We offer plasma homocysteine assay routinely.
Suggest take fasting plasma, separate promptly and send by first class post.
I currently recommend in patients with venous thrombosis and/or premature
atherosclerosis when the clinical story appears to have a missing factor.
If the SEARCH study is positive then it will become routine as for
cholesterol, and especially if the interaction is multiplicative then this
recommendation will be unduly restrictive.
The observational data is reasonable, vitamin supplementation to suppress
homocysteine to 9 umol/L seems to make carotid ultrasound look
better/improve vascular function tests, and folate is safe and cheap (I feel
less of a risk than simvastatin did pre-4S study).  Classical homocystinuria
patients seem to benefit from treatment.  For classical homocystinuria
family studies I recommend methionine loading (0 and 4h sample, we have some
in our pharmacy who will dispense and post to you a single dose according to
patient name and weight).  For vascular patients a fasting sample seems
enough (too much for the evidence-based, mortality data-driven sceptic!).  I
am impressed with results in young cva and peripheral vascular disease
patients - not just CHD.  I personally check creatinine, B12 and folate
before any treatment.  If creatinine is increased then treatment is more
difficult.  I use folate mainly.  Some enthusiasts for extra pyridoxine,
betaine and B12 as well.  A low protein breakfast is probably OK pre-sample
but I tend to treat with the fasting lipids and have not checked this
properly.  Prompt separation variably important in some patients.  Suggest
test again after 2 months' treatment.
regards
Andrew Iversen
Consultant Chemical Pathologist

Sample Reception
Brighton Pathology
Brighton Healthcare NHS Trust
Royal Sussex County Hospital
Eastern Road
Brighton BN2 5BE


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