When to administer thiamine (Vitamin B1) for patients with alcohol use disorder?

From the Guidelines

Thiamine should be administered to all patients with suspected or confirmed alcohol use disorder who present with acute intoxication, withdrawal symptoms, or malnutrition, with a recommended dose of 100-300 mg/day IV for 3-4 days, as stated in the most recent guideline 1. The standard regimen for thiamine administration in patients with alcohol use disorder is 100 mg IV or IM thiamine three times daily for 3-5 days, followed by oral thiamine 100 mg daily until nutritional recovery.

• Key considerations for thiamine administration include:
  • Administering thiamine before giving glucose-containing fluids or food to prevent precipitating or worsening Wernicke's encephalopathy, as glucose metabolism increases thiamine utilization 1.
  • Providing thiamine to all patients admitted to emergency or intensive care without hesitation from admission for 3-4 days, as recommended by the ESPEN micronutrient guideline 1.
  • Considering higher doses of 500 mg IV three times daily for 3-5 days for patients with suspected Wernicke's encephalopathy (confusion, ataxia, eye movement abnormalities) 1. Chronic alcoholics are at high risk for thiamine deficiency due to poor dietary intake, impaired intestinal absorption, decreased hepatic storage, and increased metabolic requirements, making thiamine supplementation crucial in preventing Wernicke's encephalopathy and the irreversible Korsakoff syndrome, characterized by permanent memory impairment 1.
• The most recent guideline recommends thiamine administration in patients admitted on the ward with any suspicion of reduced food intake during the previous days or high alcohol consumption, with a grade of recommendation B and strong consensus of 92% 1. In summary, thiamine administration is a critical component of managing patients with alcohol use disorder, and the recommended dose and duration of treatment should be followed to prevent morbidity and mortality associated with thiamine deficiency, as supported by the most recent and highest quality study 1.

From the FDA Drug Label

In the treatment of Wernicke-Korsakoff syndrome, thiamine hydrochloride has been administered IV in an initial dose of 100 mg, followed by IM doses of 50 mg to 100 mg daily until the patient is consuming a regular, balanced diet. Patients with marginal thiamine status to whom dextrose is being administered should receive 100 mg thiamine hydrochloride in each of the first few liters of IV fluid to avoid precipitating heart failure.

Thiamine should be administered to patients with alcohol use disorder immediately if they are suspected of having Wernicke-Korsakoff syndrome, with an initial dose of 100 mg IV.

• For patients with alcohol use disorder who are receiving dextrose, 100 mg of thiamine should be added to the first few liters of IV fluid to prevent precipitating heart failure. 2

From the Research

Thiamine Administration for Patients with Alcohol Use Disorder

• Thiamine deficiency is a common issue in patients with alcohol use disorder, and it can lead to Wernicke-Korsakoff syndrome (WKS) 3, 4, 5, 6.
• Early supplementation of thiamine is crucial to avoid irreversible neurological damage in patients with alcohol use disorder 4, 7.
• The optimal thiamine dose for the prevention and treatment of WKS is still unclear, with studies showing no significant differences between different dosage regimens 3, 6.

Timing of Thiamine Administration

• Thiamine should be administered prior to glucose in patients with suspected thiamine deficiency to prevent exacerbating Wernicke encephalopathy 7.
• Patients at high risk of Wernicke's encephalopathy should immediately receive an intravenous or intramuscular dose of thiamine 4.
• Empiric therapy for Wernicke encephalopathy should be started as soon as possible, using the Caine criteria to guide the decision to start treatment 7.

Dosage and Route of Administration

• Parenteral or intramuscular thiamine doses of ≥100 mg are recommended for patients with confirmed alcohol-induced Wernicke's encephalopathy 6.
• The route of administration (intravenous or intramuscular) and dosage regimen (e.g., 25 mg four times a day) may vary depending on the patient's condition and risk factors 4, 5.
• Oral thiamine at traditional dosages may not be sufficient for high-risk patients, and parenteral thiamine may be necessary to ensure adequate treatment 5.