Supplementation for Individuals with Alcohol Use Disorder
All individuals with alcohol use disorder require thiamine supplementation to prevent Wernicke's encephalopathy, along with comprehensive multivitamin and mineral replacement including B-complex vitamins, vitamin D, zinc, and folic acid (after B12 correction). 1, 2, 3
Thiamine (Vitamin B1) - The Critical Priority
Thiamine must be administered first and aggressively, as Wernicke's encephalopathy is a medical emergency that is frequently underdiagnosed. 4
Dosing Algorithm Based on Clinical Presentation:
Established Wernicke's encephalopathy: Parenteral thiamine 200-500 mg three times daily for 3-5 days, followed by oral thiamine 250-1000 mg/day 4
Suspected Wernicke's encephalopathy: Parenteral thiamine 250-300 mg twice daily for 3-5 days, followed by oral thiamine 250-300 mg/day 4
High risk patients (severe malnutrition, liver disease): Parenteral thiamine 250-500 mg/day for 3-5 days, followed by oral thiamine 250-300 mg/day 4
Uncomplicated alcohol dependence: Oral thiamine 250-500 mg/day for 3-5 days, followed by oral thiamine 100-250 mg/day 4
Before dextrose administration: Give 100 mg thiamine in the first few liters of IV fluid to avoid precipitating heart failure 5
Vitamin B12 (Cobalamin) - Second Priority
Vitamin B12 deficiency must be identified and treated before folic acid supplementation to prevent masking B12 deficiency and precipitating irreversible neurological damage. 2
Treatment Protocol:
Without neurological involvement: Hydroxocobalamin 1 mg (1000 μg) intramuscularly three times weekly for 2 weeks 2
With neurological involvement: Hydroxocobalamin 1 mg intramuscularly on alternate days until no further improvement, with urgent neurology and hematology consultation 2
Maintenance: Long-term supplementation is required for life, as discontinuation leads to recurrence 2
Folic Acid - Only After B12 Correction
Dosing: 5 mg daily for minimum 4 months 2
Critical caveat: Never treat folate deficiency before correcting B12 deficiency 1, 2
Vitamin D
Measure serum 25-hydroxyvitamin D levels in all patients, as deficiency occurs in 64-92% of those with chronic liver disease. 3
Target: Supplement until serum levels exceed 30 ng/ml 3
Dosing: Higher doses may be necessary in advanced disease, though specific protocols vary 3
Monitoring: Recheck levels after supplementation and continue long-term 3
Additional Essential Micronutrients
Empiric supplementation with multivitamins and minerals is more cost-effective than measuring individual deficiencies before replacement. 1
Core Supplementation:
B-complex vitamins: Pyridoxine (B6), niacin (B3) - deficiencies are common and affect multiple physiological systems 6, 7
Zinc: Frequently deficient and affects immune function 1
Vitamin A: Common deficiency but avoid excess in long-term supplementation 6, 7
Fat-soluble vitamins: Vitamins D, K should be included 1
Nutritional Support Beyond Vitamins
Protein-calorie malnutrition is common and associated with increased complications and mortality. 1
Macronutrient Targets:
Standard patients: 35-40 kcal/kg/day with protein 1.2-1.5 g/kg/day 2, 3
Severely ill patients: 40 kcal/kg/day with protein 1.5 g/kg/day 2, 3
Feeding pattern: Frequent interval feedings with nighttime snack and morning feeding to improve nitrogen balance 1
If inadequate intake: Add smaller meals in early morning and late evening 2
Critical Pitfalls to Avoid
Never give glucose before thiamine - this can precipitate acute Wernicke's encephalopathy 5
Never treat folate before B12 - this masks B12 deficiency and worsens neurological complications 1, 2
Do not discontinue B12 after normalization - lifelong maintenance is required 2
Do not assume oral intake is adequate - alcoholics have absorption issues beyond dietary insufficiency 8, 6
The Foundation: Alcohol Abstinence
Complete alcohol abstinence is the fundamental first step, as continued drinking perpetuates all nutritional deficiencies. 2