Dietary practices in pyridoxine non-responsive homocystinuria: A European survey

Within Europe, the management of pyridoxine (B6) non-responsive homocystinuria (HCU) may vary but there is limited knowledge about treatment practice. A comparison of dietetic management practices of patients with B6 non-responsive HCU in European centres. A cross-sectional audit by questionnaire was completed by 29 inherited metabolic disorder (IMD) centres: (14 UK, 5 Germany, 3 Netherlands, 2 Switzerland, 2 Portugal, 1 France, 1 Norway, 1 Belgium). 181 patients (73% >16years of age) with HCU were identified. The majority (66%; n=119) were on dietary treatment (1–10years, 90%; 11–16years, 82%; and >16years, 58%) with or without betaine and 34% (n=62) were on betaine alone. The median natural protein intake (g/day) on diet only was, by age: 1–10years, 12g; 11–16years, 11g; and >16years, 45g. With diet and betaine, median natural protein intake (g/day) by age was: 1–10years, 13g; 11–16years, 20g; and >16years, 38g. Fifty-two percent (n=15) of centres allocated natural protein by calculating methionine rather than a protein exchange system. A methionine-free l-amino acid supplement was prescribed for 86% of diet treated patients. Fifty-two percent of centres recommended cystine supplements for low plasma concentrations. Target treatment concentrations for homocystine/homocysteine (free/total) and frequency of biochemical monitoring varied. In B6 non-responsive HCU the prescription of dietary restriction by IMD centres declined with age, potentially associated with poor adherence in older patients. Inconsistencies in biochemical monitoring and treatment indicate the need for international consensus guidelines. •Dietary management practices of B6 non-responsive HCU from 29 European IMD centres•Clinical treatment choice of low methionine diet declined with increasing patient age.•Diet and betaine treated patients had similar protein intakes to those on diet alone.•Almost all patients (86%) were prescribed a methionine-free l-amino acid supplement.•Inconsistencies in monitoring & treatment suggest international guidelines are needed.