, and then use other B vitamins as needed (based on lab testing, which again, hopefully there is a doctor to interpret).

....

 

[MB50]

After balance has been achieved (use blood markers), a combo of :

- some NAD or NADH source at decent doses (see note below on COMT)
- B6 as Pyridoxal-5-phosphate, typically at least 50mg a day (but again, dosages need to be adjusted)
- Lysine, usually low dose (<1,000mg a day)
- Zinc, moderate dose (10-30mg)
- Magnesium source, but not glycinate or aspartate (see note below)

All of these are co-factors that seem to need to work together. Best if taken just before bed, since lysine tends to be best absorbed with little food (this assumes that dinner is not too heavy). B6 and lysine seems to be a synergistic combo that both need to be present to work (again, reader can do their research). Lysine tends to be de-acetylated and therefore be ineffective if there is insufficient Magnesium, and these reactions are often NAD-dependent.

I remember in one of your posts from a while ago you cautioned against using Niacinamide during the evening because it inhibits SIRT1 activity, which can be bad because that protein also displays a circadian rhythm (i.e. it is more active at night). Do people need to take this into consideration when evaluating whether or not to supplement with this combo at night? Or, does the dose matter?

Would it make sense to experiment with taking niacinamide with dinner, and then taking the rest of the combo just before bed to potentially alleviate any negative affects of inhibiting SIRT1 at the wrong time?

 

[paymanz]

Saturated fats have a higher choline requirement then other fats, but higher fat diets in general will have high choline requirements - and there is some interplay between high fat diets, the microbiome, genetics, and choline requirements

In other words, potentially acting as a methyl sink / requiring a higher intake of methyl donors.

https://chrismasterjohnphd.com/2010/11/23/sweet-truth-about-liver-and-egg-yolks/

Gut Microbiota and Nonalcoholic Fatty Liver Disease: Insights on Mechanism and Application of Metabolomics

View attachment 4793

thanks , good to know.

 

[paymanz]

manganese and magnesium are both factors affecting thiamin levels in body.to form pyrophosphatic thiamine, the active form.

 

[tyw]

I remember in one of your posts from a while ago you cautioned against using Niacinamide during the evening because it inhibits SIRT1 activity, which can be bad because that protein also displays a circadian rhythm (i.e. it is more active at night). Do people need to take this into consideration when evaluating whether or not to supplement with this combo at night? Or, does the dose matter?

Would it make sense to experiment with taking niacinamide with dinner, and then taking the rest of the combo just before bed to potentially alleviate any negative affects of inhibiting SIRT1 at the wrong time?

Good topic to address. The TL;DR is that:

- theoretically niacinamide / nicotinamide is not an appropriate choice at night
- SIRT1 suppression is dose dependent.
- for the purposes of B-vitamin support, doses of 100mg Niacin seem to be sufficient
- at such doses, form of NAD+ precursor may not matter, but experimentation is needed

Addressing topics separately.

---
SIRT1 in circadian regulation

This is clearly an important factor. SIRT1 should be high at night, as per the "WT" (wild-type, aka: normal phenotype) line in the chart below. Note that "BTSG" refers to a transgenic mice that had 10-times SIRT1 activity, and "BSKO" referred to mice with complete SIRT1 knockout. Once again, we see that both too much and too little SIRT1 cause major disruptions to circadian protein expression.

This chart was taken from paper, see full paper for more effects based on this SIRT1 disruption -- http://www.cell.com/cell/fulltext/S0092-8674(13)00594-1

In a similar study (mouse model), brain SIRT1 knockout basically destroys all circadian signalling, and SIRT1 depletion leads to major disruptions -- SIRT1 mediates central circadian control in the SCN by a mechanism that decays with aging

See Figure 5 for the reduction in all circadian signalling proteins after SIRT1 depletion, we're basically looking at 30-50% losses in protein expression -- SIRT1 mediates central circadian control in the SCN by a mechanism that decays with aging

The reader can get into the detailed mechanics in their own time. The important thing to note is that SIRT1 expression must be elevated during the darkness hours for proper subsequent expression of all circadian related proteins.

SIRT1 acts in an NAD+ dependent manner, and NAD+ depletion can reduce its effects. Ensuring a good NAD+ pool is required for SIRT1 function, and this is clearly regulated in various tissues.

Two examples, liver studies, whereby circadian NAMPT expression regulates amount of NAD+ available to the liver at different times of the day -- Circadian Clock Feedback Cycle Through NAMPT-Mediated NAD+ Biosynthesis

Note that NAMPT is the rate-limiting step for NAD+ biosynthesis in mammals, and there is clearly a very large difference from day and night. (Fig 1 reproduced below)

As an aside, once again we see that it syncing up both food intake and drug delivery during daylight hours has a very significant effect. See this paper for details, which is a good overview of how the Central Clock (dominated by light signalling) synchronises the peripheral clocks -- Circadian timing of metabolism in animal models and humans

This is also a good paper on why peripheral clock mismatch is a bad idea. The entire paper is recommended , though the most important major sections are:

- Circadian coordination of metabolism
- Circadian clock and human metabolic diseases

While section 'Architecture of the circadian timing system: central and peripheral oscillators' explains how the Central Clock entrainment is a dominant factor.

With reference to NAD+ and SIRT1, see the commentary on NAD+ decline and drop in SIRT1 oscillations as a pre-condition for chronic circadian rhythm disruption (especially in the elderly).

SIDENOTE: SIRT1 is obviously very important. For example, it is needed for the acute inflammatory response and subsequent healing -- http://www.anti-agingfirewalls.com/2015/05/01/part-4-of-the-nad-world-the-nq1-gene-the-warburg-effect-sirt-1-and-inflammation-and-possible-interventions/

Also see section number (5) on Niacinamide in this post -- 30 Major Factors that Control SIRT1 Expression, SIRT1 Activity, and SIRT1-mediated Aging. Part 3 of the series NAD+ an emerging framework for health and life extension | AGINGSCIENCES™ – Anti-Aging Firewalls™

All 5 parts are worth reading for those who really want to understand the state of research regarding NAD+ and SIRT1. All parts are linked to from the front matter of the blog post.​

Now, with regards to supplementation of NAD+, we do not want to disrupt this normal rise in SIRT1 at about Zeitgeiber time (ZT) +12 (12 hours after waking). This will affect the choice of precusor

----
NAD+ precursor choice

First, in practical terms, we are dealing with either the choice of:

(1) Niacin
(2) Nicotiamide Riboside (NR)
(3) Niacinamide (NAM)

Only number (3), niacinamide has been observed to decrease SIRT1 activity, and quite significantly as well. The reader can look up the research themselves, but it is fair to say that Niacinamide suppresses SIRT1 activity, while the observed SIRT1 affect in either Niacin or Nicotinamide Riboside supplementation is either neutral, or increased.

For those who are interested, I have made similar commentary on the differing effects of these 3 NAD+ precursors here -- Tobacco Smoke And It's Effect On PUFA

Again, Vince Giuliano did some good comparisons between Niacin and Niacinamide here -- http://www.anti-agingfirewalls.com/2010/03/30/niacin-or-niacinamide-supplementation-–-good-or-bad-idea/

The half life of Niacinamide seems to be dose dependent. Any dose is likely to suppress SIRT1 to some extent, but we do not know for how long, if the dose-to-SIRT1-suppression relationship is linear or not, and if half-life times are any indicator of SIRT1 expression activity.

The half-life of Niacinamide according to -- nicotinamide | C6H6N2O - PubChem

The mean half life values were 2.7 hr, 5.9 hr, and 8.1 hr after taking 1, 3, or 6 g of Niacinamide, respectively.​

That is a high dose of niacinamide. In any case, I think that taking at dinner may have anywhere from small to very significant effects on SIRT1.

Whether or not this can lead to circadian disruption, is again, going to be dose dependent. If we follow the considerations seen in the research however, it is clear that Niacinamide is a "day-time supplement", with night time use potentially being disruptive, and hence not recommended.

A mix of niacinamide in the day and then niacin at night can also be used of course.

Clinically speaking in the context of the B-vitamin balancing and methylation support, all it seems to take to get B-vitamins to balance out is about 100mg niacin a day. This is the lower dose protocol that I would recommend. Higher doses have potential side effects.

Personally, I never do well with niacinamide at night, and if we look to other anti-ageing forums, we find a very mixed response (eg: one person will say that it puts them to sleep, another will say that it keeps them up).

Again, we need to ask, "What are we using an NAD+ precursor for?". The topic of this thread is very specific -- to support proper methylation reactions via B-vitamin balancing. Toward that goal, only low doses of NAD+ precursors are needed, and timed to transiently elevate NAD+ when a specific mixture of other nutrients are added.

As a final commentary, all NAD+ supplementation should be viewed as transient elevators of NAD+ status, with little impact on chronic NAD+ status (this is referring to NAD+ precursor supplementation alone). I will not elaborate on this point here, interested readers can look to the recommended 5-part series of NAD+ on anti-aging-firewalls.com

.....

 

[managing]

Good topic to address. The TL;DR is that:

- theoretically niacinamide / nicotinamide is not an appropriate choice at night
- SIRT1 suppression is dose dependent.
- for the purposes of B-vitamin support, doses of 100mg Niacin seem to be sufficient
- at such doses, form of NAD+ precursor may not matter, but experimentation is needed

Addressing topics separately.

---
SIRT1 in circadian regulation

This is clearly an important factor. SIRT1 should be high at night, as per the "WT" (wild-type, aka: normal phenotype) line in the chart below. Note that "BTSG" refers to a transgenic mice that had 10-times SIRT1 activity, and "BSKO" referred to mice with complete SIRT1 knockout. Once again, we see that both too much and too little SIRT1 cause major disruptions to circadian protein expression.

This chart was taken from paper, see full paper for more effects based on this SIRT1 disruption -- http://www.cell.com/cell/fulltext/S0092-8674(13)00594-1

View attachment 4800


In a similar study (mouse model), brain SIRT1 knockout basically destroys all circadian signalling, and SIRT1 depletion leads to major disruptions -- SIRT1 mediates central circadian control in the SCN by a mechanism that decays with aging

See Figure 5 for the reduction in all circadian signalling proteins after SIRT1 depletion, we're basically looking at 30-50% losses in protein expression -- SIRT1 mediates central circadian control in the SCN by a mechanism that decays with aging

The reader can get into the detailed mechanics in their own time. The important thing to note is that SIRT1 expression must be elevated during the darkness hours for proper subsequent expression of all circadian related proteins.

SIRT1 acts in an NAD+ dependent manner, and NAD+ depletion can reduce its effects. Ensuring a good NAD+ pool is required for SIRT1 function, and this is clearly regulated in various tissues.

Two examples, liver studies, whereby circadian NAMPT expression regulates amount of NAD+ available to the liver at different times of the day -- Circadian Clock Feedback Cycle Through NAMPT-Mediated NAD+ Biosynthesis

Note that NAMPT is the rate-limiting step for NAD+ biosynthesis in mammals, and there is clearly a very large difference from day and night. (Fig 1 reproduced below)

View attachment 4802

As an aside, once again we see that it syncing up both food intake and drug delivery during daylight hours has a very significant effect. See this paper for details, which is a good overview of how the Central Clock (dominated by light signalling) synchronises the peripheral clocks -- Circadian timing of metabolism in animal models and humans

This is also a good paper on why peripheral clock mismatch is a bad idea. The entire paper is recommended , though the most important major sections are:

- Circadian coordination of metabolism
- Circadian clock and human metabolic diseases

While section 'Architecture of the circadian timing system: central and peripheral oscillators' explains how the Central Clock entrainment is a dominant factor.

With reference to NAD+ and SIRT1, see the commentary on NAD+ decline and drop in SIRT1 oscillations as a pre-condition for chronic circadian rhythm disruption (especially in the elderly).

SIDENOTE: SIRT1 is obviously very important. For example, it is needed for the acute inflammatory response and subsequent healing -- http://www.anti-agingfirewalls.com/2015/05/01/part-4-of-the-nad-world-the-nq1-gene-the-warburg-effect-sirt-1-and-inflammation-and-possible-interventions/

Also see section number (5) on Niacinamide in this post -- 30 Major Factors that Control SIRT1 Expression, SIRT1 Activity, and SIRT1-mediated Aging. Part 3 of the series NAD+ an emerging framework for health and life extension | AGINGSCIENCES™ – Anti-Aging Firewalls™

All 5 parts are worth reading for those who really want to understand the state of research regarding NAD+ and SIRT1. All parts are linked to from the front matter of the blog post.​

Now, with regards to supplementation of NAD+, we do not want to disrupt this normal rise in SIRT1 at about Zeitgeiber time (ZT) +12 (12 hours after waking). This will affect the choice of precusor

----
NAD+ precursor choice

First, in practical terms, we are dealing with either the choice of:

(1) Niacin
(2) Nicotiamide Riboside (NR)
(3) Niacinamide (NAM)

Only number (3), niacinamide has been observed to decrease SIRT1 activity, and quite significantly as well. The reader can look up the research themselves, but it is fair to say that Niacinamide suppresses SIRT1 activity, while the observed SIRT1 affect in either Niacin or Nicotinamide Riboside supplementation is either neutral, or increased.

For those who are interested, I have made similar commentary on the differing effects of these 3 NAD+ precursors here -- Tobacco Smoke And It's Effect On PUFA

Again, Vince Giuliano did some good comparisons between Niacin and Niacinamide here -- http://www.anti-agingfirewalls.com/2010/03/30/niacin-or-niacinamide-supplementation-–-good-or-bad-idea/

The half life of Niacinamide seems to be dose dependent. Any dose is likely to suppress SIRT1 to some extent, but we do not know for how long, if the dose-to-SIRT1-suppression relationship is linear or not, and if half-life times are any indicator of SIRT1 expression activity.

The half-life of Niacinamide according to -- nicotinamide | C6H6N2O - PubChem

The mean half life values were 2.7 hr, 5.9 hr, and 8.1 hr after taking 1, 3, or 6 g of Niacinamide, respectively.​

That is a high dose of niacinamide. In any case, I think that taking at dinner may have anywhere from small to very significant effects on SIRT1.

Whether or not this can lead to circadian disruption, is again, going to be dose dependent. If we follow the considerations seen in the research however, it is clear that Niacinamide is a "day-time supplement", with night time use potentially being disruptive, and hence not recommended.

A mix of niacinamide in the day and then niacin at night can also be used of course.

Clinically speaking in the context of the B-vitamin balancing and methylation support, all it seems to take to get B-vitamins to balance out is about 100mg niacin a day. This is the lower dose protocol that I would recommend. Higher doses have potential side effects.

Personally, I never do well with niacinamide at night, and if we look to other anti-ageing forums, we find a very mixed response (eg: one person will say that it puts them to sleep, another will say that it keeps them up).

Again, we need to ask, "What are we using an NAD+ precursor for?". The topic of this thread is very specific -- to support proper methylation reactions via B-vitamin balancing. Toward that goal, only low doses of NAD+ precursors are needed, and timed to transiently elevate NAD+ when a specific mixture of other nutrients are added.

As a final commentary, all NAD+ supplementation should be viewed as transient elevators of NAD+ status, with little impact on chronic NAD+ status (this is referring to NAD+ precursor supplementation alone). I will not elaborate on this point here, interested readers can look to the recommended 5-part series of NAD+ on anti-aging-firewalls.com

.....

I believe niacinamide riboside is same as NADH referenced in your first post? And you were referencing it as a potential choice for those who "don't react well" to niacinimide, ie, puts me to sleep?

 

[tyw]

I believe niacinamide riboside is same as NADH referenced in your first post? And you were referencing it as a potential choice for those who "don't react well" to niacinimide, ie, puts me to sleep?

Those are separate things.

This is nicotinamide riboside, an NAD+ precursor -- Nicotinamide riboside - Wikipedia , also know as 'Niagen'. Example product -- NAD+ Cell Regenerator™ Nicotinamide Riboside, 100 mg 30 vegetarian capsules

NADH refers to the literal NADH. Example product -- NADH, 5 mg 60 tablets

The use of NADH is specific only to those with a COMT V158M -/- SNP. I do not know the exact mechanics, but it play out in clinical practice, and I speculate that it has to do with the boundary conditions between Mitochondrial Matrix and Cytosolic NAD+/NADH cycling.

In all other cases, experimenting between the 3 direct NAD+ precursors is the way to go.

SIDENOTE: links to lifeextension are purely out of convenience, to illustrate the differences in supplemental products. I do not necessarily recommend any of those supplements.

....

 

[managing]

Those are separate things.

This is nicotinamide riboside, an NAD+ precursor -- Nicotinamide riboside - Wikipedia , also know as 'Niagen'. Example product -- NAD+ Cell Regenerator™ Nicotinamide Riboside, 100 mg 30 vegetarian capsules

NADH refers to the literal NADH. Example product -- NADH, 5 mg 60 tablets

The use of NADH is specific only to those with a COMT V158M -/- SNP. I do not know the exact mechanics, but it play out in clinical practice, and I speculate that it has to do with the boundary conditions between Mitochondrial Matrix and Cytosolic NAD+/NADH cycling.

In all other cases, experimenting between the 3 direct NAD+ precursors is the way to go.

SIDENOTE: links to lifeextension are purely out of convenience, to illustrate the differences in supplemental products. I do not necessarily recommend any of those supplements.

....

Thanks @tyw . Very enlightening.

 

[managing]

I was looking forward to adding riboflavin this week. Diligently went through options and ordered one that had no silica. Took one. Got horrible headache. Horrible about 12 hours of throbbing base of the skull headache. Another 18 hours of nagging headache. Another day of feeling crappy. Read the bottle. Silica. Image online shows no silica. Bottle says silica. Doh! So, I need to get another . . . I react horribly to silica every single time I'm exposed to it.

 

[Mango]

I was looking forward to adding riboflavin this week. Diligently went through options and ordered one that had no silica. Took one. Got horrible headache. Horrible about 12 hours of throbbing base of the skull headache. Another 18 hours of nagging headache. Another day of feeling crappy. Read the bottle. Silica. Image online shows no silica. Bottle says silica. Doh! So, I need to get another . . . I react horribly to silica every single time I'm exposed to it.

A 50mcg tablet gives me a terrible headache too, apparently it's very common. Now I bite a bit off the tablet each day, about 10mcgs-worth, and I don't have headaches