What is the recommended thiamine (Vitamin B1) dosage and duration for managing alcohol withdrawal?

Thiamine Dosing for Alcohol Withdrawal

All patients with alcohol withdrawal syndrome should receive thiamine 100-300 mg/day before any glucose-containing fluids to prevent Wernicke encephalopathy, with continuation for 2-3 months following resolution of withdrawal symptoms. 1, 2

Acute Phase Dosing

Standard Alcohol Withdrawal (Prophylactic)

• Administer thiamine 100-300 mg/day to all patients with alcohol withdrawal syndrome 1, 2
• The critical timing is to give thiamine before any glucose-containing fluids to avoid precipitating acute thiamine deficiency 2
• For patients receiving IV dextrose, give 100 mg thiamine hydrochloride in each of the first few liters of IV fluid to prevent heart failure 3

Route Selection Based on Risk

• Low-risk patients (uncomplicated alcohol dependence): Oral thiamine 250-500 mg/day for 3-5 days 4
• High-risk patients (severe withdrawal, poor nutrition, history of WE): Parenteral thiamine 250-500 mg/day for 3-5 days 4
• Suspected Wernicke's encephalopathy: Parenteral thiamine 250-300 mg twice daily for 3-5 days 4
• Established Wernicke's encephalopathy: Parenteral thiamine 200-500 mg three times daily for 3-5 days 4

FDA-Approved Dosing for Wernicke-Korsakoff Syndrome

• Initial dose of 100 mg IV, followed by 50-100 mg IM daily until the patient consumes a regular, balanced diet 3
• In emergency cardiac situations ("wet" beriberi), administer slowly by IV route 3

Maintenance Phase Duration

Continue thiamine for 2-3 months following resolution of withdrawal symptoms 1

Transition to Oral Therapy

• After 3-5 days of parenteral therapy, transition to oral thiamine 4
• Low-risk patients: Oral thiamine 100-250 mg/day 4
• High-risk patients: Oral thiamine 250-300 mg/day 4
• Established Wernicke's encephalopathy: Oral thiamine 250-1000 mg/day 4

Critical Timing Considerations

• Treatment should begin within 2 hours of intake for optimal outcomes 5
• Disease progression is significantly dependent on time to treatment, with faster recovery when protocols start earlier regardless of initial presentation 5
• Delayed treatment increases risk of noncompliance with oral management 5

Common Pitfalls to Avoid

• Never administer glucose before thiamine - this can precipitate Wernicke encephalopathy in thiamine-deficient patients 2, 3
• The risk of anaphylactic shock from parenteral thiamine is extremely low (below 1 in 100,000), so fear of adverse reactions should not prevent appropriate treatment 6
• Undertreatment is more dangerous than overtreatment - even protracted cases may respond to aggressive dosing (600 mg/day orally plus 300 mg/day IM) for extended periods 7
• Standard doses may be insufficient for established Wernicke's encephalopathy; doses over 500 mg/day for at least 3 months should be considered in refractory cases 7

Monitoring and Adjunctive Care

• Ensure adequate hydration and electrolyte replacement, especially magnesium 1, 2
• Use CIWA-Ar scores to guide overall withdrawal treatment intensity 1, 2
• Continue thiamine supplementation throughout the entire benzodiazepine taper and beyond 1