Recommended Doses of Thiamine and Folic Acid for Alcohol Use Disorder
For individuals with alcohol use disorder, thiamine should be administered at a dose of 100-300 mg/day for 2-3 months following resolution of withdrawal symptoms, while folic acid should be given at a dose of 400-1000 μg (0.4-1 mg) daily. 1, 2
Thiamine (Vitamin B1) Recommendations
Standard Dosing for Alcohol Use Disorder
- Thiamine should be administered to all patients with alcohol use disorder at a dose of 100-300 mg/day and maintained for 2-3 months following resolution of withdrawal symptoms 1
- For patients with uncomplicated alcohol dependence (low risk), oral thiamine 250-500 mg/day should be given for 3-5 days, followed by oral thiamine 100-250 mg/day 3
Special Situations
- For prevention of Wernicke encephalopathy: 100-300 mg/day for 4-12 weeks 1
- For management of Wernicke encephalopathy: 100-500 mg/day for 12-24 weeks 1
- For high-risk patients (malnutrition, poor dietary intake), parenteral thiamine 250-500 mg/day should be given for 3-5 days, followed by oral thiamine 250-300 mg/day 3
- Thiamine should always be given before administering IV fluids containing glucose, as glucose administration may precipitate acute thiamine deficiency 1, 4
Folic Acid Recommendations
Standard Dosing for Alcohol Use Disorder
- The usual therapeutic dosage for adults is up to 1 mg daily 2
- For maintenance therapy in the presence of alcoholism, 0.4-1 mg daily is recommended 2
- Oral supplementation is preferred as most patients can absorb folic acid given orally even if they cannot absorb food folates 2
Important Considerations
- Folic acid deficiency may occur in up to 80% of alcoholics and can lead to macrocytic and megaloblastic anemia 5
- Chronic alcohol consumption leads to folate deficiency through dietary inadequacy, intestinal malabsorption, decreased hepatic uptake, and increased urinary excretion 5, 6
- Daily doses greater than 1 mg do not enhance the hematologic effect, and most excess is excreted unchanged in the urine 2
Clinical Approach to Supplementation
Assessment and Monitoring
- Anticipate micronutrient deficiencies in patients with alcohol use disorder, particularly B vitamins, zinc, and vitamin D 1
- Consider empiric oral supplementation as it is less expensive than laboratory measurements to establish deficiency before replacing individual micronutrients 1
- Monitor for improvement in neurological symptoms and cognitive function 3, 7
Common Pitfalls to Avoid
- Failure to recognize thiamine deficiency, which is underdiagnosed in up to 80% of cases 8
- Administering glucose-containing IV fluids before thiamine, which can precipitate or worsen Wernicke encephalopathy 1, 4
- Exceeding 1 mg/day of folic acid without ruling out vitamin B12 deficiency, as high doses of folic acid may mask the diagnosis of vitamin B12 deficiency 2
- Discontinuing supplementation too early before body stores are replenished 1, 2
By following these evidence-based dosing recommendations for thiamine and folic acid, healthcare providers can help prevent and treat common nutritional deficiencies in patients with alcohol use disorder, potentially improving neurological outcomes and supporting recovery.