Should all eating disorder patients receive oral thiamine (Vitamin B1) to mitigate refeeding syndrome?

Thiamine Supplementation in Eating Disorder Patients to Prevent Refeeding Syndrome

All eating disorder patients should receive oral thiamine supplementation during the refeeding process to prevent thiamine deficiency and mitigate the risk of refeeding syndrome. 1, 2

Risk Assessment and Rationale

Patients with eating disorders are at high risk for developing refeeding syndrome when nutritional rehabilitation is initiated. This potentially life-threatening condition occurs due to:

• Prolonged malnutrition leading to depleted intracellular electrolytes
• Rapid reintroduction of nutrition causing shifts in fluid and electrolyte balance
• Increased metabolic demands during refeeding

Key Risk Factors for Refeeding Syndrome:

• Low energy intake for >10 days or weight loss >15% 1
• Starvation (the most reliable predictor) 1
• Eating disorders 1
• Low serum magnesium (<0.7 mmol/L) 1
• Older age and high Nutritional Risk Screening scores 1

Thiamine Dosing Recommendations

For eating disorder patients during refeeding:

1. Initial phase (first 3-4 days):

   • Oral thiamine 200-300 mg daily 2
   • For severe cases with neurological symptoms: 500 mg three times daily 2

2. Maintenance phase:

   • Oral thiamine 50-100 mg daily 2
   • Continue for 2-3 months following resolution of symptoms 2

Implementation Protocol

Before Initiating Refeeding:

• Administer thiamine before introducing carbohydrates to prevent precipitation of Wernicke's encephalopathy 2
• Start with hypocaloric feeding (5-15 kcal/kg/day) for high-risk patients 1
• Ensure adequate phosphate supplementation alongside thiamine 1, 3

During Refeeding:

• Monitor electrolytes (particularly potassium, phosphate, magnesium) daily during initial refeeding 4
• Gradually increase caloric intake over 5-10 days based on individual risk 1
• Continue thiamine supplementation throughout the refeeding process 2

Special Considerations

• Severe malnutrition (BMI <13): Higher vigilance required but rapid refeeding can still be safe with proper thiamine and phosphate supplementation 3
• Patients with vomiting or diarrhea: May require higher thiamine doses or parenteral administration 1
• Patients receiving parenteral nutrition: Ensure parenteral nutrition provides at least 2.5 mg thiamine daily 2

Warning Signs of Thiamine Deficiency

Monitor for:

• Confusion or altered mental status
• Ophthalmoplegia or nystagmus
• Ataxia
• Cardiovascular abnormalities (tachycardia, heart failure)

Pitfalls to Avoid

1. Administering glucose without thiamine: This can precipitate acute thiamine deficiency and Wernicke's encephalopathy 2
2. Inadequate monitoring: Electrolyte imbalances can develop rapidly despite supplementation 4
3. Overfeeding: Starting with too high caloric intake increases refeeding syndrome risk 1
4. Discontinuing thiamine too early: Continue supplementation throughout the refeeding process 2

By following these guidelines, the risk of refeeding syndrome can be significantly reduced while safely reestablishing nutrition in patients with eating disorders.