What vitamins should be checked in alcoholics?

Vitamins to Check in Alcoholics

Alcoholic patients should be routinely screened for deficiencies in vitamin A, thiamine (B1), vitamin B12, folic acid, pyridoxine (B6), vitamin D, and zinc, as these are the most common deficiencies that impact morbidity and mortality in this population. 1

Priority Vitamins to Check

Fat-Soluble Vitamins

1. Vitamin A

   • Deficiency prevalence: 3-14.5% in chronic liver disease 1
   • Clinical significance: Impaired night vision, immune dysfunction

2. Vitamin D

   • Deficiency prevalence: 58-77.9% in chronic liver disease 1
   • Target level: >30 ng/ml
   • Supplement if levels <20 ng/ml 1

3. Vitamin K

   • Especially important in jaundiced patients or those with cholestatic disease 1
   • Deficiency prevalence: 13-63% in chronic liver disease 1

Water-Soluble Vitamins

1. Thiamine (B1)

   • Most critical vitamin to assess in alcoholics
   • Deficiency prevalence: Up to 46% in chronic alcoholics 2
   • Clinical significance: Prevents Wernicke's encephalopathy and Korsakoff's syndrome 3
   • Warning signs: Anemia, abnormal liver function, low diastolic blood pressure 2

2. Folate (B9)

   • Deficiency common in alcoholics
   • Supplementation: 5mg daily for minimum 4 months when deficient 3

3. Vitamin B12

   • Check before initiating folate treatment to avoid precipitating subacute combined degeneration of the spinal cord 3

4. Pyridoxine (B6)

   • Depletes rapidly due to diminished hepatic storage 1
   • Contributes to peripheral neuropathy when deficient

Minerals and Trace Elements

1. Zinc

   • Improves dysgeusia (taste disturbances) and may help with hepatic encephalopathy 1
   • Involved in albumin metabolism

2. Magnesium

   • Deficiency correlates with exocrine pancreatic failure 1

3. Selenium

   • Deficiency observed in both alcoholic and non-alcoholic liver disease 1

Clinical Approach to Vitamin Assessment

When to Check

• At initial presentation with alcohol-related illness
• During alcohol withdrawal management
• When evaluating malnutrition
• Before initiating nutritional support to prevent refeeding syndrome 3

Warning Signs of Vitamin Deficiencies

• Neurological symptoms: Confusion, ataxia, nystagmus, ophthalmoplegia
• Anemia (may be related to thiamine deficiency) 2
• Peripheral neuropathy
• Abnormal liver function tests
• Skin or mucosal changes

Treatment Approach

Thiamine Supplementation

• Acute presentation with encephalopathy or high suspicion:

  • 500 mg IV three times daily for 3-5 days
  • Then 250 mg IV daily for 3-5 additional days 3
  • CRITICAL: Give thiamine BEFORE any glucose-containing fluids 3

• Maintenance therapy:

  • 50-100 mg oral daily for 2-3 months 3

Nutritional Support

• Provide adequate protein (1.2-1.5 g/kg/day) and calories (35-40 kcal/kg/day) 1
• Consider branched-chain amino acids in hepatic encephalopathy 1
• For critically ill alcoholic patients, increase to 1.5 g/kg/day protein and 40 kcal/kg/day calories 1

Common Pitfalls to Avoid

1. Administering glucose before thiamine - can precipitate or worsen Wernicke's encephalopathy 3
2. Overlooking thiamine deficiency in non-alcoholic conditions - consider in malnutrition, prolonged vomiting, post-bariatric surgery 3
3. Inadequate dosing or premature discontinuation of thiamine therapy 3
4. Failing to identify concurrent deficiencies - multiple vitamin deficiencies often coexist 4
5. Blind supplementation without testing - not all alcoholics have vitamin deficiencies, and some may have excess levels (e.g., 19% had excess vitamin A) 1

Monitoring Response

• Reassess vitamin levels after 1-2 months of supplementation
• Monitor for clinical improvement in neurological symptoms
• Consider thiamine challenge test: immediate clinical improvement after thiamine administration supports diagnosis 3

By systematically assessing these key vitamins and minerals in alcoholic patients and providing appropriate supplementation, you can significantly reduce morbidity and mortality related to nutritional deficiencies in this vulnerable population.