General: There is currently no cure for trimethylaminuria (TMAU), and treatment options are limited. However, with proper treatment or precautions, individuals with TMAU may be able to live normal, healthy lives. Generally, treatment is based on symptom management, although widely varying degrees of effectiveness have been reported. Depending on the type and cause of TMAU, an individual may experience mild to complete symptom relief. Getting tested for the disorder is an important first step.
It is important for patients with TMAU to follow the treatment advice of their healthcare providers. Patients should not attempt to self-administer treatments. Medications, supplements, and dietary modifications may have unintended interactions and dietary restrictions, for example restriction of choline may result in nutritional deficits. Choline is essential for nerve and brain development in fetuses and infants. Therefore, pregnant and breastfeeding women should consult with their healthcare provider before restricting their dietary choline.
Diet: The offensive odor associated with TMAU can by minimized with special diets low in trimethylamine (TMA) or its precursors. Since TMAU patients cannot metabolize TMA, limiting certain foods may reduce the buildup of TMA in the body.
Avoiding or minimizing intake of foods such as eggs, legumes, certain meats, fish, and foods that contain choline, nitrogen, and sulfur may reduce the severity of body odor given off. Food sources of choline include soy, egg yolk, butter, banana, barley, cauliflower, corn, flax seeds, lentils, milk, oranges, potatoes, sesame seeds, tomatoes, and whole wheat bread. Affected individuals should also avoid lecithin and lecithin-containing fish oil supplements, which contain high levels of choline.
Milk from wheat-fed cows may have significant amounts of TMA and should be avoided.
Freshwater fish have a lower content of trimethylamine N-oxide than salt water fish and may be suitable for patients with TMAU.
Patients should talk with their healthcare providers and/or nutritionists to design a safe and healthy diet.
Counseling: Psychological complications or depression associated with TMAU may be treated through behavioral counseling.
Genetic counseling may help patients and other individuals to better understand the condition.
Aside from professional dietary advice and counseling, patients may also seek advice about other conditions that may worsen the symptoms of TMAU. These include menstruation, fever, and stress.
Antibiotics: Antibiotics may be used to reduce odor-causing bacteria in the stomach and intestines. Neomycin, amoxicillin, and metronidazole have been used to suppress TMA production by bacteria.
Antibiotic treatment may be useful during times associated with increased TMA production, such as during menstruation, infection, emotional upset, stress, or exercise. Neomycin appears to be the most effective in preventing the formation of TMA from choline. However, antibiotic treatment has not been effective in all cases.
Side effects of taking antibiotics may include nausea, vomiting, stomach pain, headache, swollen tongue, or white patches inside the mouth or throat. Patients should get immediate medical attention if any signs of allergic reaction occur, including hives, fever, sore throat, severe stomach pain, diarrhea, chills, weakness, or seizure. Antibiotic treatment should be administered with caution by healthcare providers, as continued use may increase the risk of antibiotic resistance in the patient.
Other treatments: Using soaps and other personal care products with a moderate pH between 5.5 and 6.5 may help mask body odor. This pH range helps to retain secreted TMA in a salt form, which has reduced odor and can be removed by washing.
It has been suggested that daily intake of charcoal and/or copper chlorophyllin may minimize the odor associated with TMAU. However, the effectiveness of this treatment method may vary. Activated charcoal or copper chlorophyllin, taken by mouth, may help suppress odor-causing bacterial activity in the gut.
Taking laxatives may help prevent odor by decreasing intestinal transit time, which reduces the amount of TMA produced in the gut. Laxatives should be used cautiously and should not be taken regularly for long periods of time.
There is controversy regarding exercise as a treatment for body odor caused by TMAU. While some feel that exercise increases the rate at which certain compounds are broken down in the body, thus allowing sufferers to quickly excrete excess TMA, others warn that the strong body odor of TMAU is more prominent during times of excessive perspiration.
: Currently, there is insufficient evidence available on the safety and effectiveness of integrative therapies for preventing or treating trimethylaminuria. The integrative therapies listed below should be used only under the supervision of a qualified healthcare provider and should not be used in replacement of other proven therapies or preventive measures.
Strong scientific evidence
Music therapy: Music has been referred to as an ancient tool of healing. Many different forms of music intervention have been used to reduce depression and anxiety in a variety of medical conditions and medical procedures. There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood.
St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions, with the most common modern-day use being the treatment of depression. St. John's wort has been extensively studied in Europe over the last two decades, with more recent research in the United States. Short-term studies (one to three months) suggest that St. John's wort is more effective than placebo (sugar pill), and equally effective as tricyclic antidepressants (TCAs) in the treatment of mild-to-moderate depression. Comparisons to the more commonly prescribed selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (Prozac®) or sertraline (Zoloft®), are more limited. However, other data suggest that St. John's wort may be just as effective as SSRIs with fewer side effects. Safety concerns exist as with most conventional and integrative therapies. Studies of St. John's wort for severe depression have not provided clear evidence of effectiveness.
In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
Avoid if allergic or hypersensitive to plants in the Hypericaceaefamily. Rare allergic skin reactions like itchy rash have been reported. Avoid with HIV/AIDS drugs (protease inhibitors) like indinavir (Crixivan®), or non-nucleoside reverse transcriptase inhibitors, like nevirapine (Viramune®). Avoid with immunosuppressant drugs (like cyclosporine, tacrolimus or myophenic acid). Avoid with organ transplants, suicidal symptoms, or before surgery. Use cautiously with a history of thyroid disorders. Use cautiously with drugs that are broken down by the liver, with monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRIS), digoxin, or birth control pills. Use cautiously with diabetes or with a history of mania, hypomania (as in bipolar disorder), or affective illness.
Good scientific evidence
Dehydroepiandoseterone (DHEA): DHEA is a hormone made in the human body that serves as precursor to male and female sex hormones (androgens and estrogens). The majority of clinical trials investigating the effect of DHEA on depression support its use for this purpose under the guidance of a healthcare provider. Further research is needed to confirm these results. Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Side effects may include fatigue, nasal congestion, headache, acne, or rapid/irregular heartbeats. In women, the most common side effects are abnormal menses, emotional changes, headache, and insomnia. Individuals with a history of abnormal heart rhythms, blood clots or hypercoagulability, and those with a history of liver disease, should avoid DHEA supplements. Caution is advised when taking DHEA supplements, as numerous drug interactions are possible. DHEA is not recommended during pregnancy or breastfeeding.
Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). A broad range of psychotherapies have been shown to be effective for the treatment of depression, including behavior therapy, cognitive-behavioral therapy, and interpersonal therapy. Brief dynamic therapy, marital therapy, and family therapy may work best, depending on the patient's problems and circumstances. Psychotherapy, in combination with prescription medicine, may help treat depression as a complication of trimethylaminuria.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several human studies support the use of yoga for depression in both children and adults. Although this early research is promising, better studies are needed.
It should be noted that there is controversy regarding exercise, including yoga, as a treatment method for people with TMAU. While some feel that exercising will increase the rate at which certain compounds are metabolized in the body, thus allowing sufferers to faster excrete as much excess TMA as possible, others warn that symptoms (strong body odor) of TMAU may be more prominent during times of excessive perspiration.
Unclear or conflicting scientific evidence
Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, fruits, shellfish, avocado, beef, and animal organs (liver and kidneys). Preliminary evidence suggests that the use of copper chlorophyllin results in a reduced urinary free trimethylamine (TMA) concentration and normalization of trimethylamine N-oxide (TMAO). Further research is required in this field before recommendations can be made.
Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia or genetic disorders affecting copper metabolism (such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis). Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than six milligrams per liter. Use cautiously with anemia, arthralgias, or myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The Recommended Dietary Allowance (RDA) is 1,000 micrograms for pregnant women. The Recommended Dietary Allowance (RDA) is 1,300 micrograms for breastfeeding women.
Riboflavin (Vitamin B2): Riboflavin is a water-soluble vitamin that is involved in many processes in the body, including normal cell function, growth, and energy production. Adequate nutrient supplementation with riboflavin may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins, including riboflavin, has been reported to improve depression scores in patients taking tricyclic antidepressants. This may be related to tricyclic-caused depletion of riboflavin levels.
Supplements of riboflavin, a precursor of the FAD prosthetic group of FMOs, may help maximize residual FMO3 enzyme activity in patients with trimethylaminuria, allowing further breakdown of trimethylamine. Children given riboflavin should be monitored closely because excessive amounts may cause gastrointestinal distress.
Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as being safe during pregnancy and breastfeeding. The U.S. Recommended Dietary Allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women, and is 1.4 milligrams daily (1.6 milligrams for breastfeeding women).
For inherited cases of trimethylaminuria (TMAU), there is currently no known effective method of prevention of the disorder. However, there are treatments an individual may follow to reduce the severity of their symptoms. These may include dietary restrictions or low-dose antibiotics. Patients with TMAU should take their medications exactly as prescribed and/or strictly follow their diets in order to reduce symptoms.
Although preventing metabolic disorders is generally difficult, individuals can be tested to determine if they are carriers of the disease. Although carriers do not experience symptoms of the disease, they may pass the disease to their children. Anyone with a family history of TMAU or who experiences symptoms of the disorder should be tested.
Individuals who experience temporary TMAU symptoms may reduce their risks of developing a permanent metabolic disorder by eating healthy foods that are low in choline, sulfur, or nitrogen content, and by exercising regularly. It should be noted that although exercise is a healthy preventive measure for many metabolic disorders, there is controversy regarding exercise during symptomatic episodes in TMAU patients.