Thiamine Supplementation for Alcohol Use Disorder
For individuals with alcohol use disorder, thiamine supplementation should be provided at 100-300 mg/day for 2-3 months following resolution of withdrawal symptoms to prevent Wernicke's encephalopathy. 1
Recommended Dosing Regimens
For Prevention of Wernicke's Encephalopathy:
- Dosage: 100-300 mg/day of thiamine
- Duration: 4-12 weeks
- Route: Oral administration for most patients without acute symptoms
For Treatment of Established Wernicke's Encephalopathy:
- Dosage: 100-500 mg/day of thiamine
- Duration: 12-24 weeks
- Route: Parenteral (IV/IM) administration preferred 1
Important Clinical Considerations
Timing of Administration
- Thiamine should be given before administering IV fluids containing glucose, as IV glucose may precipitate acute thiamine deficiency and worsen neurological symptoms 1
- In patients receiving parenteral nutrition, administer thiamine before commencing PN to prevent Wernicke's encephalopathy or refeeding syndrome 1
Risk Assessment
Patients at high risk for thiamine deficiency include those with:
- Poor nutritional status/malnutrition
- Chronic alcohol use
- History of withdrawal seizures
- Liver dysfunction
- Vomiting or poor oral intake
Route of Administration
- Oral route: Appropriate for most patients with alcohol use disorder for prevention
- Parenteral route (IV/IM): Required for:
- Patients with established Wernicke's encephalopathy
- Patients with severe vomiting or malabsorption
- When rapid restoration of thiamine is necessary 2
Clinical Rationale
Thiamine deficiency is extremely common in patients with alcohol use disorder due to:
- Decreased dietary intake
- Impaired intestinal absorption
- Decreased hepatic storage
- Impaired thiamine utilization
Diminished cognitive function due to thiamine deficiency is common in patients with alcohol use disorder, making supplementation essential for all patients 1. Thiamine is a critical cofactor for several enzymes involved in carbohydrate metabolism, and deficiency can lead to Wernicke's encephalopathy, which can progress to Korsakoff syndrome if left untreated.
Implementation in Clinical Practice
Despite clear guidelines, thiamine is significantly underprescribed in clinical practice. Studies show that only 2.2% of ED visits with alcohol-related diagnoses and only 17.8% of visits specifically for alcohol dependence resulted in thiamine prescriptions 3. This represents a missed opportunity to prevent significant morbidity and mortality.
Monitoring and Follow-up
- Assess for clinical improvement in neurological symptoms
- Monitor for adverse effects (rare but include anaphylactic reactions with parenteral administration)
- Continue supplementation for the recommended duration even after acute symptoms resolve
The evidence strongly supports routine thiamine supplementation for all patients with alcohol use disorder, with dosing tailored to the presence or absence of Wernicke's encephalopathy.