From the Guidelines
The recommended intravenous thiamine dose for alcohol withdrawal is 100-300 mg/day for 3-4 days, as stated in the most recent and highest quality study 1. This dose is crucial in preventing Wernicke's encephalopathy, a condition characterized by confusion, ataxia, and eye movement abnormalities, which can progress to Korsakoff syndrome with permanent memory impairment if left untreated. The administration of thiamine should be started before giving any glucose-containing fluids to prevent precipitating or worsening Wernicke's encephalopathy. Some key points to consider when administering IV thiamine include:
- Monitoring for rare allergic reactions, which can include pruritus, urticaria, angioedema, or anaphylaxis
- Using the IV route for patients with acute disease or suspicion of inadequate intake, even short term
- Considering the severity of acute deficiency symptoms and using the IV route as the most efficient way to provide thiamine
- Transitioning to oral thiamine 100 mg daily for at least 1-2 weeks or longer depending on the patient's nutritional status and continued alcohol use after the initial IV course. Thiamine supplementation is a critical component of a comprehensive approach to alcohol withdrawal, which typically includes benzodiazepines for symptom management and correction of other electrolyte abnormalities, as supported by studies 1.
From the FDA Drug Label
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 to 100 mg daily until the patient is consuming a regular, balanced diet. Patients with marginal thiamine status to whom dextrose is being administered should receive 100 mg thiamine hydrochloride in each of the first few liters of IV fluid to avoid precipitating heart failure.
The recommended IV dose of thiamine for patients at risk of Wernicke-Korsakoff syndrome, which can be associated with alcohol withdrawal, is 100 mg. This dose is administered to prevent precipitating heart failure in patients with marginal thiamine status who are receiving dextrose IV fluids 2.
From the Research
Thiamine IV Dose for Alcohol Withdrawal
- The optimal thiamine IV dose for alcohol withdrawal is not well established, with different studies suggesting various dosing regimens 3, 4, 5, 6, 7.
- A study published in 2017 recommends giving patients with alcohol use disorder 25 mg of thiamine four times a day, rather than 50 mg twice a day, based on the pharmacokinetic properties of thiamine 3.
- Another study from 2010 suggests that routine administration of large doses of intravenous thiamine to all patients admitted with alcohol withdrawal symptoms should be considered to avoid insufficient treatment 4.
- A 2017 study recommends the following thiamine dosing regimens:
- For patients with established Wernicke's encephalopathy: parenteral thiamine 200-500mg three times a day for 3-5 days, followed by oral thiamine 250-1000mg/day.
- For patients with suspected Wernicke's encephalopathy: parenteral thiamine 250-300mg two times a day for 3-5 days, followed by oral thiamine 250-300mg/day.
- For patients at high risk of thiamine deficiency: parenteral thiamine 250-500mg/day for 3-5 days, followed by oral thiamine 250-300mg/day 5.
- A 2021 review of the literature suggests that clinicians should provide parenteral or IM thiamine in doses of ≥100 mg to patients with confirmed alcohol-induced Wernicke's encephalopathy, with no apparent difference in patient outcomes for doses ranging from 100 to 1500 mg intravenous thiamine and up to 300 mg IM thiamine 6.
- Another study published in 2011 recommends immediate prophylactic therapy with parenteral thiamine for alcoholics at risk of Wernicke's encephalopathy, and high-dose intravenous thiamine for suspected cases of Wernicke's encephalopathy 7.