What is the recommended dose of vitamin B6 (pyridoxine) for the treatment of alcohol use disorder?

Vitamin B6 Dosage in Alcohol Use Disorder

For patients with alcohol use disorder, oral vitamin B6 (pyridoxine) should be supplemented at a dose of 50-100 mg daily for one to two weeks to address deficiency. 1

Rationale for Vitamin B6 Supplementation in AUD

Vitamin B6 deficiency is common in alcoholics and requires appropriate supplementation for several reasons:

• Alcoholics are identified as a high-risk population for vitamin B6 deficiency 1
• Deficiency can lead to serious complications including:
  • Seborrheic dermatitis with cheilosis and glossitis
  • Microcytic anemia
  • Epileptiform convulsions
  • Confusion and depression
  • Angular stomatitis

Dosing Recommendations

Initial Treatment Phase

• Oral supplementation: 50-100 mg daily for 1-2 weeks 1
• This dosage is considered safe and widely available
• PLP (pyridoxal phosphate) levels respond to intake and reflect liver stores, plateauing in 6-10 days

Maintenance Phase

• After initial treatment, consider continuing with a lower maintenance dose
• The American College of Hepatology recommends B-complex vitamins including pyridoxine as part of standard care for AUD patients 2

Safety Considerations

It's important to be aware of potential toxicity with long-term high-dose supplementation:

• Long-term doses as low as 100 mg/day have been associated with Lhermitte signs (effect on spinal cord) 1
• The No-Observed-Adverse-Effect-Level (NOAEL) is 100 mg/day 1
• Higher doses (>300-500 mg/day) have been associated with sensory neuropathy, ataxia, areflexia, and dermatologic lesions 1, 3

Monitoring

• Vitamin B6 status should be determined by measuring plasma pyridoxal phosphate (PLP) levels 1
• In patients with inflammation or serious illness, red cell PLP should be measured instead of plasma levels 1

Comprehensive Approach

While vitamin B6 is important, it should be part of a comprehensive nutritional approach:

• Thiamine (vitamin B1) supplementation is the primary nutritional intervention for AUD patients 2
• Other B-complex vitamins, zinc, and vitamin D should also be considered 2
• Patients with AUD often have multiple vitamin deficiencies that need simultaneous treatment 4, 5

Clinical Pitfalls to Avoid

1. Overlooking vitamin B6 deficiency: Studies show that vitamin supplementation is often neglected in patients with AUD, especially when they present with conditions other than alcohol withdrawal 6

2. Excessive supplementation: Long-term high-dose supplementation (>100 mg/day) may lead to neurotoxicity 3

3. Focusing only on thiamine: While thiamine is critical to prevent Wernicke's encephalopathy, other B vitamins including B6 are essential for neurological function 2, 4

4. Delayed administration: Early supplementation is important, ideally within the first days of treatment 5