Methylfolate

The basics are simple and maddening

There’s a nutrient called folate which is so important that it’s added to (fortified in) flour as a matter of course. Not having it during pregnancy results in birth defects. Unfortunately there’s a small fraction of all people who have genetic issues which make their bodies have trouble processing folate into methylfolate. For them folate supplements make the problem even worse as the unprocessed folate drowns out the small amounts of methylfolate their bodies have managed to produce and are trying to use. For those people taking methylfolate supplements fixes the problem.

First of all in the very good news: folinic acid produces miraculous effects for some number of people with autism symptoms. It’s such a robust effect that the FDA is letting treatment get fast-tracked through which is downright out of character for them. This is clearly a good thing and I’m happy for anyone who’s benefiting and applaud anyone who is trying to promote it with one caveat.

The caveat is that although this is all a very good thing there isn’t much of any reason to believe that folinic acid is much better than methylfolate, which both it and folate get changed into in the digestive system. This results in folinic acid being sold as leucovorin, its drug name, at an unnecessarily large price markup with unnecessary involvement of medical professionals. Obviously there’s benefit to medical professionals being involved in initial diagnosis and working out a treatment plan, but once that’s worked out there isn’t much reason to think the patient needs to be getting a drug rather than a supplement for the rest of their life.

This is not to say that the medical professionals studying folinic acid for this use are doing anything particularly wrong. There’s a spectrum between doing whatever is necessary to get funding/approvals working within the existing medical system and simply profiteering off things being done badly instead of improving on it. What’s being done with folinic acid is slightly suboptimal but clearly getting stuff done with an only slightly more expensive solution (it’s thankfully already generic.) Medical industry professionals earnestly thought they were doing the right thing working within the system have given me descriptions of what they’re doing which made me want to take a shower afterwards. This isn’t anything like that. Those mostly involved ‘improving’ on a treatment which is expensive and known to be useless by offering a marginally less useless but less expensive intervention. They’re also conveniently at a much higher markup. Maybe selling literal snake oil at a lower price can help people waste less money but it sure looks like profiteering.

The thing with folate which is a real problem is that instead of fortification being done with folate it should be done with methylfolate. People having the folate issue is a known thing and the recent developments mostly indicate that a lot more people have it than was previously known. It may be that a lot of people who think they have a gluten problem actually have a folate problem. There would be little downside to switching over, but I fear that people have tried to suggest this and there’s a combination of no money in it and the FDA playing its usual games of claiming that folate is so important that doing a study of whether methylfolate is better would be unethical because it might harm the study participants.

There’s a widespread claim that the dosage of methylfolate isn’t as high as folinic acid, which has a kernal of truth because the standard sizes are different but you can buy 15mg pills of methylfolate off of amazon for about the same price as the 1mg pills. There are other claims of different formulations having different effects which are likely mostly due to dosage differences. The amounts of folinic acid being given to people are whopping huge, and some formulations only have one isomer which throws things off by a factor of 2 on top of the amount difference. My guess is that most people who notice any difference between folinic acid and methylfolate are experiencing (if it’s real) differences between not equivalent dosages and normalizing would get rid of the effect. This is a common and maddening problem when people compare similar drugs (or in this case nutrients) where the dosages aren’t normalized to be equivalent leading people to think the drugs have different effects when for practical purposes they don’t.