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Publication numberUS20040266724 A9
Publication typeApplication
Application numberUS 10/309,802
Publication date30 Dec 2004
Filing date4 Dec 2002
Priority date29 Dec 1992
Also published asUS6207651, US6297224, US6528496, US20030212039, US20030216350, US20030225030, US20050054606, US20070060542
Publication number10309802, 309802, US 2004/0266724 A9, US 2004/266724 A9, US 20040266724 A9, US 20040266724A9, US 2004266724 A9, US 2004266724A9, US-A9-20040266724, US-A9-2004266724, US2004/0266724A9, US2004/266724A9, US20040266724 A9, US20040266724A9, US2004266724 A9, US2004266724A9
InventorsRobert Allen, Sally Stabler
Original AssigneeAllen Robert H., Stabler Sally P.
Export CitationBiBTeX, EndNote, RefMan
External Links: USPTO, USPTO Assignment, Espacenet
Non-liquid vitamin compositions
US 20040266724 A9
Abstract
A method for orally administering vitamin preparations is described which combine vitamin B12 (B12, cobalamin) and folic acid (folate), with and without pyridoxine (B6), for preventing and treating elevated serum homocysteine (HC), cystathionine (CT), methylmalonic acid (MMA), or 2-methylcitric acid (2-MCA) levels. These metabolites have been shown to be indicative of B12 and/or folic acid deficiencies. Further, it is likely that a B6 deficiency may be present with a B12 or folate deficiency. The method of the invention is also for use in lowering serum HC, CT, MMA, or 2-MCA in patients with or at risk for neuropsychiatric, vascular, renal or hematologic diseases. The method of the present invention eliminates the costly and time consuming steps of distinguishing between vitamin deficiencies once a deficiency is found by measurement of serum metabolite levels. The present invention is of particular benefit to the populations at risk for elevated serum metabolite levels, such as the people over the age of 65, and populations that have or are at risk for neuropsychiatric, vascular, renal and hematologic diseases.
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Claims(40)
What is claimed is:
1. A non-liquid formulation, comprising 2-10 mg vitamin B12 and 0.1-0.4 mg folic acid.
2. The formulation of claim 1, having approximately 0.4 mg folic acid.
3. The formulation of claim 2, having approximately 2 mg vitamin B12.
4. A non-liquid formulation, comprising 2-10 mg vitamin B12 and 0.1-0.4 mg folic acid and 5-75 mg vitamin B6.
5. The formulation of claim 4, having approximately 25 mg vitamin B6.
6. The formulation of claim 5, having approximately 0.4 mg folic acid.
7. The formulation of claim 6, having approximately 2 mg vitamin B12.
8. A non-liquid formulation, comprising 2-10 mg vitamin B12 and 0.4-10 mg folic acid.
9. The formulation of claim 8, having approximately 1 mg folic acid.
10. The formulation of claim 8, having approximately 2 mg folic acid.
11. The formulation of claim 8, having approximately 2.5 mg folic acid.
12. The formulation of claim 8, having approximately 2 mg vitamin B12.
13. The formulation of claim 12, having approximately 1 mg folic acid.
14. The formulation of claim 12, having approximately 2 mg folic acid.
15. The formulation of claim 12, having approximately 2.5 mg folic acid.
16. A non-liquid formulation, comprising 2-10 mg vitamin B12 and 0.4-10 mg folic acid and 5-75 mg vitamin B6.
17. The formulation of claim 16, having approximately 25 mg vitamin B6.
18. The formulation of claim 17, having approximately 1 mg folic acid.
19. The formulation of claim 17, having approximately 2 mg folic acid.
20. The formulation of claim 17, having approximately 2.5 mg folic acid.
21. The formulation of claim 16, having approximately 2 mg vitamin B12.
22. The formulation of claim 21, having approximately 25 mg vitamin B6.
23. The formulation of claim 22, having approximately 1 mg folic acid.
24. The formulation of claim 22, having approximately 2 mg folic acid.
25. The formulation of claim 22, having approximately 2.5 mg folic acid.
26. A non-liquid formulation, comprising 0.3-10 mg vitamin B12 and 2-10 mg folic acid.
27. The formulation of claim 26, having approximately 2 mg folic acid.
28. The formulation of claim 26, having approximately 2.5 mg folic acid.
29. The formulation of claim 27, having approximately 1 mg vitamin B12.
30. The formulation of claim 28, having approximately 1 mg vitamin B12.
31. A non-liquid formulation, comprising 0.3-10 mg vitamin B12 and 2-10 mg folic acid and 5-75 mg vitamin B6.
32. The formulation of claim 31, having approximately 25 mg vitamin B6.
33. The formulation of claim 32, having approximately 2 mg folic acid.
34. The formulation of claim 32, having approximately 2.5 mg folic acid.
35. The formulation of claim 31, having approximately 2 mg folic acid.
36. The formulation of claim 31, having approximately 2.5 mg folic acid.
37. The formulation of claim 31, having approximately 1 mg vitamin B12.
38. The formulation of claim 37, having approximately 25 mg vitamin B6.
39. The formulation of claim 38, having approximately 2 mg folic acid.
40. The formulation of claim 38, having approximately 2.5 mg folic acid.
Description
  • [0001]
    This application is a continuation of Ser. No. 09/793,214, filed on Feb. 26, 2001, which is a continuation of Ser. No. 09/273,754 filed Mar. 22, 1999, now issued as U.S. Pat. No. 6,297,224, which is a continuation of application Ser. No. 09/012,955 filed Jan. 26, 1998 now issued as U.S. Pat. No. 5,795,873, which is a divisional of application Ser. No. 07/999,499, which was filed Dec. 29, 1992, now issued as U.S. Pat. No. 5,563,126.
  • FIELD OF THE INVENTION
  • [0002]
    This invention relates to the field of nutrition. Specifically, the invention is comprised of new oral vitamin preparations combining vitamin B12 (B12, cobalamin) and folic acid (folate), and vitamin B12, folate, and pyridoxine (B6) for use in patients with elevated serum metabolite levels of homocysteine (HC), cystathionine (CT), methylmalonic acid (MMA), or 2-methylcitric acid (2-MCA). The elevation of these metabolites has been shown to be indicative of tissue deficiencies of B12 and/or folate and/or B6, and related to increased risk of neuropsychiatric, vascular, renal and hematologic diseases. One embodiment of the present invention uses a non-prescription formulation comprising between 0.3-10.0 mg B12 and 0.1-0.4 mg folate, with the preferred embodiment using 2.0 mg B12 and 0.4 mg folate. Another embodiment of the non-prescription formulation uses 0.3-10 mg B12, 0.1-0.4 mg folate, and 5-75 mg B6, with the preferred embodiment using 2.0 mg B12, 0.4 mg folate, and 25 mg B6. Another embodiment of the present invention uses a prescription strength formulation comprising between 0.3-10.0 mg B12 and 0.4-1.0 mg folate, with the preferred embodiment using 2 mg B12 and 1.0 mg folate. In a further embodiment of the present invention, a prescription strength formulation is used comprising 0.3-10 mg B12, 0.4-1.0 mg folate, and 5-75 mg B6, with the preferred embodiment using 2 mg B12, 1.0 mg folate, and 25 mg B6. The formulations of the present invention eliminate the costly and time-consuming steps of distinguishing between vitamin deficiencies once a deficiency is found by measurement of serum metabolite levels. The present invention is of particular benefit to the populations at risk for tissue deficiencies of B12, folate, and B6, such as people over the age of 65, and populations that have or are at risk for neuropsychiatric, vascular, renal and hematologic diseases.
  • BACKGROUND
  • [0003]
    Vitamins B12, folate, and B6 are required cofactors in metabolic pathways involving methionine, homocysteine, cystathionine, and cysteine. B12 in the form of 5′-deoxyadenosylcobalamin is an essential cofactor in the enzymatic conversion of methylmalonylCoA to succinylCoA. The remethylation of homocysteine (HC) to methionine catalyzed by methionine synthase requires folate (methyltetrahydrofolate) and B12 in the form of methylcobalamin. HC is condensed with serine to form cystathionine (CT) in a reaction catalyzed by cystathionine □-synthase which requires B6 (pyridoxal phosphate). CT is hydrolyzed in another B6-dependent reaction to cysteine and □-ketobutyrate.
  • [0004]
    It is important to diagnose and treat B12, folate, and B6 deficiencies because these deficiencies can lead to life-threatening hematologic abnormalities which are completely reversible by proper treatment. B12 deficiency is a multisystem disorder with extremely varied clinical presentation which has been thought to occur in 0.4% of the population, e.g., about 1 million people in the United States. Symptoms of B12 deficiency include significant anemia, displayed for example in decreased hematocrit (e.g., <25%) or hemoglobin (e.g., ≦8 g %), with macrocytic red blood cells (i.e., mean cell volume generally greater than 100 fl), or neurologic symptoms of peripheral neuropathy and/or ataxia. See, for example, Babior and Bunn (1983) in Harrison's Principles of Internal Medicine, (Petersdorf et al., eds.), McGraw-Hill Book Co., New York; Lee and Gardner (1984) in Textbook of Family Practice, 3rd Ed. (Rakel, ed.), Saunders & Co., Philadelphia). The hematological abnormalities seen are due to intracellular folate deficiency since folate is required for a number of essential enzymatic reactions involved in DNA and RNA synthesis and since the form of folate in serum (5-methyltetrahydrofolate) must be metabolized to tetrahydrofolate by the B12-dependent enzyme methionine synthase before it can be utilized by the RNA- and DNA-related enzymes. While it has been well recognized that individuals with B12 deficiency could display neurologic disorders in the absence of anemia, such situations were believed to be exceptional and rare. See, Beck (1985) in Cecil Textbook of Medicine, 17th Ed., (Wyngaarden and Smith, eds.), W. B. Saunders, Philadelphia, pp. 893-900; Babior and Bunn (1987) in Harrison's Principles of Internal Medicine, 11th Ed., (Braunwald et al., eds.) McGraw-Hill, New York, pp. 1498-1504; Walton (1985) in Brain's Diseases of the Nervous System, 9th Ed., Oxford University Press, Oxford, UK. The neurologic symptoms of B12 deficiency were considered to be late manifestations of the disease most typically occurring after the onset of anemia or, if they occurred first, were soon to be followed by the onset of anemia. See, Woltmann (1919) Am. J. Med. Sci. 157:400-409 Victor and Lear (1956) Am. J. Med. 20:896-911.
  • [0005]
    However, it has recently been shown that the textbook description of severe megaloblastic anemia and combined systems disease of the nervous system is the rarest presentation of B12 deficiency at the present time (Stabler et al. (1990) Blood 76:871-881; Carmel (1988) Arch. Int. Med. 148:1712-1714 Allen (1991) in Cecil Textbook of Medicine, 19th Ed., (Wyngaarden and Smith, et al. eds.), W. B. Saunders, Philadelphia, pp. 846-854.). Therefore, contrary to previous teachings, patients that may benefit from B12 therapy may have minimal to no hematologic changes while manifesting a wide variety of neurologic and psychiatric abnormalities (Lindenbaum et al. (1988) N. Engl. J. Med. 318:1720-1728; Greenfield and O'Flynn (1933) Lancet 2:62-63). This is particularly true for populations at risk for B12 deficiency, such as the elderly population (Pennypacker et al. (1992) J. Am. Geriatric Soc. 40: (in press).
  • [0006]
    The incidence of folate deficiency in the population is unknown, but has been thought to occur commonly in individuals with various degrees of alcoholism. The hematologic abnormalities seen with folate deficiency, such as macrocytic anemia, are indistinguishable from those seen with B12 deficiency. Folate is required for a number of essential enzymatic reactions involved in DNA and RNA synthesis, and is particularly important in rapidly dividing cells like those in the bone marrow.
  • [0007]
    B6 is required for the first step in heme synthesis and serves a major role in transamination reactions of amino acid metabolism, in decarboxylations, and in the synthesis of the neuroactive amines histamine, tyramine, serotonin, and □-aminobutyric acid (GABA). Clinical manifestations include microcytic hypochromic anemia, characteristic skin changes of dermatitis and acrodynia, muscular weakness, and a variety of neuropsychiatric abnormalities including hyperirritability, epileptiform convulsions, depression and confusion (Newberne and Conner (1989) in Clinical Biochemistry of Domestic Animals, Academic Press, San Diego, pp. 796-834).
  • [0008]
    Vitamin deficiencies are generally determined by measurement of serum levels. Normal serum B12 levels are 200-900 pg/ml, with levels of less than 100 pg/ml being said to indicate clinically significant deficiency (Beck (1985) supra). However, serum B12 levels are a relatively insensitive determinant of B12 deficiency in that only 50% of patients with clinically confirmed B12 deficiency have levels less than 100 pg/ml, 40% are 100-200 pg/ml, and at least 5-10% have values in the 200-300 pg/ml range. Diagnosis is further complicated by the fact that 2.5% of normal subjects (6,250,000 people in the U.S.) have low serum B12 levels (Allen (1991) supra), with no evidence of B12 deficiency and are unlikely to benefit from B12 therapy (Schilling et al. (1983) Clin. Chem. 29:582; Stabler (1990) supra).
  • [0009]
    Normal serum folate levels are 2.5-20 ng/ml, with levels less than 2.5 ng/ml indicating the possibility of clinically significant deficiency. Like B12 serum levels, however, serum folate levels are a relatively insensitive measure in that only 50-75% of patients with folate deficiency have levels less than 2.5% ng/ml, with most of the remaining 25-50% being in the 2.5-5.0 ng/ml range (Allen (1991) in Cecil Textbook of Medicine, 19th Ed. supra)
  • [0010]
    The development of sensitive serum metabolite assays for HC, CT, MMA, and 2-MCA has allowed the relationship between metabolite levels and vitamin deficiencies to be investigated (Stabler et al. (1987) Anal. Biochem. 162:185-196; Stabler et al. (1986) J. Clin. Invest. 77:1606-1612; Stabler et al. (1988) J. Clin. Invest. 81:466-474). It has been found that elevated serum levels of HC and MMA are clinically useful tests of functional intracellular deficiencies of B12 and folate, with elevated HC levels seen with both B12 and folate deficiencies, and elevated MMA levels seen with a B12 deficiency (Allen et al. (1990) Am. J. Hematol. 34:90-98 Lindenbaum et al. (1990) Am. J. Hematol. 34:99-107; Lindenbaum et al. (1988) N. Engl. J. Med. 318:1720-1728; Beck (1991) in Neuropsychiatric Consequences of Cobalamin Deficiency, Mosby Year Book 36:33-56 Moelby et al. (1990) 228:373-378; Ueland and Refsum (1989( ) J. Lab. Clin. Med. 114:473-501; Pennypacker et al. (1992) supra). Increased serum levels of CT are seen in both deficiencies and 2-MCA is elevated in B12 deficiency (Allen et al. (1991) in Proceedings of the 1st International Congress on Vitamins and Biofactors in Life Science, Kobe (Japan); Allen et al. (1993) Metabolism (in press)). HC and CT may be elevated in patients with intracellular deficiency of B6, but this has not been as well documented (Park and Linkswiler (1970) J. Nutr. 100:110-116; Smolin and Benvange (1982) J. Nutr. 112:1264-1272).
  • [0011]
    Elevated serum metabolite levels are observed in disease states other than classic vitamin deficiencies. For example, elevated HC levels have been observed in the presence of vascular disease. The homocysteine theory of atherosclerosis, formulated by McCully and Wilson (1975) Atherosclerosis 22:215-227, suggests that high levels of HC are responsible for the vascular lesions seen in homocystinuria, a genetic defect caused by a deficiency in the enzyme cystathionine □-synthase. The theory also implies that moderate elevations of HC might be associated with increased risk for vascular disease (Ueland et al. (1992) in Atherosclerotic Cardiovascular Disease, Hemostasis, and Endothelial Function (Francis, Jr., ed.), Marcel Dekker, Inc., New York, pp. 183-236). Moderate hyperhomocysteinemia has been shown to be frequently present in cases of stroke and to be independent of other stroke risk factors (Brattstrom et al. (1992) Eur. J. Clin. Invest. 22:214-221). Clinical and experimental evidence demonstrates that patients who are homozygotes for cystathionine □-synthase deficiency have a markedly increased incidence of vascular disease and thrombosis. A number of studies (see, Clarke et al. (1991) N. Engl. J. Med. 324:1149-1155) strongly suggest that heterozygotes for a deficiency of cystathionine β-synthase also have an increased incidence of vascular disease and thrombosis and that such heterozygotes may constitute as many as one-third of all patients who develop strokes, heart attacks, or peripheral vascular disease under age 50. It is also likely that such heterozygotes are also at increased risk for vascular disease and thrombosis after age 50. Since the incidence of heterozygosity for cystathionine β-synthase deficiency is estimated to be 1 in 60-70, this means that there are approximately 4 million heterozygotes in the U.S. It is also possible that patients with vascular disease due to other causes, such as hypercholesterolemia, would also benefit from a decrease in their serum HC levels even if their existing levels are only slightly elevated or actually within the normal range.
  • [0012]
    Renal disease is another condition that gives rise to elevated levels of serum metabolites. Approximately 75% of patients with renal disease have elevated serum concentrations of HC, CT, MMA, and 2-MCA. Since patients with renal disease have a significant incidence and marked acceleration of vascular disease, it might be beneficial to lower their serum metabolite levels, especially that of HC.
  • [0013]
    An increasing prevalence of low serum B12 concentrations with advancing age has been found by many but not all investigators (Bailey et al. (1980) J. Am. Geriatr. Soc. 28:276-278 Eisborg et al. (1976) Acta Med. Scand. 200:309-314; Niisson-Ehle et al. (1989) Dig. Dis. Sci. 34:716-723; Norman (1985) 33:374; Hitzhusen et al. (1986) Am. J. Clin. Pathol. 85:3236), folate (Magnus et al. (1982) Scan. J. Haematol. 28:360-366; Blundell et al. (1985) J. Clin. Pathol. 38:1179-1184 Elwood et al. (1971) Br. J. Haematol. 21:557-563; Garry et al. (1984) J. Am. Geriatr. Soc. 32:71926; Hanger et al. (1991) J. Am. Geriatr. Soc. 39:1155-1159), and B6 (Ranke et al. (1960) J. Gerontol. 15:41-44; Rose et al. (1976) Am. J. Clin. Nutr. 29:847-853; Baker et al. (1979) J. Am. Geriatr. Soc. 27:444-450). Moreover, prevalence estimates for these vitamin deficiencies vary widely depending on the population groups studied. It has been unclear whether this increased prevalence is a normal age related phenomena or a true reflection of tissue vitamin deficiency and whether the low serum vitamin concentrations are a reliable indicator of functional intracellular deficiency.
  • [0014]
    It is difficult, expensive and time-consuming to distinguish between deficiencies of vitamins B12, folate, and B6. The hematologic abnormalities seen with B12 deficiency are indistinguishable from those seen with folate deficiency. Similarly to a B12 deficiency, B6 deficiencies also result in hematologic as well as neuropsychiatric abnormalities. The traditional methods of determining deficiencies by measurement of serum vitamin levels are often insensitive. As a result, in order to determine if and which vitamin deficiency is present, a patient will be treated with one vitamin at a time and the response to that vitamin determined by normalization of serum vitamin levels and the correction of hematologic abnormalities. These steps are then repeated with each vitamin. This method of treatment is both expensive and time-consuming. In the presence of multiple deficiencies, the diagnosis of vitamin deficiencies is further confused and give rise to the dangerous possibility that only one deficiency will be treated. For example, the hematologic abnormalities seen with a B12 deficiency will respond to treatment with folate alone. However, the neuropsychiatric abnormalities caused by the B12 deficiency will not be corrected and may indeed by worsened.
  • [0015]
    It has now been discovered for the first time that the prevalence of intracellular deficiencies of vitamins B12, folate, and B6, alone or in combination, is substantially higher than that previously estimated by measurement of serum vitamin concentrations. The present disclosure establishes that tissue deficiencies of one or more of the vitamins B12, folate and B6, as demonstrated by the elevated metabolite concentrations, occurs commonly in the elderly population even when serum vitamin levels are normal. Based on this new discovery, the present invention addresses the problem of distinguishing between vitamin deficiencies when low, low-normal, or normal serum vitamin concentrations are found by providing formulations for the treatment of high serum metabolites and at-risk populations for combinations of one or more tissue deficiencies of vitamins B12, folate, and B6.
  • [0016]
    Hathcock and Troendle (1991) JAMA 265:96-97, have suggested the treatment of pernicious anemia with an oral pill containing 300 to 1000 ug or more per day of B12. However, contrary to the present invention, Hathcock and Troendle teach away from combining B12 therapy with folate, since “if the oral cobalamin therapy should fail to maintain adequate levels, folate might provide protection against development of anemia while permitting nerve damage from cobalamin deficiency.”
  • [0017]
    U.S. Pat. No. 4,945,083, issued Jul. 31, 1990 to Jansen, entitled: Safe Oral Folic-Acid-Containing Vitamin Preparation, describes a oral vitamin preparation comprising 0.1-1.0 mg B12 and 0.1-1.0 mg folate for the treatment or prevention of megaloblastic anemia. This formulation presents a problem in the case of a B12 deficient patient, in that the 0.5 mg folate may correct the hematologic abnormalities present, but the 0.5 mg B12 dose may be insufficient to correct a B12 deficiency due to inadequate intrinsic factor. By contrast, the formulation of the present invention teaches the use of the combination of B12 and folate, and of B12, folate and B6, sufficient to treat either single or multiple deficiencies of B12, folate, and B6. The present invention does not rely on the determination of vitamin deficiencies by the measurement of serum vitamin levels, but uses the more sensitive measurement of elevated serum metabolites of HC, CT, MMA, and 2-MCA, shown to be related to the presence of B12 and/or folate and/or to B6 deficiencies or to the presence of the increased risk of neuropsychiatric, vascular, renal, and hematologic diseases.
  • [0018]
    It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention as claimed.
  • SUMMARY OF THE INVENTION
  • [0019]
    This invention includes a method for orally administering two new vitamin preparations containing vitamin B12 and folate, and vitamin B12, folate and B6, for the treatment of patients with elevated serum metabolites, such as homocysteine, cystathionine, methylmalonic acid, and 2-methylcitric acid, as well as populations at risk for tissue deficiencies in one or more of the vitamins B12, folate, and B6 or for neuropsychiatric, vascular, renal, or hematologic diseases.
  • [0020]
    One embodiment of the present invention uses an over-the-counter formulation comprised of between 0.3-10 mg CN-cobalamin (B12) and 0.1-0.4 mg folate. Another embodiment of the non-prescription formulation uses 0.3-10 mg B12, 0.1-0.4 mg folate, and 5-75 mg B6. Preferred embodiments of the over-the-counter formulation are comprised of about 2.0 mg B12 and 0.4 mg folate, and 2.0 mg B12, 0.4 mg folate, and 25 mg B6, respectively.
  • [0021]
    Another embodiment of the present invention uses a prescription formulation comprised of between 0.3-10 mg CN-cobalamin (B12) and 0.4-10.0 mg folate. Another embodiment of the prescription formulation of the present invention uses 0.3-10 mg B12, 0.4-10.0 mg folate, and 5-75 mg B6. Preferred embodiments of the prescription formulation use about 2.0 mg B12 and 1.0 mg folate, and 2.0 mg B12, 1.0 mg folate, and 25 mg B6, respectively.
  • BRIEF DESCRIPTION OF THE DRAWINGS
  • [0022]
    [0022]FIG. 1 shows the distribution of serum B12 levels for a population of elderly outpatients (ages 65-99, n=152) and a normal population (ages 17-65, n=100).
  • [0023]
    [0023]FIG. 2 shows serum MMA levels for a population of elderly outpatients with serum B12 values<300 pg/ml (ages 65-99, n=38/152) and a normal population with serum B12 values<300 pg/ml (ages 17-65, n=10/100)
  • [0024]
    [0024]FIG. 3 shows serum HC levels for a population of elderly outpatients with serum B12 values<300 pg/ml (ages 65-99, n=38/152) and a normal population with serum B12 values<300 pg/ml (ages 17-65, n=10/100).
  • [0025]
    [0025]FIG. 4 shows serum MMA levels before and after treatment with parenteral cobalamin for a population of elderly outpatients with elevated MMA values and serum B12 values<300 pg/ml (ages 65-99, n=15/38).
  • [0026]
    [0026]FIG. 5 shows serum HC levels before and after treatment with parenteral cobalamin for a population of elderly outpatients with elevated HC values and serum B12 values of <300 pg/ml (ages 65-99, n=10/38)
  • [0027]
    [0027]FIG. 6 shows the distribution of serum B12 levels for a population of elderly nursing home patients (ages 55-107, n=212) and a normal population (ages 17-65, n=100).
  • [0028]
    [0028]FIG. 7 shows serum MMA levels for a population of elderly nursing home patients with serum B12 values<300 pg/ml (ages 55-107, n=29/212) and a normal population with serum B12 values (ages 17-65, n=10/100).
  • [0029]
    [0029]FIG. 8 shows serum HC levels for a population of elderly nursing home patients with serum B12 values<300 pg/ml (ages 55-107, n=29/212) and a normal population with serum B12 values<300 pg/ml (ages 17-65, n=10/100).
  • [0030]
    [0030]FIG. 9 shows serum MMA levels before and after treatment with parenteral cobalamin for a population of elderly nursing home patients with serum B12 values<300 pg/ml (ages 55-107, n=14/29).
  • [0031]
    [0031]FIG. 10 shows serum HC levels before and after treatment with parenteral cobalamin for a population of elderly nursing home patients with serum B12 values<300 pg/ml (ages 55-107, n=14/29).
  • [0032]
    [0032]FIG. 11 shows the distribution of serum B12 levels for a population of elderly patients (ages 65-99, n=548) and a normal population (ages 22-63, n=117) (Framingham study).
  • DETAILED DESCRIPTION OF THE INVENTION
  • [0033]
    Reference will now be made in detail to the presently preferred embodiments of the invention, which, together with the following examples, serve to explain the principles of the invention.
  • [0034]
    This invention uses new oral vitamin formulations combining vitamin B12 (B12, cobalamin) and folic acid (folate), and vitamin B12, folate and pyridoxine (B6). The formulations of the present invention are for use in the treatment of elevated serum levels of one or more of the metabolites homocysteine (HC), cystathionine (CT), methylmalonic acid (MMA), or 2-methylcitric acid (2-MCA). The use of the formulations of the present invention further include as a method of lowering serum metabolite levels of one or more of HC, CT, MMA, or 2-MCA, where these metabolite levels are not elevated but the patients are at risk for or have neuropsychiatric, vascular, renal, or hematologic diseases.
  • [0035]
    One embodiment of the present invention uses a non-prescription formulation comprised of between about 0.3-10 mg CN-cobalamin (B12) and 0.1-0.4 mg folate. Another embodiment of the present invention uses a non-prescription formulation comprised of between about 0.3-10 mg B12, 0.1-0.4 mg folate, and 5-75 mg B6. Preferred embodiments of the non-prescription formulation are comprised of about 2.0 mg B12 and 0.4 mg folate, and 2.0 mg B12, 0.4 mg folate, and 25 mg B6, respectively.
  • [0036]
    Another embodiment of the present invention is comprised of a prescription formulation comprised of between about 0.3-10 mg B12 and 0.4-10.0 mg folate, with the preferred embodiment comprised of about 2.0 mg B12 and 1.0 mg folate. Another embodiment of the prescription strength formulation is comprised of about 0.3-10 mg B12, 0.4-10.0 mg folate, and 5-75 mg B6, with a preferred embodiment comprised of about 2.0 mg B12, 1.0 mg folate, and 25 mg B6.
  • [0037]
    The formulations of the present invention are for the treatment and prevention of elevated metabolite levels in at risk populations, such as the elderly, and people that have or are at risk for neuropsychiatric, vascular, renal and hematologic diseases. The present invention eliminates the costly and time consuming need to differentiate between B12, folate, and B6 deficiencies.
  • [0038]
    The administration of a daily dose of the vitamin formulations of the present invention provides better long-term normalization of serum HC and other metabolites than prior art formulations, and eliminates the difficulty in differentiating between deficiencies of two or three of the vitamins, the difficulty in diagnosing multiple deficiencies of two or three of the vitamins, and the expense of doing so. Further, the administration of an oral preparation of B12 and folate, with or without B6, is preferred over intramuscular injections for patient convenience and ease of administration.
  • [0039]
    For example, the inclusion of B12 will be useful as a safeguard for patients misdiagnosed as folate deficient, even though they are actually B12 deficient, since treatment with folate alone in such patients is extremely dangerous. The danger arises from the fact that treating a B12 deficient patient with folate alone may reverse or prevent the hematologic abnormalities seen in B12 deficiency, but will not correct the neuropsychiatric abnormalities of a B12 deficiency and may actually precipitate them. Even in the absence of intrinsic factor, approximately 1% of a 2.0 mg oral dose of B12 is absorbed by diffusion. Thus, approximately 20 ug of B12 would be absorbed from the formulations of the present invention which would be more than adequate even in patients with pernicious anemia who have lost their intrinsic factor-facilitated absorption mechanism for B12. The inclusion of folate will be of benefit since B12 deficiency causes a secondary intracellular deficiency of folate. The inclusion of folate and B6 will also be of benefit in patients with mixed vitamin deficiencies.
  • [0040]
    The formulations of the present invention may be administered as a non-injectable implant or orally. Non-injectable use may be as a patch. Formulations for oral administration are preferably encapsulated. Preferably, the capsule is designed so that the formulation is released gastrically where bioavailability is maximized. Additional excipients may be included to facilitate absorption of the vitamin formulations. Diluents, flavorings, low melting point waxes, vegetable oils, lubricants, suspending agents, tablet disintegrating agents, and binders may also be employed.
  • [0041]
    Example 1 describes the methods used to measure serum vitamin and metabolite levels. Example 2 describes a new study conducted with 412 subjects over the age of 65 with a variety of medical conditions correlating the incidence of low serum vitamin levels with elevated serum metabolite levels. A study determining the incidence of undetected B12 deficiency and response of serum MMA and HC to B12 treatment in a geriatric outpatient population is described in Example 3. Example 4 describes a similar study conducted with a geriatric nursing home population, and Example 5 describes a similar study conducted with another geriatric population.
  • EXAMPLE 1 Methods for Measurement of Serum Vitamin and Metabolite Levels
  • [0042]
    Serum vitamin assays. Serum vitamins B12 and folate were measured by a quantitative radioassay method using purified intrinsic factor and purified folate binding protein. Vitamin B6 was measured by a radioenzymatic assay method wherein serum is incubated with apoenzyme tyrosine-decarboxylase, C14 labelled tyrosine is added to start the enzymatic reaction which is stopped with HC1. Subsequently the free C14-labelled CO2 is adsorbed by a KOH impregnated filtering paper. The measured C14 activity is directly proportional to the B6 (pyridoxal phosphate) concentration (Laboratory Bioscientia, Germany).
  • [0043]
    Serum metabolite assays. Serum metabolite assays for homocysteine and methylmalonic acid were conducted by the capillary gas chromatography and mass spectrometry methods of Marcell et al. (1985) Anal. Biochem. 150:58; Stabler et al. (1987) supra, and Allen et al. (1990) Am. J. Hematol. 34:90-98. Serum cystathionine levels were assayed by the method of Stabler et al. (1992) Blood (submitted). Serum 2-methylcitric acid was assayed by the method of Allen et al. (1993) Metabolism supra.
  • [0044]
    Statistical methods. Statistical analysis was done with the SAS statistical package (version 6.06). Nonparametric data for two or more groups were tested with the two sample Wilcoxon rank sum test (with Bonferroni's correction for the significance level α) and the Kruskall Wallis test. From the results of the healthy young subjects reference intervals were calculated. Since the frequency distribution of the values of each parameter were markedly abnormal they were transformed to normal distributions using log transformation. The sample prevalence p with 95% confidence intervals of low serum vitamins B12, folate, and B6 concentrations was calculated as (p±2 p (l−p)/n×100 wherein n is the total sample size, p is the number of low serum vitamin concentrations/n; low serum concentrations are defined as <mean−2 S.D.
  • EXAMPLE 2 Incidence of Elevated MMA, 2-MCA, HC, and CT Levels in the Geriatric Population
  • [0045]
    The serum concentrations of B12, folate, and B6were measured in 412 subjects over the age of 65 (subgroups A-D), and in 99 healthy control subjects aged 20-55 years (subgroup E). The geriatric subgroups were defined as follows: A, 110 patients with atherosclerosis; B, 98 patients with neuropsychiatric disorders; C, 102 patients with atherosclerosis and multiple diseases including rheumatoid arthritis and diabetes; D, 102 subjects who were healthy.
  • [0046]
    Venous blood was obtained from all subjects in the morning after an overnight fast. The blood was spun within one hour after collection and the serum was transported in dry ice to the central laboratory. Serum vitamins B12 and folate were measured as described in Example 1 with a vitamin B12/folate dual RIA kit (CT301/CT302 Amersham Buchier, UK). Vitamin B6 and serum metabolites were measured as described in Example 1.
  • [0047]
    Since renal function can influence serum metabolite concentrations (Ueland and Refsum (1989) supra Moelby et al. (1992) Scand. J. Clin. Lab. Invest. 52:351-354), serum creatinine concentrations were measured in all subjects by the Jaffe photometric method (Laboratory Bioscientia, Germany). Normal range was 62-124 μmol/L. Creatinine clearance was calculated using the formulation of Cockroft and Gault (1976) Nephron 16:31-41.
  • [0048]
    Normal ranges for serum vitamin and metabolite levels were determined by the mean±2 standard deviations after log normalization using the values from subgroup E. Results are shown in Table 1:
    TABLE 1
    INCIDENCE OF LOW SERUM VITAMIN AND HIGH METABOLITE
    LEVELS IN GERIATRIC POPULATIONS A-D AND A YOUNGER
    HEALTHY POPULATION E.
    Folic
    Group B12 Acid B6 MMA 2-MCA HC CT
    A 6% 12% 48% 36% 44% 55% 64%
    B 6% 19% 53% 47% 39% 59%  6%
    C 3% 10% 50% 32% 45% 39% 73%
    D 6%  6% 17% 26% 23% 38% 41%
    E 2%  1%  1%  3%  6%  2%  4%
  • [0049]
    There was a rough correlation with low vitamin levels and elevated metabolites, but many of the patients with elevated metabolites had low normal or normal vitamin levels. Correlations between clinical abnormalities within groups A, B, and C were not present. Patients were treated with weekly injections of a multi-vitamin preparation containing 1.0 mg B12, 1.1 mg folate, and 5 mg B6, resulting in a marked lowering or normalization of elevated metabolite levels in virtually every elderly patient.
  • [0050]
    These data support the conclusions that there is an increased incidence of low levels of serum B12, folate, and B6 in the geriatric population, and that serum MMA, 2-MCA, HC and CT are elevated in an even higher percentage of geriatric patients. The presence of elevated levels of one or more of the metabolites HC, CT, MMA, or 2-MCA indicate a tissue or intracellular deficiency of one or more of the vitamins B12, folate and B6. It not possible to tell without expensive, time-consuming, and extensive testing which one vitamin or pair of vitamins, or whether all three vitamins are deficient. These observations, together with the fact that elevated metabolite levels are corrected by parenteral therapy with a combination of vitamins B12, folate, and B6, indicate that a tissue deficiency of one or more of these vitamins occurs commonly in the geriatric population and that measurement of serum vitamin levels alone is an inadequate method for identifying such deficiencies.
  • EXAMPLE 3 Determination of Serum B12 Folate, MMA, HC, CT and 2-MCA Levels in a Geriatric Outpatient Population
  • [0051]
    A study was conducted with 152 elderly outpatient subjects to measure the prevalence of B12 deficiency in geriatric outpatients as determined by both low serum B12 levels and elevations of MMA and HC, and to determine the response to B12 treatment. Blood samples were obtained on 152 consecutive geriatric outpatients, ages 65-99. Control values were determined from 100 subjects, ages 17-65. Serum B12 folate, MMA, HC, CT, and 2-MCA levels were obtained for each patient, shown in Table 2. The significance of the results marked as “**” in Table 2 are as follows: B12 levels of <200 pg/ml; folate<3.8 ng/ml; homocysteine>16.2 uM; MMA>271 nM; CT>342 nM; and 2-MCA>228 nM. Serum MMA, HC, CT, and 2-MCA levels were measured as described in Example 1. Serum B12 and folate were measured as described in Example 1 using a Corning Immophase kit (CIBA-Corning, Medfield, Mass.) with the normal range defined as 200-800 pg/ml for B12 and 3.8 ng/ml for folate. After evaluation, patients received weekly parenteral cyanocobalamin injections (1,000 ug IM) for 8 weeks, followed by monthly injections. Repeat laboratory and clinical assessments were administered at 8 weeks and at 6 months.
  • [0052]
    Results show that 25% of the subjects had a serum B12 level≦300 pg/ml and 8.5% had a low level of <200 pg/ml. FIG. 1 shows the shift seen in elderly subject towards lower serum B12 levels. More than half of the subjects with low or low-normal serum B12 levels had elevations of MMA (FIG. 2) and/or HC (FIG. 3) greater than 3 S.D. above the means in normals and representing 14.5% of the total screened population.
  • [0053]
    Patients with low and low/normal serum B12 levels were treated with weekly injections of 1.0 mg B12. Parenteral B12 administration caused elevated metabolite levels to fall to or towards normal (FIGS. 4 and 5) in every subject treated with B12. It appears that the true prevalence of previously unrecognized B12 deficiency in this elderly population was at least 14.5%.
  • [0054]
    It can be seen from the data presented in Table 2 that serum B12 levels are insensitive for screening B12 deficiencies since similar numbers of patients with low normal serum B12 levels of 201-300 pg/ml compared with patients with low B12 levels (≦200 pg/ml) had markedly elevated metabolites which fell with B12 treatment. Further, this study shows that elderly patients have a high incidence (at least 14.5%) of unrecognized B12 deficiency, detectable by measurement of serum HC and MMA levels in patients with serum B12 levels<300 pg/ml.
  • [0055]
    A further finding in this study emphasizes the need to treat elevated metabolite levels with a combination of vitamin B12 and folate with or without B6. Some of the patients exhibiting elevated metabolite levels did not fully respond to B12 treatment. This may indicate a concomitant deficiency of folate and/or B6. The lack of response to B12 treatment could result from a deficiency of one, a pair, or all three vitamins. However, it would be expensive and time-consuming to attempt to distinguish between the vitamin deficiencies.
  • [0056]
    Another, and perhaps the most important, finding in this study is the large number of patients with serum B12>300 pg/ml who have elevated values for one or more metabolites as indicated by a “**” next to the individual values. As can readily be seen in Table 2, there are many examples of elevated value for MMA and/or 2-MCA at all levels of serum B12 including the mid-normal (300-600 pg/ml), the high-normal (600-800 pg/ml), and even the elevated (>800 pg/ml) ranges. The same is true for elevations of HC and CT. In some patients the serum folate is low, indicating that folate deficiency may be present, but in many cases both B12 and folate levels are normal. B6 levels were not performed in this study, but B6 deficiency would not be expected to cause elevations of MMA or 2-MCA. Thus in many patients it is not clear which vitamin, or pair of vitamins, or whether all three vitamins is or are deficient. One could pick a single vitamin, often at random, with which to treat a patient for several weeks or months, and then repeat measurement of metabolite levels to determine if a partial or full correction had occurred. If there was no response, one could try another vitamin, or if there was a partial response one could add a second vitamin, and then repeat metabolite measurement after several weeks or months. If there was still no response, one could try the third vitamin, or if there was a partial response, one could try a different pair of vitamins. Eventually one could determine whether an individual vitamin, a particular pair of vitamins, or all three vitamins were required to normalize or maximally reduce the metabolite levels, but it would often require months or even a year to make this determination. Such a determination would be expensive. In addition, a patient who was optimally treated with a single vitamin or pair of vitamins might subsequently develop a deficiency of one or even two of the other vitamins as evidenced by a re-elevation or increase in the levels of one or more metabolites. Therapeutic testing could be reinitiated and continued as described above, although this would also be time-consuming and expensive.
  • [0057]
    It requires less time and expense to treat patients with elevated metabolite levels with a combination of vitamin B12 and folate, or a combination of vitamin B12, folate and vitamin B6. The utility of the approach of the present invention is appreciated only after it is taught, for the first time in the present disclosure, that a deficiency of one or more of the three vitamins occurs commonly in the elderly population as evidenced by elevation of one or more metabolites, i.e., MMA, 2-MCA, HC and CT.
  • EXAMPLE 4 Determination of Serum B12, Folate, MMA, and HC Levels in a Geriatric Nursing Home Population
  • [0058]
    A study was conducted with 212 elderly nursing home patients to determine serum B12, folate, MMA, and HC levels (Table 3). The significance of the results shown in Table 3 marked with “**” are as described for Table 2 (Example 3). The control group consisted of 100 subjects between the ages of 17-65 years. As in the study described in Example 3, the elderly population exhibited a shift to lower serum B12 levels (FIG. 6), elevated serum MMA (FIG. 7) and HC (FIG. 8) levels. Parenteral administration of B12 1 mg per week for 8 weeks to those with serum B12<300 pg/ml caused elevated MMA (FIG. 9) and HC (FIG. 10) levels to fall to or towards normal.
  • [0059]
    As in the study reported in Example 3, a further finding in this study emphasizes the need to treat elevated metabolite levels with a combination of vitamins B12 and folate, with or without B6. Some of the patients exhibiting elevated metabolite levels did not fully respond to B12 treatment. This may indicate a concomitant deficiency of folate and/or B6. The lack of response to B12 treatment could result from a deficiency of one, a pair, or all three vitamins. However, it would be expensive and time-consuming to attempt to distinguish between the vitamin deficiencies.
  • [0060]
    Again, an important finding in this study is the large number of patients with serum B12>300 pg/ml who have elevated values for one or more metabolites as indicated by a “**” next to the individual values. As is seen in Table 3, there are many examples of elevated values for MMA at all levels of serum B12 including the mid-normal (300-600 pg/ml), the high-normal (600-800 pg/ml), and even the elevated (>800 pg/ml) ranges. The same is true for elevations of HC. In some patients the serum folate is low, indicating that folate deficiency may be present, but in many cases both B12 and folate levels are normal. B6 levels were not performed in this study, but B6 deficiency would not be expected to cause elevations of MMA. Thus, again it is not clear which vitamin, or pair of vitamins, or whether all three vitamins is or are deficient. One could pick a single vitamin with which to treat a patient for several weeks or months, and then repeat measurement of metabolite levels to determine if a partial or full correction had occurred. If there was no response, one could try another vitamin, or if there was a partial response one could add a second vitamin, and then repeat metabolite measurement after several weeks or months. If there was still no response, one could try the third vitamin, or if there was a partial response, one could try a different pair of vitamins. Eventually one could determine whether an individual vitamin, a particular pair of vitamins, or all three vitamins were required to normalize or maximally reduce the metabolite levels, but it would often require months or even a year to make this determination. Such a determination would be expensive. In addition, a patient who was optimally treated with a single vitamin or pair of vitamins might subsequently develop a deficiency of one or even two of the other vitamins as evidenced by a re-elevation or increase in the levels of one or more metabolites. Therapeutic testing could be reinitiated and continued as described above, although this would also be time-consuming and expensive.
  • [0061]
    It requires less time and expense to treat patients with elevated metabolite levels with a combination of vitamin B12 and folate, or a combination of vitamin B12, folate and vitamin B6. The utility of the approach of the present invention is appreciated only after it is taught, for the first time in the present disclosure, that a deficiency of one or more of the three vitamins occurs commonly in the elderly population as evidenced by elevation of one or more metabolites, i.e., MMA, 2-MCA, HC and CT.
  • EXAMPLE 5 Determination of Serum B12 Folate, I4MA, and HC Levels in a Geriatric Population
  • [0062]
    A study was conducted with 548 elderly subjects from the Framingham study between the ages of 65-99 to determine serum B12, folate, MMA, and HC levels (Table 4). The significance of the results shown in Table 4 (marked with “**”) are as described for Table 2 (Example 2).
  • [0063]
    As in the study described in Examples 3 and 4, the elderly population exhibited a shift to lower serum B12 levels (FIG. 11), and elevated serum MMA and HC levels. The elderly population also exhibited a high incidence (9.5%) of low serum folate levels (Table 4). As in the studies reported in Examples 2, 3 and 4, the incidence of tissue or intracellular vitamin deficiencies based on elevated metabolite levels was higher than that predicted from measurement of serum vitamin levels.
  • [0064]
    As in Examples 3 and 4 above, these results confirm the importance of the finding that there are a large number of patients with serum B12>300 pg/ml who have elevated values for one or more metabolites as indicated by a “**” next to the individual values. As is seen in Table 4, there are many examples of elevated MMA values at all levels of serum B12 including the mid-normal (300-600 pg/ml), the high-normal (600-800 pg/ml), and even the elevated (>800 pg/ml) ranges. The same is true for elevations of HC. In some patients the serum folate is low, indicating that folate deficiency may be present, but in many cases both B12 and folate levels are normal. B6 levels were not performed in this study, but B6 deficiency would not be expected to cause elevations of MMA. Thus, again it is not clear which vitamin, or pair of vitamins, or whether all three vitamins is or are deficient. One could pick a single vitamin with which to treat a patient for several weeks or months, and then repeat measurement of metabolite levels to determine if a partial or full correction had occurred. If there was no response, one could try another vitamin, or if there was a partial response one could add a second vitamin, and then repeat metabolite measurement after several weeks or months. If there was still no response, one could try the third vitamin, or if there was a partial response, one could try a different pair of vitamins. Eventually one could determine whether an individual vitamin, a particular pair of vitamins, or all three vitamins were required to normalize or maximally reduce the metabolite levels, but it would often require months or even a year to make this determination. Such a determination would be expensive. In addition, a patient who was optimally treated with a single vitamin or pair of vitamins might subsequently develop a deficiency of one or even two of the other vitamins as evidenced by a re-elevation or increase in the levels of one or more metabolites. Therapeutic testing could be reinitiated and continued as described above, although this would also be time-consuming and expensive.
  • [0065]
    It requires less time and expense to treat patients with elevated metabolite levels with a combination of vitamin B12 and folate, or a combination of vitamin B12, folate and vitamin B6. The utility of the approach of the present invention is appreciated only after it is taught, for the first time in the present disclosure, that a deficiency of one or more of the three vitamins occurs commonly in the elderly population as evidenced by elevation of one or more metabolites, i.e., MMA, 2-MCA, HC and CT.
    TABLE 2
    SERUM METABOLITE & VITAMIN LEVELS IN A GERIATRIC OUTPATIENT
    POPULATION
    Patient B12 Folate Homocysteine MMA CT Total MC
    116   66** 9.8 41.8**  1508**  507**  759**
    118   79** 9.3 29.6**  2200**  343**  428**
    016  155** 7.6 15.3  1316** 208 196
    067  163** 6.6 9.9  93 164  69
    091  178** 12.0 29.2**  3108**  438**  318**
    042  181** 11.3 13.0  452** 300  262**
    030  185** 6.6 26.0**  282** 310 223
    037  187** 9.4 12.3 160 218  334**
    100  187** 9.5 13.6 208  453** 141
    036  188* 9.9 16.3**  298**  385**  322**
    109  189** 7.6 12.3 127 188 161
    007  191** 11.7 67.1**  6349**  619**  1005**
    018  193** 5.8 16.7**  412** 272  235**
    050 210 4.0 25.3**  464**  727** 121
    108 214 6.0 31.1** 264  523**  315**
    041 216 7.2 19.1**  418**  360**  288*
    126 224 6.5 8.8 103  361** 121
    005 231 12.5 17.1** 269  825**  276**
    024 235 13.0 18.5**  2946** 232  289**
    111 237 6.3 14.6 135  380** 203
    023 239 4.1 21.9**  385**  775**  279**
    010 256 12.9 11.5  652** 119 144
    055 258 6.8 7.5 189 342 185
    102 259 10.9 23.9**  1894**  423**  400**
    026 260 18.5 20.4**  1949** 295  248**
    107 262 13.1 10.1 231  628** 153
    038 269 7.6 15.7 222 152 152
    140 277 4.0 29.1**  744**  602**  254**
    074 278 5.2 24.1**  699** 296 187
    002 278 14.6 14.8  554** 259  277**
    019 282 8.5 12.4  329** 262 161
    035 287 5.8 9.8 230  390** 218
    049 290 3.9 33.0** 140 275 138
    078 290 10.9 12.5 197 240 209
    045 291 8.7 9.5 162  613** 132
    092 294 14.9 19.3**  500** 246 167
    137 297 6.8 10.1  631** 340 184
    072 298 6.7 19.7**  375** 302  246**
    149 310 8.3 16.1  314** 199 149
    047 312 4.9 15.9  277** 271 173
    060 312 9.4 8.0 100 228 203
    046 314 6.5 16.2 142 336 125
    093 318 6.4 16.5**  304**  361** 130
    014 321 14.5 10.7  275** 233 170
    088 327 7.1 17.8** 263  507**  258**
    032 340 6.6 8.6 150 133 133
    147 347 7.6 18.2**  305** 219  265**
    001 351 4.7 20.8** 199  402** 223
    090 353 4.9 20.7** 144  419** 178
    008 358 5.4 11.6  372**  529** 177
    104 360 12.7 12.1 260  89  77
    110 370 3.0** 17.1**  456** 297 150
    103 371 18.7 14.5 257 219 180
    056 373 6.5 12.4 236  415** 189
    048 374 3.6** 9.7 167 237  230**
    131 377 10.9 13.6 256 220  85
    122 378 76 21.9**  906** 227 196
    004 385 8.6 10.3 109 288  92
    120 390 9.8 22.9**  499**  529**  260**
    138 405 6.9 14.7  334** 238 188
    141 407 8.1 14.3 168 259  263**
    101 408 5.9 9.2 160 134  40
    145 410 3.7** 25.4**  567**  550**  349**
    027 415 11.1 10.6 169 278 164
    028 418 5.6 34.6**  608**  589**  351**
    011 420 10.6 18.8**  683**  1014**  282**
    081 421 6.6 16.5**  861**  641**  531**
    033 423 4.2 16.3** 156 194 170
    057 425 18.3 13.5 209  381**  321**
    021 427 18.9 12.1 223  524** 168
    135 430 8.8 13.5  284**  412** 180
    097 435 15.4 10.9  353**  465** 119
    052 438 6.8 15.2  281**  372**  238**
    132 448 12.6 16.8**  1931**  394**  250**
    086 451 12.1 6.6 139 208 107
    148 458 13.9 11.4 187 322  238**
    012 466 15.3 8.3  560** 250 144
    083 466 12.0 13.7  366** 214 193
    133 470 13.8 10.8  290** 275  55
    017 475 4.0 39.6** 196  467** 220
    053 476 13.4 12.3 226 206 125
    009 482 6.5 25.3** 240  470** 214
    066 498 9.6 12.9  374** 233  92
    031 507 11.0 14.8 173 278 220
    099 507 10.4 9.6 124 233  63
    128 507 4.6 9.4  294** 324 176
    013 514 11.3 15.9 163
    151 522 7.8 14.3  370** 324 215
    077 523 6.8 17.7** 184 210 214
    079 523 15.6 13.0  316** 223  251**
    054 524 4.9 10.0 148 230 123
    020 524 9.9 14.2 235  366** 190
    069 528 7.0 9.7 257 281  83
    085 536 4.0 22.5**  97 191 114
    084 551 14.2 12.5 166 179 131
    082 559 12.3 14.6 208  371** 182
    117 560 3.4** 18.8** 102 176  88
    061 561 12.7 9.8 170  404** 152
    006 567 4.6 16.8** 138  688** 165
    129 567 4.9 16.2  363**  495**  331**
    003 570 11.4 12.9 189 330  230**
    115 576 6.3 17.8** 128 231  95
    089 578 10.3 12.0 147 258  236**
    143 581 2.6** 42.7** 165  555** 208
    114 583 5.1 16.6**  599**  660** 177
    080 593 9.5 18.0** 208 289 142
    015 598 7.0 12.4 167  381**  95
    039 598 9.6 18.1**  691**  719**  354**
    070 612 5.6 13.7 197 296  82
    051 622 12.9 8.3 119 246 150
    139 628 8.5 7.8 145 166  83
    150 628 8.6 14.5  295** 315 183
    043 635 5.9 13.7 239 272 189
    096 651 17.4 9.7  326**
    073 657 7.0 9.5 186 283  78
    127 665 5.8 8.1 166  344** 147
    121 677 10.2 9.5 226  346** 173
    034 694 15.9 12.1  406**  592**  584**
    124 697 9.7 11.0  63 179  60
    123 702 10.4 10.6 186 148  96
    113 705 7.6 8.4 107  534**  92
    071 709 10.6 11.3 207  584** 141
    076 722 8.1 10.5 271  489** 138
    044 724 7.3 12.1 212  683** 217
    040 731 15.1 7.4 205 149 136
    062 741 4.4 18.7** 153  856**  416**
    025 741 10.0 12.2 224  344** 121
    119 755 5.9 10.1 187  377**  61
    075 757 10.0 24.7** 246  345**  276**
    098 759 13.8 13.9  380** 239 156
    134 769 7.5 10.4 125 131  81
    087 773 25.0 10.1 181 285 135
    142 788 4.6 12.1 166 273 129
    064 792 15.4 8.6 218 299 139
    094 793 16.6 10.0 186 179 173
    022 808 8.8 14.4 184 271 161
    112 812 12.0 9.2 181 184 108
    125 817 14.4 11.0 158 242  72
    106 862 5.3 9.2  94 300  95
    146 890 13.9 11.9 135
    058 897 5.3 18.5** 154  460**  80
    063 943 17.8 19.7**  277**  642**  306**
    095 960 25.3 10.7 135 181 111
    152 963 9.4 8.8 198
    130 971 15.9 13.5 106 307  84
    059 1063 9.4 9.7 129  378**  54
    105 1109 11.0 6.1  87 155  64
    136 1163 6.0 13.1 250  565** 122
    065 1251 14.5 10.7  88 147  88
    029 1490 22.2 9.7 129 111 105
    144 1536 7.0 17.7** 216  694**  418**
    068 1809 12.7 10.4  59 128  39
  • [0066]
    [0066]
    TABLE 3
    SERUM METABOLITE & VITAMIN LEVELS IN A
    GERIATRIC NURSING HOME POPULATION
    Patient B12 Folate Homocysteine Methylmalonic Acid
    NH170   8** 14.0 34.8**  3365**
    NH129   40** 7.4 40.9**  6245**
    NH156   44** 22.4 17.4**  1130**
    NH139   56** 9.7 20.9**  1180**
    NH132   67** 7.6 92.4** 12641**
    NH176  129** 9.2 20.3**  1156**
    NH196  136** 6.2 41.0**  1077**
    NH109  139** 9.8 20.9**  1294**
    NH203  146** 4.3 12.2  437**
    NH141  161** 13.4 12.2 223
    NH178  172** 8.2 5.9 141
    NH103  189** 5.5 13.1  362**
    NH181  196** 6.3 14.7  296**
    NH160 206 11.9 12.5  640**
    NH197 221 24.0 10.5  654**
    NH073 222 3.6** 19.8**  490**
    NH110 227 5.5 13.7  1297**
    NH010 228 4.0 21.1**  413**
    NH012 234 8.7 16.0  596**
    NH037 236 11.5 22.5** 11299**
    NH114 238 12.8 13.2  442**
    NH211 240 6.0 14.1 166
    NH075 250 9.3 12.1 170
    NH172 255 7.2 14.4  552**
    NH148 259 5.7 19.2**  317**
    NH138 264 9.2 16.7**  340**
    NH150 264 4.0 13.7  98
    NH099 272 5.5 12.5 125
    NH124 275 6.9 11.5  87
    NH179 301 7.6 7.1 143
    NH135 302 6.5 23.4**  397**
    NH087 304 7.8 10.8  327**
    NH180 304 5.8 10.5 237
    NH209 306 7.6 11.9 105
    NH107 310 3.3** 8.6 148
    NH081 320 4.3 23.6**  470**
    NH068 324 7.9 13.4 243
    NH183 325 7.7 11.1 144
    NH033 330 13.8 7.7 149
    NH161 333 8.5 11.3  385**
    NH192 337 10.7 9.5 209
    NH136 340 6.7 18.2**  409**
    NH191 342 20.2 13.4 271
    NH137 343 4.0 15.6 183
    NH182 346 8.2 14.4  448**
    NH020 347 8.4 10.4 149
    NH165 351 18.5 11.8  425**
    NH095 352 8.5 14.5  366**
    NH194 361 4.3 20.3**  305**
    NH106 362 4.8 12.9  298**
    NH060 367 4.7 16.4**  71
    NH009 368 5.1 15.9  325**
    NH071 382 4.9 12.9  330**
    NH080 390 6.1 15.0 171
    NH013 407 6.7 12.4  310**
    NH126 409 9.2 17.4** 137
    NH030 411 11.2 10.4  844**
    NH210 413 8.6 11.9 210
    NH158 414 5.7 16.2  508**
    NH027 416 10.2 15.5  769**
    NH003 424 16.5 9.5 167
    NH187 429 4.7 8.8  439**
    NH022 430 10.5 14.0 214
    NH082 436 10.6 17.7**  340**
    NH162 438 6.1 19.2** 180
    NH021 439 5.3 15.1 191
    NH056 447 11.7 10.9 184
    NH119 448 3.2** 14.1 241
    NH120 448 5.6 12.0 138
    NH186 450 4.7 23.1** 213
    NH064 451 6.9 10.6 237
    NH057 453 14.6 10.4  282**
    NH131 454 8.1 16.2 258
    NH059 462 6.0 9.1 147
    NH202 465 3.3** 17.0**  393**
    NH134 475 15.3 11.6  321**
    NH083 475 7.4 10.6 178
    NH199 479 15.1 10.4 141
    NH042 482 6.0 15.0 141
    NH200 491 13.6 9.8 154
    NH213 497 8.1 10.0  92
    NH143 500 5.2 22.1** 175
    NH031 502 6.4 16.1 151
    NH188 504 12.5 15.1  1461**
    NH171 504 10.7 12.9  344**
    NH008 505 4.6 9.9 185
    NH102 506 16.6 9.1 236
    NH145 512 7.7 22.2** 161
    NH093 514 5.1 17.7** 185
    NH118 524 25.0 10.1  314**
    NH185 524 8.7 12.1  84
    NH111 527 5.1 18.4** 250
    NH149 530 12.6 18.2**  531**
    NH011 534 8.1 12.5  654**
    NH128 540 4.3 11.6 120
    NH035 547 7.5 9.8 193
    NH005 551 17.7 5.0  365**
    NH212 552 11.9 12.1 202
    NH007 554 6.4 26.1**  646**
    NH086 554 9.5 5.1 127
    NH069 555 22.7 6.8 134
    NH121 555 8.2 10.0 112
    NH117 571 6.6 9.7  351**
    NH055 581 14.8 9.1 265
    NH025 581 5.2 15.3 181
    NH104 583 3.9 14.6  1699**
    NH173 583 11.2 10.6 160
    NH177 584 6.2 5.7 111
    NH207 586 8.5 16.4** 243
    NH070 591 5.4 12.0 168
    NH038 592 8.0 8.8 230
    NH049 599 10.7 21.7** 238
    NH062 606 4.5 7.7  96
    NH153 608 7.7 13.6 221
    NH206 611 6.6 16.4**  400**
    NH018 614 6.3 10.9 123
    NH163 616 5.0 9.6 132
    NH189 619 7.6 12.0 158
    NH045 620 21.0 12.4 265
    NH074 621 10.2 9.2 172
    NH054 623 8.0 9.8 121
    NH152 625 8.2 7.8 206
    NH140 637 21.7 13.6  300**
    NH050 642 16.3 13.5  275**
    NH089 644 7.7 16.7**  444**
    NH036 649 7.9 10.7  68
    NH097 651 6.6 13.4  426**
    NH016 656 4.1 61.0**  356**
    NH053 657 14.2 10.6  320**
    NH066 658 7.7 11.4 228
    NH051 659 4.0 10.7 216
    NH108 671 5.8 24.0**  823**
    NH058 673 6.0 11.2  392**
    NH028 675 22.3 9.1 105
    NH204 678 4.7 10.2 148
    NH169 679 6.9 19.2** 267
    NH032 681 12.7 5.9  99
    NH065 682 11.0 13.5 176
    NH061 683 13.4 9.6 190
    NH116 685 9.0 7.5 244
    NH015 699 6.8 16.8** 236
    NH157 711 10.0 12.8 198
    NH155 715 10.0 17.6**  308**
    NH034 715 7.9 11.4 179
    NH040 717 10.5 15.7 256
    NH105 718 6.0 13.2  308**
    NH048 719 8.0 10.8 207
    NH084 720 6.8 9.4 169
    NH115 724 16.3 9.4 161
    NH205 734 8.5 13.3 232
    NH113 738 11.7 10.3 171
    NH154 738 13.7 9.6 123
    NH167 741 17.0 6.6 129
    NH190 752 5.2 14.1 254
    NH067 760 22.5 9.5 232
    NH014 767 8.9 7.3 100
    NH072 768 8.3 6.9 131
    NH133 772 8.8 20.4** 219
    NH122 778 6.0 10.4 108
    NH076 781 12.1 14.9  282**
    NH147 785 7.5 24.5**  411**
    NH026 786 9.7 8.3 146
    NH151 789 24.4 11.1 182
    NH198 797 10.9 10.7 158
    NH088 801 6.4 18.3** 184
    NH004 806 11.3 8.8  96
    NH024 818 5.1 14.1 219
    NH100 826 16.4 10.5 103
    NH078 831 7.2 10.3 266
    NH052 844 19.6 8.0 193
    NH142 848 18.6 12.1  398**
    NH002 862 9.4 11.3 212
    NH091 891 4.9 12.6 169
    NH127 897 22.0 8.4 132
    NH096 901 9.3 5.2 104
    NH201 910 25.0 15.7  424**
    NH184 941 21.5 10.8 170
    NH208 945 20.2 9.8 111
    NH130 968 22.4 10.4  339**
    NH164 989 8.0 16.8** 102
    NH077 1006  15.1 9.2 188
    NH017 1015  11.9 9.5 175
    NH029 1053  18.6 11.4 161
    NH023 1055  9.3 9.7 193
    NH047 1079  6.4 11.4 106
    NH043 1082  14.5 13.9 144
    NH195 1088  36.9 12.2 150
    NH193 1092  8.2 15.7 225
    NH046 1093  9.2 18.8** 186
    NH101 1108  3.9 8.1 139
    NH098 1117  11.3 12.5  88
    NH168 1124  25.2 15.0 203
    NH006 1126  6.9 8.1 159
    NH144 1135  8.0 21.9** 262
    NH044 1159  26.8 10.2 109
    NH175 1162  7.8 12.0 210
    NH146 1179  9.8 10.1 129
    NH112 1238  10.3 15.0  347**
    NH001 1304  13.1 6.9 142
    NH166 1337  13.4 8.3  67
    NH079 1346  18.0 12.0 248
    NH041 1528  20.7 8.2 155
    NH063 1559  15.0 7.0  66
    NH159 1566  6.6 15.5  451**
    NH125 1703  8.2 20.6** 153
    NH094 1768  15.9 8.4 182
    NH123 2028  10.2 16.8** 206
    NH174 2106  13.3 12.8  280**
    NH039 2227  23.8 8.9 119
    NH019 2297  11.1 15.5 177
    NH092 2360  5.7 9.8 131
    NH085 3141  22.0 26.9**  1947**
  • [0067]
    [0067]
    TABLE 4
    SERUM METABOLITE & VITAMIN
    LEVELS IN A GERIATRIC POPULATION
    Patient B12 Folate Homocysteine MMA
    495   77** 10.0 65.4**  3145**
    484   84** 10.0 77.5**  6820**
    522  100** 3.6** 15.5  967**
    455  115** 1.9** 21.8** 170
    493  135** 4.4 16.9**  421**
    528  145** 3.9 38.3**  729**
    510  155** 4.6 14.1  804**
    502  155** 2.1** 16.9**  347**
    412  160** 18.5** 33.8**  1301**
    409  160** 4.8 16.8** 164
    470  165** 9.2 19.9**  1468**
    460  165** 6.8 11.5 142
    437  170** 4.9 16.5** 813
    439  170** 1.2** 21.3**  502**
    525  175** 11.5 15.3  1058**
    442  175** 4.2 17.5**  328**
    456  180** 7.3 11.1 206
    450  180** 5.0 11.8 196
    477  185** 3.4** 31.4**  369**
    508  190** 4.1 19.5**  335**
    423  190** 2.5** 19.0**  329**
    462  190** 3.8 11.6  276**
    523  190** 5.6 16.8** 207
    482  190** 2.9** 25.1** 179
    459  190** 5.3 19.6** 167
    543  195** 4.3 13.5  470**
    520  195** 1.7** 22.2**  309**
    431  195** 7.2 13.5 251
    513 200 5.0 25.0**  1184**
    534 200 4.9 32.6**  1080**
    515 200 4.9 17.3**  478**
    531 200 5.1 26.8**  466**
    516 200 3.6** 17.8**  279**
    526 200 1.6** 23.5** 171
    471 205 5.7 22.0**  542**
    413 205 2.6** 20.4**  304**
    497 205 3.3** 19.4** 258
    539 205 4.1 15.4 247
    544 205 12.5 11.7 233
    540 205 4.0 17.1** 185
    517 205 2.2** 15.0 151
    496 210 3.7** 15.2  1103**
    488 210 16.5 21.8**  600**
    416 215 12.5 10.0 197
    434 220 7.1 24.8**  439**
    545 220 11.5 14.4  407**
    547 220 5.3 17.5**  396**
    408 220 3.2** 16.4**  357**
    449 220 3.7** 13.7  272**
    507 220 8.5 10.0 179
    458 225 10.5 21.1**  964**
    491 225 7.2 16.0  472**
    529 230 2.0** 61.1  1172**
    415 230 3.2** 28.9**  377**
    453 230 3.6** 19.8**  336**
    448 230 5.2 13.1  319**
    498 230 5.9 20.1** 255
    533 230 5.7 11.7 151
    466 235 35.0 12.1  617**
    537 235 5.7 10.7  394**
    483 235 8.6 16.6**  344**
    512 235 3.9 12.5 190
    452 240 4.7 26.5**  1068**
    454 240 5.2 11.9 201
    535 240 4.4 15.3 195
    421 245 10.5 12.5  464**
    469 245 6.2 20.0**  448**
    474 245 7.3 10.3  327**
    486 245 9.2 12.6 156
    536 250 22.5 20.3**  1068**
    475 250 5.6 23.0  456**
    511 250 2.7** 23.1**  398**
    465 250 4.1 23.1**  323**
    506 250 5.2 11.5 252
    417 250 5.5 25.2** 241
    524 1250  2.5** 14.4 212
    411 250 9.9 11.5 200
    492 250 5.2 10.7 182
    548 250 2.9** 12.4 179
    441 250 4.5 8.5 147
    480 255 4.8 16.9**  558**
    532 255 7.0 14.8  419**
    464 255 11.5 12.9  400**
    494 255 6.2 12.1  293**
    106 255 4.5 11.7 203
    546 260 5.5 14.7  662**
    541 260 5.4 30.8**  426**
    420 260 5.3 13.6  347**
    500 260 6.7 14.0  330**
    538 260 9.3 17.3**  298**
    457 260 2.9** 12.6  286**
    472 260 8.3 13.8  278**
    424 260 8.3 10.1 242
    433 260 6.8 10.5 197
    425 265 7.3 14.7  724**
    468 265 3.8 16.7**  289**
    435 265 7.4 14.0 150
    499 265 2.2** 12.4 131
    432 270 4.3 28.3**  432**
    521 270 3.7** 15.3  349**
    549 270 4.21 12.4  343**
    518 270 10.0 10.1  276**
    418 270 26.0 9.4 213
    419 270 6.5 12.5 212
    428 270 4.2 18.7** 189
    443 270 8.8 12.0 187
    446 270 11.0 8.1 157
    461 275 7.6 15.1  663**
    440 275 4.9 12.9 248
    436 275 6.3 30.1** 233
    530 275 7.4 13.6 231
    438 275 4.6 8.5 221
    527 275 7.5 10.5 219
    444 275 4.0 12.2 180
    429 280 5.3 15.3  463**
    503 280 4.4 25.7**  421**
    485 280 3.5** 15.6  381**
    410 280 14.5 10.0 201
    487 280 3.9 10.5 166
    430 280 9.2 8.8 161
    519 285 3.9 22.2**  919**
    476 285 10.5 12.8  339**
    509 285 5.4 13.0  331**
    501 285 5.5 12.4 252
    542 285 6.9 15.5 242
    445 285 7.2 14.9 237
    427 285 4.0 17.1** 233
    490 290 4.7 13.9 203
    451 290 2.1** 20.0** 226
    414 290 7.0 9.7 117
    467 290 4.1 6.5  68
    463 295 5.8 12.3  296**
    473 295 7.5 14.4  290**
    505 295 4.1 12.4 257
    198 300 11.5 10.9  323**
    195 300 9.8 12.2 216
    207 305 7.7 13.2  330**
     67 305 8.6 15.4  312**
     50 305 9.0 11.6 235
     70 305 12.5 12.7 228
    113 305 5.6 13.5 201
     39 305 6.9 19.7** 170
     3 305 4.2 11.5 135
    325 305 14.5 9.4  94
    368 310 4.7 15.9  371**
    322 310 7.8 15.3  362**
    295 310 7.2 13.8  305**
    347 310 5.8 16.5** 266
    313 310 6.1 16.5** 219
    355 310 5.5 15.4 138
    291 310 4.5 15.2 125
    478 315 23.0 17.7**  857**
     53 315 5.8 12.1  505**
    240 315 6.7 12.3  394**
     14 315 9.6 14.2  331**
    137 315 7.8 24.3**  306**
    254 315 8.7 17.0**  285**
    109 315 3.7** 16.5** 263
    252 315 5.2 10.1 241
    186 315 4.1 15.4 238
    183 315 5.5 10.7 195
    390 315 6.9 10.0 188
    267 315 2.2** 12.0 124
    310 320 12.0 13.8  395**
     31 320 17.0 12.9  334**
     88 320 4.8 13.8 217
    403 320 9.6 11.3 162
     60 320 6.2 11.4 155
    315 320 6.4 9.9 136
    175 325 6.3 17.8**  486**
    317 325 22.0 14.0  294**
     18 325 6.3 11.1 241
    247 325 13.5 13.2 231
    223 325 9.2 12.6 203
    132 325 3.7** 15.4 184
    168 325 4.3 10.2 174
    238 325 5.5 9.9 166
    117 325 5.2 15.0 154
    404 330 2.5** 33.1**  1085**
    138 330 4.8 11.3  360**
    316 330 3.6** 10.2  272**
     61 330 5.1 12.5 242
    333 330 34.0 9.2 235
     16 330 4.6 13.3 211
    276 330 5.7 11.9 200
    391 330 4.1 8.4 184
    362 330 9.2 11.7 178
     1 330 9.9 8.9 170
    379 335 16.0 12.1  471**
    147 335 9.0 9.7  427**
     89 335 8.0 15.3  385**
    211 335 5.0 12.2  374**
     45 335 5.9 16.3** 250
     47 335 5.0 13.6 249
    402 335 4.7 13.5 230
    314 335 7.6 9.7 203
    150 335 4.8 11.2 119
    120 340 1.9** 21.0**  775**
    284 340 7.2 25.6**  439**
    230 340 14.0 11.4  419**
    149 340 8.8 18.9**  337**
    269 340 3.9 16.2  302**
    197 340 10.5 12.8 233
     19 340 9.6 11.0 232
    422 340 3.1** 14.4 188
    196 340 11.5 8.9 169
     40 345 8.7 14.6  610**
    244 345 8.6 15.8  461**
    287 345 5.7 18.1**  427**
    100 345 8.3 14.8  403**
    383 345 4.3 27.2**  284**
     62 345 19.5 9.6 250
    350 345 8.0 10.0 249
     65 345 8.0 10.2 247
    307 345 16.5 11.6 208
     69 345 17.0 9.9 197
    328 345 7.5 8.9 192
     43 345 6.0 13.2 191
    222 345 6.1 9.2 175
    306 345 4.3 17.2** 160
    154 345 7.1 10.2 148
     94 350 4.8 16.1  302**
    201 350 6.1 9.9 200
     13 350 5.1 10.9 193
    236 355 7.2 14.8  309**
    191 355 5.8 15.3 257
    481 355 5.2 17.1** 134
     92 360 4.2 25.2**  321**
    324 360 3.8 16.6** 264
     87 360 3.3** 13.3 200
     46 360 5.4 11.1 179
    289 360 9.5 7.9 129
    392 360 5.1 10.3 125
    320 365 6.4 17.3** 240
    134 365 13.5 11.8 238
    239 365 7.7 13.2 236
    326 365 6.0 10.9 180
    364 365 4.1 13.9 154
    218 365 7.5 11.2 126
    216 365 6.2 12.2 119
    248 365 5.7 13.3 117
    375 370 4.1 20.7**  532**
    288 370 6.4 18.8**  436**
    161 370 6.3 11.2  340**
    244 370 19.5 9.8  286**
    330 370 18.0 12.2 228
    334 370 12.5 8.7 172
    275 370 6.9 12.7 162
     54 375 7.3 10.1  583**
    185 375 9.3 10.5  386**
     52 375 8.1 15.5  291**
    366 375 5.0 12.5  280**
     93 375 3.3** 16.2 248
    151 375 2.9** 12.3 235
     85 375 6.7 14.8 217
    294 375 7.0 12.2 184
    361 375 7.9 10.7 179
    318 375 5.5 13.7 160
    386 375 7.6 10.4 153
    304 375 9.1 9.4 132
    228 380 7.7 17.1**  320**
    110 380 4.0 7.2 135
    204 380 5.7 10.6  91
    348 385 2.3** 17.4**  368**
    146 385 11.5 12.5 253
    260 385 5.5 13.7 211
    136 385 3.6** 19.8** 205
    338 385 5.0 16.2 180
    376 385 3.6** 13.7 154
    194 385 12.5 7.9 153
    504 385 38.0 9.5 138
    160 390 8.1 24.7**  475**
    354 390 11.5 12.8 212
     25 390 5.1 11.3 205
    387 390 8.7 8.4 162
     86 390 21.0 12.6 133
    133 390 3.9 11.3 113
    331 395 12.0 20.1**  638**
    130 395 10.5 10.8 256
     82 395 2.8** 9.8 236
    119 395 12.5 16.3** 209
    380 395 10.5 14.3 159
    373 395 5.5 11.6 152
    256 395 10.5 9.9 149
    384 395 7.3 14.7 116
    105 400 19.0 10.5  322**
    251 400 4.8 14.9  289**
    352 400 11.5 9.6 181
    279 400 4.5 11.7 170
    339 400 7.4 13.6 168
    381 405 6.7 12.4  294**
    285 405 7.0 14.2  281**
    340 405 3.6** 19.6**  275**
     51 405 6.5 14.3 233
     33 405 6.5 9.6 207
    268 405 3.3** 14.9 205
     73 405 5.2 13.1 172
     17 410 7.5 16.2  473**
    286 410 4.7 18.8**  415**
    140 410 5.9 21.7**  302**
    116 410 6.8 14.5 218
    396 410 5.6 16.1 190
    356 410 1.9** 27.6** 149
    237 410 3.6** 16.6** 122
    112 410 5.5 8.9 107
    259 410 4.7 11.6  99
    176 415 5.2 21.9**  453**
    193 415 10.5 11.3 163
    323 415 6.1 9.6 163
    202 415 11.5 9.4 150
    398 415 8.0 12.6 134
    321 420 5.2 10.7  383**
    142 420 29.0 8.3 234
    327 420 3.2** 14.6 203
    342 420 7.3 9.4 156
    170 420 20.5 10.3 142
    345 420 29.5 13.2 136
    302 420 8.6 8.8 128
    115 425 6.3 22.2**  628**
     97 425 12.5 19.8**  313**
    246 425 8.7 15.1 241
     72 425 10.5 13.5 241
    365 425 6.7 16.7** 237
    139 425 12.5 10.4 224
    143 425 8.1 13.5 216
    426 425 19.5 14.5 201
    303 425 3.0** 14.5 154
    388 425 6.2 12.3 135
    127 425 6.7 8.4 100
    262 430 10.0 12.1  323**
    270 430 4.8 12.9  293**
    514 430 4.3 12.9 197
    341 430 3.5** 19.9** 190
    278 430 5.2 10.8 182
    370 430 11.0 15.3 174
     55 430 7.6 11.0 162
    274 430 5.0 8.2 131
    367 430 17.5 8.0 126
     98 430 13.5 12.8 125
    337 435 13.5 14.1  395**
    309 435 8.7 12.9  349**
    305 435 17.5 15.4 187
    144 435 25.0 8.9 167
     34 435 8.6 7.6 157
    234 435 9.7 9.2 116
    123 440 9.6 12.2  622**
    200 440 4.8 12.4 257
    250 440 7.5 12.9 248
    107 440 6.3 14.7 183
    300 440 6.5 7.9 123
    374 445 5.4 14.0 247
    372 445 11.0 11.0 181
     36 445 4.0 10.0 181
    271 445 7.2 10.4 124
    242 445 15.5 9.6 112
    264 445 6.0 10.7 100
    172 450 11.5 14.9  607**
     32 450 11.5 13.6  362**
    346 450 13.5 15.8  330**
     41 450 8.5 11.4 194
     95 450 5.1 12.5 182
    357 455 6.3 14.4  296**
    319 455 17.0 10.2 147
    308 455 15.0 9.8 131
    235 455 23.0 9.0 114
    349 455 9.2 8.3  82
    178 460 5.6 20.6**  473**
    312 460 4.7 14.4 197
     79 460 5.0 10.4 173
    131 460 18.0 10.2 162
    243 460 2.6** 11.6 160
    261 465 7.7 10.6 252
    378 465 5.4 13.2 221
     49 465 47.0 10.8 179
    226 465 7.7 10.2 173
    377 465 5.6 8.5 143
    253 465 10.0 7.0 138
     76 470 12.5 14.8  304**
    203 470 15.0 7.6 233
    296 470 23.5 11.0 161
    382 470 5.3 11.1 109
     6 475 10.5 12.5 232
     75 475 4.5 8.1 150
    332 475 9.4 10.0 144
    290 475 14.0 9.1 143
    128 475 5.9 9.3 133
    124 475 6.0 13.5 111
    177 475 8.8 9.1 106
    126 480 11.0 11.0 212
    283 480 5.2 10.6 175
    209 480 10.5 10.5 175
    293 480 6.8 15.5 135
    121 485 4.7 20.0**  345**
    282 485 12.0 10.9 236
     71 485 13.5 8.1 168
    385 485 9.0 14.1 128
    190 495 9.9 10.4  410**
    210 495 8.6 12.0 243
    155 495 5.9 10.4 219
    336 495 13.5 9.9 135
    280 500 8.7 14.5  334**
     96 500 4.7 10.8 237
    145 500 5.9 17.5** 233
    199 500 4.2 13.8 199
    489 500 11.5 9.7 198
    217 500 6.4 9.6 166
     90 500 7.5 8.5 106
    164 510 5.2 23.8**  408**
    343 510 4.5 13.7  284**
     42 510 4.9 7.4 233
    351 510 8.5 11.0 207
    299 510 12.0 8.0 104
     99 520 10.5 25.8**  322**
    114 520 30.0 10.9 220
    369 520 29.0 16.7** 206
     37 520 10.5 8.6 191
    215 520 6.7 16.8** 151
    401 520 7.5 12.6 148
    229 520 7.9 11.0 116
    135 520 3.2** 8.3  88
     81 530 6.8 14.8  372**
     91 530 14.5 10.6 228
    167 530 23.5 9.2 176
    181 530 5.5 9.3 171
     56 530 20.0 8.3 163
     5 530 13.5 8.1 159
    180 540 12.0 9.0 216
    311 540 4.1 13.3 214
    389 540 3.9 13.9 169
    125 540 5.5 13.0 159
     35 540 22.5 11.0 123
    104 550 10.5 16.5**  544**
    393 550 4.9 11.9  339**
    394 550 23.0 14.0  278**
    292 550 6.9 16.2 263
    163 550 6.7 14.3 219
     66 550 10.5 11.6 206
     29 550 17.5 9.6 191
    227 550 7.9 11.7 154
     38 550 7.5 11.9 152
    241 550 10.5 9.8 100
    102 550 9.7 8.6  91
     77 560 24.0 14.8  554**
    162 560 10.5 11.8  275**
    273 560 8.7 9.4 180
     80 560 6.3 11.2 108
    255 560 8.8 9.9  93
    122 570 66.0 13.8  304**
    208 570 34.0 10.2 255
     23 570 21.5 8.3 241
    447 570 25.0 10.0 164
    225 570 5.7 12.2 154
    174 570 7.1 11.0 127
     11 570 19.0 8.9 113
    165 580 10.5 14.8 226
    182 580 8.9 8.2 189
    245 590 15.5 10.0 262
     83 590 17.5 8.3 199
    166 590 11.5 9.4 188
    158 590 7.3 10.7 166
    187 590 4.5 11.0 146
    156 590 23.5 11.3 112
    231 600 9.5 9.0 192
     78 600 11.5 9.4 151
    329 610 15.0 7.3  312**
     57 610 16.0 11.9  286**
     7 610 12.0 10.4 195
    277 610 9.5 7.8 153
    108 620 13.5 8.4 191
    205 620 18.0 7.5 145
    263 620 9.8 10.2 101
     9 630 4.9 11.4  300**
    111 630 8.3 11.1  276**
     68 630 11.5 8.9 143
    399 630 14.0 11.0  90
    266 640 5.1 15.7  364**
     12 640 24.5 9.0 233
    152 640 8.1 10.0 209
    405 640 7.0 12.8 186
     27 640 22.5 8.4 136
    258 640 8.3 11.2 120
    249 640 8.7 9.1  81
    297 650 16.0 10.0  279**
    192 650 4.9 14.9 213
    257 650 3.3** 16.3** 208
    184 650 12.5 9.9 193
     58 650 18.5 10.7 172
    301 650 16.0 15.5 162
    397 650 12.5 8.4 146
    272 650 11.0 7.4 120
    153 650 7.1 13.1 116
    406 650 6.6 5.8  81
     10 660 9.0 7.6 154
     26 660 22.0 8.3 132
    265 670 3.9 19.3**  509**
    359 670 21.0 8.3 269
     48 670 32.0 9.9 262
    335 670 11.5 8.1 121
    189 680 6.6 17.9**  358**
    220 680 15.5 10.9 115
     15 690 13.5 13.4 159
     44 700 20.0 12.7 244
     21 700 13.5 10.2 129
     74 700 15.0 7.1  65
     4 710 29.0 8.5 266
    353 710 11.5 11.4 206
    281 710 10.5 9.6 185
     2 710 8.0 8.5 109
    212 740 20.0 11.1 250
     8 740 12.0 11.5 216
    206 750 12.5 8.3 116
    101 770 14.5 12.7  372**
    344 770 32.0 11.7  297**
     20 770 35.0 10.1 245
    407 770 10.5 12.0 110
    360 780 2.7** 20.9** 157
    232 790 15.5 10.1 151
    141 790 12.5 9.5  74
    129 800 8.7 11.7 211
    188 800 15.0 12.3 174
    400 800 12.5 10.3 156
     24 810 23.0 7.5 194
    173 830 35.0 11.4 243
    214 830 21.5 12.0 187
     63 830 13.8 8.8 185
    148 830 45.0 7.1 146
     84 830 23.5 7.0 136
    179 830 16.5 6.6  96
    171 840 23.5 11.2 195
     28 870 5.8 15.9 197
    233 870 7.9 12.7 169
    221 870 40.0 7.0 126
    371 880 20.0 8.5 152
    213 890 10.5 18.0** 231
    358 900 21.0 8.3 149
    298 910 15.5 10.2 221
    118 910 100.0 9.7 170
    479 950 11.5 12.1 188
     30 950 6.2 10.5 170
    159 1000  9.5 8.7  281**
    219 1050  37.0 14.3  313**
    103 1050  12.5 10.3 154
     59 1150  17.5 7.3 180
    157 1250  12.0 14.0 206
    363 1350  28.0 10.4 190
     22 1400  13.5 10.4 233
     64 1400  31.0 9.7 149
    169 1450  15.0 9.5 150
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Classifications
U.S. Classification514/52, 514/251
International ClassificationA61K31/525, A61K31/714
Cooperative ClassificationY10S514/814, A61K31/714, A61K31/525
European ClassificationA61K31/525, A61K31/714