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Levomefolic acid

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Levomefolic acid (INN, also known as L-5-MTHF, L-methylfolate and L-5-methyltetrahydrofolate and (6S)-5-methyltetrahydrofolate, and (6S)-5-MTHF) is the primary biologically active form of folate used at the cellular level for DNA reproduction, the cysteine cycle and the regulation of homocysteine. It is also the form found in circulation and transported across membranes into tissues and across the blood–brain barrier. In the cell, L-methylfolate is used in the methylation of homocysteine to form methionine and tetrahydrofolate (THF). THF is the immediate acceptor of one carbon unit for the synthesis of thymidine-DNA, purines (RNA and DNA) and methionine. The un-methylated form, folic acid (vitamin B9), is a synthetic form of folate, and must undergo enzymatic reduction by dihydrofolate reductase (DHFR) to become biologically active.[1]

Levomefolic acid
Names
IUPAC name
(2S)-2-[ [4-[(2-Amino-5-methyl-4-oxo-1,6,7,8-tetrahydropteridin-6-yl) methylamino]benzoyl]amino]pentanedioic acid
Other names
(L-5-Me-THFA, L-5-Me-H4FA),
anion: L-5-methyltetrahydrofolate (L-5-Me-THF, L-5-Me-H4F), L-methylfolate
Metafolin
Identifiers
3D model (JSmol)
ChEBI
ChemSpider
KEGG
MeSH 5-methyltetrahydrofolate
UNII
  • InChI=1S/C20H25N7O6/c1-27-12(9-23-16-15(27)18(31)26-20(21)25-16)8-22-11-4-2-10(3-5-11)17(30)24-13(19(32)33)6-7-14(28)29/h2-5,12-13,22H,6-9H2,1H3,(H,24,30)(H,28,29)(H,32,33)(H4,21,23,25,26,31)/t12-,13-/m0/s1
    Key: ZNOVTXRBGFNYRX-STQMWFEESA-N
  • InChI=1/C20H25N7O6/c1-27-12(9-23-16-15(27)18(31)26-20(21)25-16)8-22-11-4-2-10(3-5-11)17(30)24-13(19(32)33)6-7-14(28)29/h2-5,12-13,22H,6-9H2,1H3,(H,24,30)(H,28,29)(H,32,33)(H4,21,23,25,26,31)/t12-,13-/m0/s1
    Key: ZNOVTXRBGFNYRX-STQMWFEEBP
  • CN1c2c([nH]c(nc2=O)N)NC[C@@H]1CNc3ccc(cc3)C(=O)N[C@@H](CCC(=O)O)C(=O)O
Properties
C20H25N7O6
Molar mass 459.463 g·mol−1
Pharmacology
B03BB51 (WHO)
oral, transdermal, subcutaneous
Legal status
Except where otherwise noted, data are given for materials in their standard state (at 25 °C [77 °F], 100 kPa).

It is synthesized in the absorptive cells of the small intestine from polyglutamylated dietary folate. It is a methylated derivative of tetrahydrofolate.

Levomefolic acid is generated by methylenetetrahydrofolate reductase (MTHFR) from 5,10-methylenetetrahydrofolate (MTHF) and used to recycle homocysteine back to methionine by methionine synthase (MS).[2]

L-Methylfolate is water-soluble and primarily excreted via the kidneys. In a study of 21 subjects with coronary artery disease, peak plasma levels were reached in one to three hours following oral or parenteral administration. Peak concentrations were found to be more than seven times higher than folic acid (129 ng/ml vs. 14.1 ng/ml).[3]

Patients at risk for vitamin B12 deficiency should consult with their medical provider prior to taking L-Methylfolate. The interrelationship between these two vitamins (L-Methylfolate and B12) is best explained by the methyl trap hypothesis.[4][5]

Metabolism

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MTHFR metabolism: folate cycle, methionine cycle, trans-sulfuration and hyperhomocysteinemia. 5-MTHF: 5-methyltetrahydrofolate; 5,10-methyltetrahydrofolate; BAX: Bcl-2-associated X protein; BHMT: betaine-homocysteine S-methyltransferase; CBS: cystathionine beta synthase; CGL: cystathionine gamma-lyase; DHF: dihydrofolate (vitamin B9); DMG: dimethylglycine; dTMP: thymidine monophosphate; dUMP: deoxyuridine monophosphate; FAD+ flavine adenine dicucleotide; FTHF: 10-formyltetrahydrofolate; MS: methionine synthase; MTHFR: methylenetetrahydrofolate reductase; SAH: S-adenosyl-L-homocysteine; SAME: S-adenosyl-L-methionine; THF: tetrahydrofolate.

Medical uses

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Major depressive disorder

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Research suggests that levomefolic acid (L-methylfolate) taken with a first-line antidepressant[6] provides a modest adjunctive antidepressant effect for individuals who do not respond or have only a partial therapeutic response to SSRI or SNRI medication,[7][8] and might be a more cost-effective adjunctive agent than second-generation antipsychotics.[9]

Cardiovascular disease and cancer

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Levomefolic acid (and folic acid in turn) has been proposed for treatment of cardiovascular disease[10][11] and advanced cancers such as breast and colorectal cancers.[12] It bypasses several metabolic steps in the body and better binds thymidylate synthase with FdUMP, a metabolite of the drug fluorouracil.

Patent issues

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In March 2012, Merck & Cie of Switzerland, Pamlab LLC (maker of Metanx and Cerefolin, Neevo DHA, and Deplin), and South Alabama Medical Science Foundation (SAMSF) (the plaintiffs) filed a complaint in the United States District Court for the Eastern District of Texas against four defendants: Macoven Pharmaceuticals (owned by Pernix Therapeutics), Gnosis SpA of Italy, Gnosis U.S.A and Gnosis Bioresearch Switzerland. The plaintiffs alleged that the defendants infringed on several of the plaintiffs' patents.[13] The Macoven products named in the suit are: "Vitaciric-B", "ALZ-NAC", "PNV DHA", and l-methylfolate calcium (levomefolate calcium).[14]

In September 2012, the same three plaintiffs filed a complaint requesting that the International Trade Commission begin a 19 U.S.C. § 1337 investigation of the same four defendants. The complaint states that Gnosis' "Extrafolic-S" and products which are made from it, infringe upon three of their patents: US 5997915 , US 6673381 , and US 7172778 .[15]

Formulations

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Levomefolate calcium, a calcium salt of levomefolic acid is sold under the brand name Metafolin[16] and incorporated in Deplin.[17] Levomefolate magnesium is a magnesium salt of levomefolic acid, manufactured as DeltaFolate, a primary ingredient in EnLyte.[18]

See also

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References

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  1. ^ Pietrzik K, Bailey L, Shane B (August 2010). "Folic acid and L-5-methyltetrahydrofolate: comparison of clinical pharmacokinetics and pharmacodynamics". Clinical Pharmacokinetics. 49 (8): 535–48. doi:10.2165/11532990-000000000-00000. PMID 20608755. S2CID 12876272.
  2. ^ "5-methyltetrahydrofolate – Compound Summary", PubChem, NCBI, retrieved 25 September 2012
  3. ^ "CerefolinNAC Caplets Package Insert" (PDF).
  4. ^ "Vitamin B12-folate interrelationships".
  5. ^ "Cellular folate vitamer distribution during and after correction of vitamin B12 deficiency: a case for the methylfolate trap".
  6. ^ Sussman, Norman (1 March 2009). "Selecting a First-line Antidepressant: New Analysis". Primary Psychiatry. 16: 19–22.
  7. ^ Maruf, Abdullah Al; Poweleit, Ethan A.; Brown, Lisa C.; Strawn, Jeffrey R.; Bousman, Chad A. (2022). "Systematic Review and Meta-Analysis of L-Methylfolate Augmentation in Depressive Disorders". Pharmacopsychiatry. 55 (3): 139–147. doi:10.1055/a-1681-2047. ISSN 1439-0795. PMID 34794190.
  8. ^ Lam, Nelson Siu Kei; Long, Xin Xin; Li, Xuegang; Saad, Mirette; Lim, Florence; Doery, James CG; Griffin, Robert C.; Galletly, Cherrie (2022). "The potential use of folate and its derivatives in treating psychiatric disorders: A systematic review". Biomedicine & Pharmacotherapy. 146: 112541. doi:10.1016/j.biopha.2021.112541. PMID 34953391. S2CID 245436052.
  9. ^ Wade RL, Kindermann SL, Hou Q, Thase ME (January 2014). "Comparative assessment of adherence measures and resource use in SSRI/SNRI-treated patients with depression using second-generation antipsychotics or L-methylfolate as adjunctive therapy". Journal of Managed Care Pharmacy. 20 (1): 76–85. doi:10.18553/jmcp.2014.20.1.76. PMC 10438233. PMID 24372461.
  10. ^ Willems FF, Boers GH, Blom HJ, Aengevaeren WR, Verheugt FW (March 2004). "Pharmacokinetic study on the utilisation of 5-methyltetrahydrofolate and folic acid in patients with coronary artery disease". British Journal of Pharmacology. 141 (5). Nature Publishing Group: 825–30. doi:10.1038/sj.bjp.0705446. PMC 1574248. PMID 14769778.
  11. ^ Fohr IP, Prinz-Langenohl R, Brönstrup A, Bohlmann AM, Nau H, Berthold HK, Pietrzik K (February 2002). "5,10-Methylenetetrahydrofolate reductase genotype determines the plasma homocysteine-lowering effect of supplementation with 5-methyltetrahydrofolate or folic acid in healthy young women" (PDF). The American Journal of Clinical Nutrition. 75 (2). American Society for Clinical Nutrition: 275–82. doi:10.1093/ajcn/75.2.275. PMID 11815318.[dead link‍]
  12. ^ Ströhle A, Wolters M, Hahn A (June 2005). "Folic acid and colorectal cancer prevention: molecular mechanisms and epidemiological evidence (Review)". International Journal of Oncology. 26 (6): 1449–64. doi:10.3892/ijo.26.6.1449. PMID 15870856.
  13. ^ The six patents named were US 5997915 , US 6011040 , US 6254904 , US 6673381 , US 7674490  and US 7172778 .
  14. ^ "Pernix Therapeutics' Subsidiary Macoven Pharmaceuticals, LLC Named in Suit by Merck, Pamlab, L.L.C. and Others for Alleged". Bloomberg. 6 March 2012. Retrieved 1 October 2012.
  15. ^ Schweibenz EW (10 September 2012). "SAMSF, Merck, and Pamlab File New 337 Complaint Regarding Certain Reduced Folate Nutraceutical Products and L-methylfolate Raw Ingredients Used Therein". Oblon, Spivak, McClelland, Maier & Neustadt, L.L.P. Archived from the original on 30 January 2013.
  16. ^ "Metafolin". MilliporeSigma. Retrieved 28 November 2022. Metafolin® is our manufactured calcium salt of L-5-methyltetrahydrofolic or L-methylfolate. ... The life science business of Merck KGaA, Darmstadt, Germany operates as MilliporeSigma in the US and Canada.
  17. ^ "DEPLIN®". For Healthcare Professionals. Retrieved 28 November 2022.
  18. ^ "EnLyte with DeltaFolate". dailymed.nlm.nih.gov. Retrieved 28 November 2022.
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