What dose of folic acid (Vitamin B9) do you recommend for chronic alcoholics?

Folic Acid Dosing for Chronic Alcoholics

For chronic alcoholics, 1-5 mg of folic acid should be administered orally per day, with most patients requiring the higher end of this range (5 mg daily) due to malabsorption and increased excretion. 1

Rationale for Dosing

• Chronic alcoholism leads to folate deficiency through multiple mechanisms:

  • Poor dietary intake
  • Intestinal malabsorption
  • Decreased hepatic uptake
  • Increased urinary excretion 2
  • Interference with folate metabolism

• The ESPEN micronutrient guidelines specifically recommend 1-5 mg of folic acid daily for dietary deficiency, with treatment lasting four months or until the underlying cause is corrected 1

Administration Protocol

1. Initial dosing: Start with 5 mg oral folic acid daily
2. Duration: Continue for at least 4 months 1
3. Route: Oral administration is preferred and effective even in most patients with malabsorption 3
4. Alternative routes: If oral treatment is ineffective or not tolerated, folic acid can be given subcutaneously, IV, or IM at 0.1 mg/day 1

Monitoring

• Measure folate status at baseline and repeat within 3 months after starting supplementation 1
• Check both:
  • Serum folate (short-term status)
  • RBC folate (long-term status) 1
• Target levels: serum folate ≥10 nmol/L and red blood cell folate ≥340 nmol/L 1

Important Precautions

• Always check vitamin B12 status before initiating folate treatment

  • High-dose folate can mask B12 deficiency while neurological damage progresses 1
  • Alcoholics often have multiple vitamin deficiencies simultaneously

• After clinical symptoms resolve and blood parameters normalize, transition to a maintenance dose of approximately 330 μg DFE (Dietary Folate Equivalents) daily 1

Clinical Considerations

• Up to 80% of alcoholics may have decreased serum folate levels 2

• Folate deficiency in alcoholics can lead to:

  • Macrocytic and megaloblastic anemia
  • Neurological disorders
  • Elevated homocysteine (cardiovascular risk factor) 2

• The FDA label for folic acid notes that in alcoholism, the maintenance level may need to be increased above standard dosing 3

This higher-dose approach (1-5 mg daily) is appropriate for chronic alcoholics given their increased risk of severe deficiency and the safety profile of oral folic acid supplementation.