Successful Therapy with Vitamin B, and Vitamin B, of the Carpal Tunnel Syndrome and Need for Determination of the RDAs for Vitamins B, and B, for Disease States" KARL FOLKERS The Institute for Biomedical Research The University of Texas at Austin Austin, Texas 78712 J O H N ELLIS Titus County Memorial Hospital Mt. Pleasant, Texas 75455
A TRIBUTE TO ESMOND E. SNELL FROM KARL FOLKERS I am particularly pleased to participate in this Conference to honor Professor Esmond E. Snell and Professor Alton Meister. Although I have known Alton Meister, I have known Es Snell very well for a minimum of 45 years. As a tribute to the genius of Es Snell, I cite his publication in 1944' on his discovery of pyridoxal and pyridoxamine. Stanton Harris, Dorothea Heyl, and I* gave cooperative support to Es to determine the structures of pyridoxal and pyridoxamine and make samples of the synthetic vitamins available to Es and to the field of biochemistry. The achievements of Es Snell and Alton Meister are legendary in biochemistry. THE RECOMMENDED DIETARY ALLOWANCE FOR VITAMIN B, Although the expression vitamin B, includes six substances, pyridoxine, pyridoxal, pyridoxamine, and their 5'-phosphates, the expression vitamin B, is commonly used to mean pyridoxine. It is pyridoxine hydrochloride that is commonly marketed as the form of vitamin B, for dietary supplementation. Thirty-six years ago, Vilter et aL3 reported upon the effects of a vitamin B, deficiency that was induced by desoxypyridoxine in human beings. Twenty-five years ago, Yess et aL4 published a report that provided a basis for studying vitamin B, depletion in man by the urinary excretion of tryptophan metabolites. The study, from the National Research Council, most often cited even now in support of an RDA of ca. 2 mg for vitamin B, also took place 25 years ago. This study by Baker, Canham, Nunes, Sauberlich, and McDowell' was designed to evaluate the
'This text is based upon the lecture written by Karl Folkers for presentation on April 11,1989, at the International Multidisciplinary Conference on Vitamin B,, Philadelphia, PA. 295
296
ANNALS NEW YORK ACADEMY OF SCIENCES
vitamin B, requirement for adult men. Eleven subjects were initiated in the study, but only eight completed it. They administered 10 g of DL-tryptophan orally and monitored the urinary excretion of xanthurenic acid and so forth. The influence of 5 g of the unnatural D-isomer is still unknown. They observed that depletion of vitamin B, could be rapidly achieved and was directly related to the intake of protein. The change in urinary excretion of B, inversely correlated with excretion of xanthurenic acid. They concluded that the optimal daily intake of pyridoxine hydrochloride for subjects on a protein intake of 100 g appeared to be 1.75-2.0 mg per day, and that subjects with a low protein intake (30 g) required only 1.25-1.5 mg per day. Miller and Linkswiler, found that the excretion of tryptophan metabolites in students that were fed 54 g of protein were normalized by an intake of 0.6 mg per day of pyridoxine. Babcock et a1.l used the serum glutamic-oxalacetic transaminase as an index, and concluded that the pyridoxine requirement for students was considerably more than 0.5 mg per day. In critique, these studies of 25-36 years ago were based upon (a) only eight subjects, (b) a load of 10 g of DL-tryptophan with the uncertainty of the significance of the presence of the D-iSOmer, (c) the unknown variability of urinary excretion of tryptophan metabolites, and (d) protocols that were not designed for statistical analyses of data. (Such protocols were not then in common practice.)
THE CATALYSIS OF VITAMIN B, FOR THE ENTIRE HUMAN BODY One speaks of 20 amino acids that constitute the structures of all the proteins, all the enzymes, and all the peptide hormones of the entire human body. There are thousands upon thousands of proteins ranging from gene-regulatory proteins to countless others, including those for storage, transport, and contractility. What is the total number of proteins in the human body? Calculation has shown that for proteins of 300 amino acids, which are typical, there may be even more than proteins. Apparently, over a thousand enzymes have been identified for the human body. How many peptide hormones are there in the human body ranging from the classic insulin to the interleukins and the tumor necrosis factor of today? How many unknown but vital peptide hormones are yet to be discovered in the human body? Vitamin B,, as a coenzyme, is essential-is indispensable, is obligatory-to some 18 of these 20 amino acids that make up the structures of these countless proteins, enzymes, and polypeptide hormones. Obviously, vitamin B, has stupendous importance for the total health of the human body, and if the RDA of ca. 2 mg were too little for these countless proteins, enzymes, and peptide hormones, then human health is in incredible jeopardy.
QUANTITATION OF HUMAN DEFICIENCIES OF VITAMIN B, In 1975, Folkers initiated research on human deficiencies of vitamin B,, and he had an ideal post-doc, Dr. Hiroe Kishi, for the research. They accurately measured the activities of the erythrocyte glutamic oxaloacetic transaminase (EGOT) by a dual enzymic assay, which they defined by the CAS principle, that is, the unsaturation and saturation of the coenzyme (pyridoxal 5’-phosphate) of a coenzyme-apoenzyme sys-
FOLKERS & ELLIS DETERMINING THE RDA
297
tem. In this dual assay, the S A of EGOT (the specific activity in micromoles of pyruvic acid formed/hr lo8 cells) is measured in the absence and in the presence of the coenzyme. The assay provides the S A of EGOT, and the amount of the apoenzyme that is present without the coenzyme in its receptor and which measures a deficiency. This assay revealed deficiencies of EGOT activity of 11 +- 6% and 12 2 7% in a group of 24 athletes and 25 students, respectively.8 Brin et ~ 1 had . used ~ this principle to measure thiamin deficiencies in 1960.
COOPERATION OF KARL FOLKERS AND JOHN M. ELLIS One day in 1975, Karl telephoned Dr. John Ellis, who has a medical practice in Mt. Pleasant, Texas, and introduced himself by saying that his name was on page 22 of John’s book, entitled Vitamin 4, The Doctor’s Report.” From that day fourteen years ago until today, Karl Folkers and John Ellis have enjoyed a remarkably successful cooperation and a friendship of Texas size. Karl regards John as one of the most methodical, systematic, persevering, and competent physicians whom he has known in 50 years, and he considers John’s achievement on treating the carpal tunnel syndrome with vitamin B, worthy of an award.
A SUCCESSFUL DOUBLE-BLIND TRIAL FOR VITAMIN B, AND THE
CARPAL TUNNEL SYNDROME After cooperating several years on diverse open trials on vitamin B, for patients with the carpal tunnel syndrome (CTS) with emphasis on the biochemistry, the dosage, and the time of the trial, we ultimately conducted a double-blind trial with pyridoxine and a matching placebo. After a few years of intense biochemistry, Folkers had initially thought that six weeks of treatment was sufficient for the double-blind trial, but the clinical result was a clear failure. After about one more year of biochemical experimentation with countless blood samples, including effective discussions with Es Snell, Folkers concluded that the double-blind trial should be repeated but for twelve weeks instead of six weeks, and this timing was based upon his important discovery that the S A of EGOT continued to increase from 6 to 12 weeks, but then definitely stabilized at a value of ca. 0.7. Clinically, this meant that the double-blind trial was to be conducted until the SA had reached 0.7 for those patients receiving the pyridoxine. In this double-blind trial, two physicians identified those receiving pyridoxine (clinically improved) and those receiving placebo (did not improve) without error, p < 0.0078. The apparent K , values of EGOT were identical for groups of patients with CTS and others without CTS, but with identical specific activities, indicating that the carpal tunnel syndrome is a primary deficiency of vitamin B, rather than one of a dependency state or some other genetic aspect.” The carpal tunnel syndrome is prominent with a S A of ca.
A TRIBUTE TO ESMOND E. SNELL FROM KARL FOLKERS I am particularly pleased to participate in this Conference to honor Professor Esmond E. Snell and Professor Alton Meister. Although I have known Alton Meister, I have known Es Snell very well for a minimum of 45 years. As a tribute to the genius of Es Snell, I cite his publication in 1944' on his discovery of pyridoxal and pyridoxamine. Stanton Harris, Dorothea Heyl, and I* gave cooperative support to Es to determine the structures of pyridoxal and pyridoxamine and make samples of the synthetic vitamins available to Es and to the field of biochemistry. The achievements of Es Snell and Alton Meister are legendary in biochemistry. THE RECOMMENDED DIETARY ALLOWANCE FOR VITAMIN B, Although the expression vitamin B, includes six substances, pyridoxine, pyridoxal, pyridoxamine, and their 5'-phosphates, the expression vitamin B, is commonly used to mean pyridoxine. It is pyridoxine hydrochloride that is commonly marketed as the form of vitamin B, for dietary supplementation. Thirty-six years ago, Vilter et aL3 reported upon the effects of a vitamin B, deficiency that was induced by desoxypyridoxine in human beings. Twenty-five years ago, Yess et aL4 published a report that provided a basis for studying vitamin B, depletion in man by the urinary excretion of tryptophan metabolites. The study, from the National Research Council, most often cited even now in support of an RDA of ca. 2 mg for vitamin B, also took place 25 years ago. This study by Baker, Canham, Nunes, Sauberlich, and McDowell' was designed to evaluate the
'This text is based upon the lecture written by Karl Folkers for presentation on April 11,1989, at the International Multidisciplinary Conference on Vitamin B,, Philadelphia, PA. 295
296
ANNALS NEW YORK ACADEMY OF SCIENCES
vitamin B, requirement for adult men. Eleven subjects were initiated in the study, but only eight completed it. They administered 10 g of DL-tryptophan orally and monitored the urinary excretion of xanthurenic acid and so forth. The influence of 5 g of the unnatural D-isomer is still unknown. They observed that depletion of vitamin B, could be rapidly achieved and was directly related to the intake of protein. The change in urinary excretion of B, inversely correlated with excretion of xanthurenic acid. They concluded that the optimal daily intake of pyridoxine hydrochloride for subjects on a protein intake of 100 g appeared to be 1.75-2.0 mg per day, and that subjects with a low protein intake (30 g) required only 1.25-1.5 mg per day. Miller and Linkswiler, found that the excretion of tryptophan metabolites in students that were fed 54 g of protein were normalized by an intake of 0.6 mg per day of pyridoxine. Babcock et a1.l used the serum glutamic-oxalacetic transaminase as an index, and concluded that the pyridoxine requirement for students was considerably more than 0.5 mg per day. In critique, these studies of 25-36 years ago were based upon (a) only eight subjects, (b) a load of 10 g of DL-tryptophan with the uncertainty of the significance of the presence of the D-iSOmer, (c) the unknown variability of urinary excretion of tryptophan metabolites, and (d) protocols that were not designed for statistical analyses of data. (Such protocols were not then in common practice.)
THE CATALYSIS OF VITAMIN B, FOR THE ENTIRE HUMAN BODY One speaks of 20 amino acids that constitute the structures of all the proteins, all the enzymes, and all the peptide hormones of the entire human body. There are thousands upon thousands of proteins ranging from gene-regulatory proteins to countless others, including those for storage, transport, and contractility. What is the total number of proteins in the human body? Calculation has shown that for proteins of 300 amino acids, which are typical, there may be even more than proteins. Apparently, over a thousand enzymes have been identified for the human body. How many peptide hormones are there in the human body ranging from the classic insulin to the interleukins and the tumor necrosis factor of today? How many unknown but vital peptide hormones are yet to be discovered in the human body? Vitamin B,, as a coenzyme, is essential-is indispensable, is obligatory-to some 18 of these 20 amino acids that make up the structures of these countless proteins, enzymes, and polypeptide hormones. Obviously, vitamin B, has stupendous importance for the total health of the human body, and if the RDA of ca. 2 mg were too little for these countless proteins, enzymes, and peptide hormones, then human health is in incredible jeopardy.
QUANTITATION OF HUMAN DEFICIENCIES OF VITAMIN B, In 1975, Folkers initiated research on human deficiencies of vitamin B,, and he had an ideal post-doc, Dr. Hiroe Kishi, for the research. They accurately measured the activities of the erythrocyte glutamic oxaloacetic transaminase (EGOT) by a dual enzymic assay, which they defined by the CAS principle, that is, the unsaturation and saturation of the coenzyme (pyridoxal 5’-phosphate) of a coenzyme-apoenzyme sys-
FOLKERS & ELLIS DETERMINING THE RDA
297
tem. In this dual assay, the S A of EGOT (the specific activity in micromoles of pyruvic acid formed/hr lo8 cells) is measured in the absence and in the presence of the coenzyme. The assay provides the S A of EGOT, and the amount of the apoenzyme that is present without the coenzyme in its receptor and which measures a deficiency. This assay revealed deficiencies of EGOT activity of 11 +- 6% and 12 2 7% in a group of 24 athletes and 25 students, respectively.8 Brin et ~ 1 had . used ~ this principle to measure thiamin deficiencies in 1960.
COOPERATION OF KARL FOLKERS AND JOHN M. ELLIS One day in 1975, Karl telephoned Dr. John Ellis, who has a medical practice in Mt. Pleasant, Texas, and introduced himself by saying that his name was on page 22 of John’s book, entitled Vitamin 4, The Doctor’s Report.” From that day fourteen years ago until today, Karl Folkers and John Ellis have enjoyed a remarkably successful cooperation and a friendship of Texas size. Karl regards John as one of the most methodical, systematic, persevering, and competent physicians whom he has known in 50 years, and he considers John’s achievement on treating the carpal tunnel syndrome with vitamin B, worthy of an award.
A SUCCESSFUL DOUBLE-BLIND TRIAL FOR VITAMIN B, AND THE
CARPAL TUNNEL SYNDROME After cooperating several years on diverse open trials on vitamin B, for patients with the carpal tunnel syndrome (CTS) with emphasis on the biochemistry, the dosage, and the time of the trial, we ultimately conducted a double-blind trial with pyridoxine and a matching placebo. After a few years of intense biochemistry, Folkers had initially thought that six weeks of treatment was sufficient for the double-blind trial, but the clinical result was a clear failure. After about one more year of biochemical experimentation with countless blood samples, including effective discussions with Es Snell, Folkers concluded that the double-blind trial should be repeated but for twelve weeks instead of six weeks, and this timing was based upon his important discovery that the S A of EGOT continued to increase from 6 to 12 weeks, but then definitely stabilized at a value of ca. 0.7. Clinically, this meant that the double-blind trial was to be conducted until the SA had reached 0.7 for those patients receiving the pyridoxine. In this double-blind trial, two physicians identified those receiving pyridoxine (clinically improved) and those receiving placebo (did not improve) without error, p < 0.0078. The apparent K , values of EGOT were identical for groups of patients with CTS and others without CTS, but with identical specific activities, indicating that the carpal tunnel syndrome is a primary deficiency of vitamin B, rather than one of a dependency state or some other genetic aspect.” The carpal tunnel syndrome is prominent with a S A of ca.
