From the Guidelines
For alcohol withdrawal in a long-term alcoholic after the initial 3 days of IV thiamine, the typical oral thiamine dosing is 100-300 mg/day, as recommended by the most recent guideline 1. This dosing is based on the need to replenish depleted thiamine stores in chronic alcoholics, as alcohol interferes with thiamine absorption, utilization, and storage in the body. The oral thiamine regimen helps prevent Wernicke-Korsakoff syndrome and other thiamine deficiency complications after the acute phase of withdrawal. Some studies suggest that thiamine should be given for 2-3 months following resolution of withdrawal symptoms 1, while others recommend 4-12 weeks for prevention of Wernicke encephalopathy 1. However, the most recent and highest quality study recommends thiamine administration for patients admitted on the ward with any suspicion of reduced food intake during the previous days or high alcohol consumption, with a dose of 100-300 mg/day by either oral or IV route 1. Patients should also take a complete multivitamin containing B-complex vitamins daily, as alcoholics are often deficient in multiple nutrients. Key points to consider in the management of alcohol withdrawal include:
- Thiamine supplementation to prevent Wernicke-Korsakoff syndrome
- Benzodiazepine therapy for seizure prevention and symptom management
- Multivitamin supplementation to address potential nutrient deficiencies
- Individualized treatment plans based on patient needs and medical history. The oral thiamine should be continued until the patient has established a stable recovery with improved nutrition, which may be indefinite in some cases of continued alcohol use or poor nutritional status.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION: ... 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. The typical thiamine daily oral dosing after the first 3 days of thiamine IV is given for alcohol withdrawal in a long term alcoholic is not directly stated in the provided drug label. However, based on the information provided for Wernicke-Korsakoff syndrome, it can be inferred that oral doses may be similar to the IM doses of 50 mg to 100 mg daily.
- The label does recommend an oral therapeutic multivitamin preparation containing 5 mg to 10 mg thiamine, administered daily for one month, to achieve body tissue saturation. It is essential to note that the provided label does not explicitly address the question for alcohol withdrawal, and the information is based on the treatment of Wernicke-Korsakoff syndrome and beriberi 2.
From the Research
Thiamine Daily Oral Dosing
After the first 3 days of thiamine IV for alcohol withdrawal in a long-term alcoholic, the typical daily oral dosing of thiamine can vary.
- According to 3, in patients with established Wernicke's encephalopathy, oral thiamine 250-1000mg/day should be given after parenteral thiamine.
- In patients with suspected Wernicke's encephalopathy, oral thiamine 250-300mg/day should be given after parenteral thiamine 3.
- For patients at high risk of thiamine deficiency, oral thiamine 250-300mg/day should be given after parenteral thiamine 3.
- In patients at low risk (with uncomplicated alcohol dependence), oral thiamine 100-250mg/day should be given after initial treatment 3.
- Another study suggests that patients with alcohol use disorder should receive 25 mg of thiamine four times a day rather than 50 mg twice a day based on the pharmacokinetic properties of thiamine 4.
Considerations for Thiamine Supplementation
It is essential to note that there are no solid evidence-based recommendations about the best dosage, route of administration, and duration of thiamine supplementation for the treatment of alcohol use disorder and Wernicke's encephalopathy 4.
- Early supplementation of thiamine is crucial to avoid irreversible neurological damage 4.
- Parenteral thiamine is underutilized in patients with alcohol use disorder and risk factors for Wernicke's encephalopathy 5.
- A thiamine prescribing protocol has been developed for further thiamine optimization 5.
- Clinicians should continue to provide parenteral or IM thiamine in doses of ≥100 mg to patients with confirmed alcohol-induced Wernicke's encephalopathy 6.