What is the replacement therapy for Thiamine (Vitamin B1) deficiency?

From the Guidelines

For B1 (thiamine) deficiency replacement, I strongly recommend administering 200-300 mg of thiamine intravenously three times a day, as this is the most efficient route, especially in cases of acute deficiency symptoms, according to the most recent guideline from 2022 1. When considering the severity of acute deficiency symptoms, using the IV route is crucial, providing 3 x 100-300 mg per day, as recommended by the espen micronutrient guideline 1.

Key Considerations

• The grade of recommendation for IV administration is 0, with a consensus of 88% 1, indicating a strong agreement among experts.
• For patients with mild deficiency, 10 mg/day of thiamin for a week, followed by 3-5 mg/daily for at least 6 weeks, may be sufficient 1.
• In cases of chronic diuretic therapy, a suggestion of 50 mg a day, by mouth, is recommended 1.
• For patients at risk for deficiency, 100 mg, 3 times a day, IV, is advised 1.
• The maintenance dose in proven deficiency should be 50-100 mg/day, orally 1.

Administration Route

• In case of suspicion of chronic deficiency without any acute disease, the oral route is adequate 1.
• However, in case of acute disease, the suspicion of inadequate intake, even short term, should prompt the use of the IV route 1.

Special Considerations

• Thiamine replacement should be given before any glucose administration in at-risk patients (especially those with alcohol use disorder) to prevent precipitating or worsening Wernicke encephalopathy.
• Common causes of deficiency include chronic alcoholism, malnutrition, prolonged vomiting, malabsorption syndromes, and bariatric surgery, so addressing these underlying conditions is essential for long-term management.

From the FDA Drug Label

Thiamine hydrochloride injection is effective for the treatment of thiamine deficiency or beriberi Thiamine hydrochloride injection is also indicated in patients with established thiamine deficiency who cannot take thiamine orally due to coexisting severe anorexia, nausea, vomiting, or malabsorption. In the treatment of beriberi, 10 mg to 20 mg of thiamine hydrochloride are given IM three times daily for as long as two weeks. An oral therapeutic multivitamin preparation containing 5 mg to 10 mg thiamine, administered daily for one month, is recommended to achieve body tissue saturation.

B1 Deficiency Replacement:

• The recommended treatment for B1 deficiency is thiamine hydrochloride injection, especially when rapid restoration of thiamine is necessary.
• The dosage for beriberi treatment is 10 mg to 20 mg of thiamine hydrochloride given IM three times daily for up to two weeks.
• For oral therapy, a multivitamin preparation containing 5 mg to 10 mg thiamine daily for one month is recommended to achieve body tissue saturation 2, 2.

From the Research

B1 Deficiency Replacement

• The replacement of vitamin B1 (thiamine) deficiency is crucial in patients with alcohol dependence, as it can lead to cognitive impairments and Wernicke's encephalopathy 3.
• The treatment of Wernicke's encephalopathy involves the administration of high-dose thiamine, with the parenteral route preferred in high-risk patients and hospital settings 4.
• In patients with suspected Wernicke's encephalopathy, parenteral thiamine 250-300mg should be given two times a day for 3-5 days, followed by oral thiamine 250-300mg/day 3.
• The use of prophylactic thiamine in low-risk patients is not universally indicated, but in high-risk patients, parenteral treatment with a recommended posology of 250mg daily for 3 to 5 days is suggested 4.
• In cases where the diagnosis of Wernicke's encephalopathy is suspected or confirmed, a curative treatment with high-dose IV thiamine is justified, with treatment regimens consisting of 500mg IV 3 times daily for 3 to 5 days, followed by 250mg IV daily for a minimum of 3 to 5 additional days 4.

Treatment Regimens

• The treatment regimens for Wernicke's encephalopathy vary depending on the patient's risk level and the severity of the condition:
  • High-risk patients: parenteral thiamine 250-500mg/day for 3-5 days, followed by oral thiamine 250-300mg/day 3, 4.
  • Suspected Wernicke's encephalopathy: parenteral thiamine 250-300mg two times a day for 3-5 days, followed by oral thiamine 250-300mg/day 3.
  • Confirmed Wernicke's encephalopathy: high-dose IV thiamine 500mg 3 times daily for 3 to 5 days, followed by 250mg IV daily for a minimum of 3 to 5 additional days 4.

Importance of Early Treatment

• Early treatment of Wernicke's encephalopathy is crucial to prevent death or Korsakoff's amnestic syndrome 5, 6.
• Delayed treatment can lead to severe cognitive impairment and increased mortality rates 7.
• Overdiagnosis and overtreatment may be preferred to prevent prolonged or persistent neurocognitive impairments given the excellent safety profile of thiamine 6.