Methylation cycle hypothesis

The methylation cycle hypothesis posits that a core component of the pathophysiology of chronic fatigue syndrome involves a partial block in the methylation cycle. Its application to CFS was developed chiefly by biochemist Rich Van Konynenburg based on Dr. Amy Yasko's protocol for autism, and is discussed heavily on Phoenix Rising's forums.

Theory
A methyl group is a carbon atom that is bonded to three hydrogen atoms. Therefore, the process of methylation is the addition of a CH3 group to a pre-existing chemical structure; and methyl donors are chemicals that can carry and then transfer methyl groups to other molecules.

Methylation is important because the presence of methyl groups on a molecule can block or encourage certain chemical reactions, functioning as a switch with the potential to turn a biological process on or off. From a genetic standpoint, methylation can cause genes to either express, or become "silent".

The methylation cycle is a series of chemical changes that occur in the body, the primary purpose of which is to regulate neurotransmitters, regulate genetic repair and expression, and generate energy-rich molecules such as ATP. Many other important biological cyclical processes intersect with the methylation cycle.

The methylation cycle begins in the blood vessels with folate (B9) obtained from diet. When methylenetetrahydrofolate reductase (MTHFR) acts on folate, it picks up a methyl group, transforming into methyltetrahydrofolate (MTHF). MTHF is able to methylate homocysteine to methionine.

Methionine becomes SAM, a second methyl donor. SAM acts as a methyl donor for multiple chemicals in the body, including DNA and RNA. Therefore, methylation is crucial to the synthesis and repair of genetic material, as well as the epigenetic regulation of gene expression.

The donation of SAM's methyl group reduces it to SAM-e (S-adenosylmethionine), which reforms homocysteine, and the cycle begins again.

Various B vitamins act as cofactors for methylation, including B2 and B12.

If methylation is not working properly due to various B vitamin deficiencies, disease states, or genetic mishap, higher levels of homocysteine may result. Homocysteine is an inflammatory marker that may increase risk of thrombosis and endothelial dysfunction, cause errors in vascular smooth muscle proliferation and skeletal muscle metabolism, and contribute to heart disease.

Poor methylation can negatively impact the body's ability to produce and regulate glutathione, produce high-energy molecules, regulate Neurotransmitters, repair DNA, and convert serotonin to melatonin.

The methylation cycle hypothesis states that many if not all of the symptoms of CFS are caused by errors in the genes that regulate or have a strong impact on one-carbon metabolism, such as MTHFR, CBS, DHPR, MTRR, or MAO-A. Through knowledge obtained by their genetic SNPs, patients can address inconsistencies in their one-carbon metabolism by supplementing nutrients in which they are deficient, or that encourage bypassing problematic aspects of the cycle, such as folinic acid, in order to optimize the efficiency of the methylation and related cycles.

Evidence
There is little direct evidence to support the popular methylation protocols. However, numerous patients have reported benefit while others have reported no benefit.

Indirect evidence supporting a possible benefit of methylation cycle supplements include findings of increased homocysteine in the cerebrospinal fluid of CFS and fibromyalgia patients.

There is compelling evidence that some ME/CFS patients are low in methylation cycle metabolites, and there are some studies that provide direct evidence of methylation cycle dysregulation in ME/CFS. However, it is important to note that there are limited studies on either protocol’s effect on methylation, and no studies on Yasko’s utilization of SNP data to drive decision-making about supplements.

There is a great deal of anecdotal evidence to support these therapies. However, the longer a therapy continues, the higher and higher the likelihood of improvement regardless of circumstance, especially in an illness with as much natural variability as ME/CFS.

Evidence
Evidence that CFS/ME patients are low in methylation cycle metabolites:

B vitamin evidence

 * In a small study of 58 chronic fatigue syndrome patients with a history of Epstein-Barr infection and B-cell immunodeficiency, 81% responded to folinic acid.
 * Folate was found to be clinically low in approximately 50% of people with CFS in a study by Jacobson et al. 1993.

Yasko's Protocol
The Yasko protocol looks at two different pathways of the methylation cycle, which she calls the long route and the short cut. The short cut utilizes BHMT, while the long route is via MTR/MTRR and Vitamin B12 (Yasko, 2013). Yasko’s protocol has undergone a number of adaptations over the years. The information below refers to her 2013 Simplified Road Map to Health.

The Yasko protocol views methylation cycle support as a six-step process:


 * 1) Regulate glutamate and GABA
 * 2) *Since a high glutamate: GABA ratio can be hyperexcitatory, this is the number one priority in Yasko's version of the protocol.
 * 3) Support the short cut pathway to help restore the methylation pathways without producing too many detoxification symptoms
 * 4) Regulate lithium levels
 * 5) *Since lithium is involved in B12 transport, lithium balance is important to the methylation cycle. Low levels of lithium in the blood or high amounts excreted the urine may require lithium supplementation.
 * 6) Determine which kind of B12 is most absorbable based off of COMT and VDR SNP status
 * 7) Support the Long Route pathway utilizing folate or 5-methyl-THF (5-MTHF), for MTHFR mutations
 * 8) Customized support
 * 9) *Yasko goes on to recommend a variety of different supplements depending on the patients' SNP status for COMT, VDR, MAO A, ACAT, MTHF, MTR, MTRR, BHMT, AHCY, CBS, SUOX, SHMT, and NOS genes.

Rich's protocol
While Yasko pioneered the methylation protocol for autism, Rich Van Konynenburg, trained as a physicist, was the first to apply the methylation protocol to CFS/ME and fibromyalgia. He wrote over a dozen papers that discussed the linkage between dysregulated methylation and fatiguing disorders, beginning in 2004.

Rich Van Konynenburg first postulated a depletion of glutathione was at the heart of many of the symptoms of CFS/ME, but quickly added information about methylation when he realized that the two were connected. By 2006, Konynenburg had developed and presented what is now known as Rich's Protocol; in 2011, he presented the final, simplified version of the protocol.


 * 1) One-quarter tablet (200 micrograms) Actifolate
 * 2) One-quarter tablet Intrinsic B12/folate (200 mcg of folate as folic acid, 5-methyl tetrahydrofolate, and 5-formyl tetrahydrofolate (folinic acid or leucovorin), 125 mcg of vitamin B12 as cyanocobalamin, 22.5 mg of calcium, 17.25 mg of phosphorus, and 5 mg of intrinsic factor).
 * 3) Up to two tablets General Vitamin Neurological Health Formula from Holistic Health Consultants (a multivitamin, multimineral with some TMG and supplements that help support sulfur metabolism).
 * 4) One softgel capsule phosphatidyl serine Complex for phospholipids and essential fatty acids
 * 5) Activated B12 Guard (Perque) (2,000 mcg hydroxocobalamin with some mannitol, sucanat, magnesium and cherry extract)

Van Konynenburg emphasized the adage start low, and go slow with these supplements, due to the potential for detoxification symptoms.

Methylation support formula and SAM-e were previously included in the protocol, but are now omitted. Additionally, Rich suggested avoiding choline or TMG supplementation, as it could push the BHMT pathway at the expense of the methionine pathway, and to avoid over-supplementing with different forms of folate that would compete for absorption. Finally, Rich stated that some ME/CFSers may benefit from the addition of glutathione or molybdenum.

Van Konynenburg's protocol does not rely on information about patient's SNP data, but is a more one size fits all approach.

Freddd's Protocol
Freddd is a member of the online ME/CFS community Phoenix Rising. He developed his own version of the methylation protocol working with Dr Rich Van Konynenberg, and began posting articles descriptions of his experiences in 2011. In Freddd's protocol, supplements are started at very low doses and titrated, or increased until no effect is noted. The recommendations end with supplements at suprapharmacological levels.


 * 1) Stop taking any supplements that contain hydroxycobalamin, cyanocobalamin, folic acid, glutathione, and glutathione precursors (e.g. NAC, glutamine, and undenatured whey).
 * 2) Supplement with basic cofactors for a week. :Basic cofactors consist of:
 * 3) *Vitamins A and Vitamin D (11,000 IU and 3000 – 5000 IU respectively)
 * 4) *Vitamin C at 4000+ mg per day
 * 5) *Vitamin E
 * 6) *B vitamin complex with P5P, biotin and pantethine (without including cyano B12 or folic acid)
 * 7) *A 1:1 magnesium:calcium supplement
 * 8) *Zinc, 50 mg per day
 * 9) *Omega 3 fatty acids, 2-6 caps per day
 * 10) *Optional Basic Cofactors include:
 * 11) **Glycophospholipids
 * 12) **Additional pantethine
 * 13) **Multimineral supplements (choline, selenium)
 * 14) **Alpha lipoic acid
 * 15) **D-Ribose
 * 16) **CoQ-10
 * 17) Titrate B12s while adjusting methylfolate and potassium
 * 18) *Methylcobalamin (MeB12) should start at 15-20 mg per day
 * 19) *Adenosylcobalamin (AdoB12) should start at 10 mg per week
 * 20) Titrate methylfolate to sufficiency, starting at 1 mg
 * 21) *Continue adjusting potassium as needed
 * 22) *If unable to relieve symptoms of folate or potassium deficiency, lower vitamin B1, B2 and B3 intake as needed.
 * 23) *After a week on MeB12, replace MeB12 with AdoB12 for one day.
 * 24) Titrate L-carnitine fumarate (LCF) to effectiveness, starting at 125 mg per day and aiming for 500-1000 mg per day, stopping when an increase of 250 mg makes no difference.
 * 25) Titrate SAM-e, starting with 100 mg and increasing to 200-600 mg per day.
 * 26) Titrate TMG, starting with 250 mg or less. If it does nothing, discontinue.
 * 27) Titrate biotin
 * 28) CNS Penetration Test – the penetration test is to determine whether the B12s are entering the cerebrospinal fluid.
 * 29) *MeB12 – use 2 tablets, adding one each half hour to total.
 * 30) *AdoB12 – wait a few days after previous test; then, try 50 mg AdoB12 (2 tablets), adding one each half hour to total.