What is the treatment for wet beriberi?

Treatment for Wet Beriberi

For wet beriberi with myocardial failure, immediate intravenous (IV) thiamine administration is essential, with recommended dosage of 100 mg IV three times daily until clinical improvement occurs. 1, 2

Clinical Presentation and Diagnosis

Wet beriberi is a form of thiamine (vitamin B1) deficiency characterized by:

• Cardiovascular manifestations including high cardiac output, low systemic vascular resistance, and congestive heart failure 1, 3
• Tachycardia and respiratory symptoms 1
• Peripheral edema 3
• May be accompanied by neurological symptoms in some cases 4

Diagnosis is primarily clinical, but can be confirmed by:

• Low serum thiamine levels or erythrocyte thiamine diphosphate (ThDP) 1
• Response to thiamine supplementation (therapeutic trial) 1
• Other biomarkers such as elevated lactate, pyruvate, alpha-ketoglutarate, and glyoxylate concentrations 1

Treatment Algorithm

Acute Phase (Cardiovascular Emergency)

1. Initial IV Thiamine Administration:

   • For wet beriberi with myocardial failure: Administer thiamine IV slowly as an emergency cardiac treatment 2
   • Dosage: 100 mg IV three times daily 1, 2
   • Continue until clinical improvement is observed 2

2. Supportive Care:

   • Monitor cardiac function and hemodynamic parameters 3
   • Avoid administration of glucose-containing fluids before thiamine repletion, as this can worsen thiamine deficiency 1
   • If patient requires dextrose, administer 100 mg thiamine in each of the first few liters of IV fluid to prevent precipitating heart failure 2

Maintenance Phase

1. Transition to Oral Therapy:

   • Once patient is stabilized, transition to oral thiamine 10-20 mg three times daily for two weeks 2
   • Follow with maintenance dose of 50-100 mg/day orally 1, 2

2. Nutritional Support:

   • Correct underlying dietary deficiencies 2
   • Prescribe a balanced diet with adequate thiamine content 2
   • Consider multivitamin supplementation to achieve body tissue saturation 2

Special Considerations

• Rapid Response: Hemodynamic improvement typically occurs within 12-48 hours of thiamine administration 3
• Monitoring: Follow cardiac function with echocardiography until normalized 3
• Risk Factors: Pay special attention to patients with:
  • Malnutrition or poor dietary intake 1
  • Chronic alcohol consumption 1, 3
  • Malabsorptive conditions including bariatric surgery 1
  • Prolonged vomiting or rapid weight loss 1
  • Increased metabolic requirements (e.g., pregnancy) 1
  • Imprisonment or institutionalization 3

Potential Pitfalls and Caveats

• Delayed Diagnosis: Wet beriberi is often misdiagnosed as other forms of heart failure, leading to treatment delays 5
• Concomitant Deficiencies: Check for other vitamin deficiencies, particularly folate, which can worsen thiamine malabsorption 4
• Mixed Presentations: Patients may present with features of both wet beriberi (cardiovascular) and dry beriberi (neurological) 6, 4
• QT Prolongation: Severe thiamine deficiency can cause QTc prolongation and potentially lethal arrhythmias like torsades de pointes 6
• Wernicke's Encephalopathy: Monitor for neurological symptoms that may indicate progression to Wernicke's encephalopathy, which requires higher doses of thiamine (500 mg IV three times daily) 1, 4

By following this treatment approach, most patients with wet beriberi will show significant improvement in cardiovascular function and overall clinical status within days of initiating appropriate thiamine replacement therapy.