Should both multivitamin and thiamine be administered before refeeding in patients at risk of refeeding syndrome?

Thiamine and Multivitamin Administration Before Refeeding

Both thiamine and multivitamin should be administered before refeeding in patients at risk of refeeding syndrome, with thiamine being the priority and administered first. 1, 2

Risk Assessment for Refeeding Syndrome

Patients at high risk for refeeding syndrome include those with:

• BMI <16 kg/m²
• Unintentional weight loss >15% in 3-6 months
• Little or no nutritional intake for >10 days
• Low baseline levels of potassium, phosphate, or magnesium
• History of alcohol abuse 2
• Severe alcoholic steatohepatitis (ASH) 1
• Malnourished patients with chronic liver disease 1

Thiamine Administration

Thiamine must be administered before initiating refeeding:

• Dosage for refeeding syndrome prevention: 300 mg IV before initiating nutrition therapy, followed by 200-300 mg IV daily for at least 3 more days 1
• In patients with severe ASH, administer a first dose of thiamine before commencing parenteral nutrition to prevent Wernicke's encephalopathy or refeeding syndrome 1
• For patients with high suspicion or proven deficiency: 200 mg, 3 times a day, IV 1
• For encephalopathy of uncertain etiology: 500 mg, 3 times a day, IV 1

Multivitamin Administration

After thiamine administration, multivitamins should be provided:

• Water-soluble and fat-soluble vitamins should be administered daily from the beginning of nutritional support 1
• Specific vitamins including vitamin A, D, and K should be administered along with thiamine, folate, and pyridoxine to correct deficiency 1
• A recent study suggested that in patients at risk for Wernicke's encephalopathy, thiamine rather than a mixed formulary of micronutrients should be administered first 1

Electrolyte Supplementation

Along with vitamins, electrolyte supplementation is crucial:

• Phosphate: 0.3-0.6 mmol/kg/day
• Potassium: 2-4 mmol/kg/day
• Magnesium: 0.2 mmol/kg/day IV or 0.4 mmol/kg/day orally 2

Refeeding Protocol

1. First step: Administer thiamine (300 mg IV) before initiating any nutritional support
2. Second step: Administer multivitamin supplements
3. Third step: Begin refeeding at low caloric rates:
   • High-risk patients: Start at 5-10 kcal/kg/day
   • Moderate-risk patients: Start at 15-20 kcal/kg/day 2
4. Fourth step: Monitor electrolytes daily for first 72 hours
5. Fifth step: Gradually increase feeding over several days 2, 3

Common Pitfalls to Avoid

1. Starting nutrition too rapidly: This is the most dangerous mistake. Begin with low caloric intake and increase gradually 3, 4
2. Failing to administer thiamine before refeeding: This can lead to Wernicke's encephalopathy 1, 5
3. Correcting electrolyte abnormalities without vitamin supplementation: Both are needed for successful management 6
4. Inadequate monitoring: Daily monitoring of electrolytes for at least 72 hours is essential 2
5. Overlooking thiamine deficiency in alcoholic patients: These patients are at particularly high risk 1, 7

The evidence strongly supports administering both thiamine and multivitamins before refeeding, with thiamine being the priority intervention that should be given first to prevent potentially fatal complications like Wernicke's encephalopathy and refeeding syndrome.