What nutritional supplements, specifically vitamins, are recommended for a patient recovering from alcohol use disorder?

Vitamin Supplementation for Recovery from Alcohol Use Disorder

Thiamine supplementation is the absolute priority, with 100-300 mg daily orally for low-risk patients or 100-300 mg intravenously for high-risk patients (those with malnutrition, severe withdrawal, or active gastritis), and must be given before any glucose administration to prevent Wernicke's encephalopathy. 1

Critical First-Line Vitamins

Thiamine (Vitamin B1) - The Non-Negotiable Priority

Thiamine deficiency occurs in 30-80% of alcohol-dependent patients and body stores can be depleted in as little as 20 days. 1

Dosing protocol:

• Low-risk patients (uncomplicated alcohol use disorder): Oral thiamine 100 mg daily 1
• High-risk patients (malnutrition, severe withdrawal, alcoholic gastritis, vomiting): Intravenous thiamine 100-300 mg daily 1
• Duration: Continue for 2-3 months after withdrawal symptoms resolve, potentially lifelong for those with persistent risk factors 1

Critical timing consideration: Always administer thiamine before any intravenous glucose solution, as thiamine is an essential cofactor for glucose metabolism and giving glucose first can precipitate acute Wernicke's encephalopathy 1

Route selection:

• Intravenous route is mandatory for patients with active alcoholic gastritis, vomiting, or suspected acute thiamine deficiency due to alcohol-induced gastrointestinal malabsorption 1
• Oral route is adequate only for suspected chronic deficiency without acute illness 1

Vitamin B12 (Cobalamin)

For patients with B12 deficiency without neurological symptoms: Hydroxocobalamin 1 mg (1000 μg) intramuscularly three times weekly for 2 weeks as loading doses 2

For patients with neurological involvement: Hydroxocobalamin 1 mg intramuscularly on alternate days until no further improvement occurs, with urgent neurologist and hematologist consultation 2

Long-term maintenance: B12 supplementation must continue indefinitely, as discontinuation leads to recurrence of deficiency 2

Folic Acid (Vitamin B9)

Critical sequencing: Never treat folic acid deficiency before correcting vitamin B12 deficiency, as this may mask B12 deficiency and precipitate or worsen neurological complications 2, 3

Dosing: 5 mg daily for a minimum of 4 months, but only after B12 repletion is initiated 2

Clinical context: Folic acid deficiency occurs in up to 80% of alcoholics and can lead to macrocytic and megaloblastic anemia, which occurs in approximately half of alcohol abusers with chronic liver disease 4

Essential Additional Micronutrients

Zinc

Zinc deficiency is nearly universal in patients with chronic alcohol abuse and alcohol-associated hepatitis. 3

Rationale: Zinc contributes to improving gut mucosal barrier integrity, which is critical given the role of gut-derived pathogen-associated molecules in alcohol-associated liver disease 3

Recommendation: Therapeutic doses of zinc should be considered in moderate and severe alcohol-associated hepatitis 3

Dosing guidance: 15-30 mg oral zinc daily, which may be contained within a multivitamin supplement 3

Vitamin D

Deficiency is common in alcohol use disorder and should be anticipated. 3

Target: Maintain serum 25-hydroxyvitamin D levels of 75 nmol/L or higher 3

Dosing: 2000-4000 IU oral vitamin D3 daily 3

Other B Vitamins

Pyridoxine (Vitamin B6), along with vitamin A and folate, should be supplemented as these deficiencies are frequent and affect immune and gut mucosal function. 3, 2

Practical Implementation Strategy

Universal Approach for All Patients Recovering from Alcohol Use Disorder

1. Immediate thiamine: Start on day one of treatment, before any glucose administration 1

2. Comprehensive multivitamin and mineral supplement: Should contain at least government dietary recommendations for all vitamins and minerals 3, 1

3. Additional targeted supplementation based on risk:

   • B12 (intramuscular if deficiency documented or suspected) 2
   • Zinc (therapeutic doses for moderate-severe cases) 3
   • Vitamin D (2000-4000 IU daily) 3
   • Folic acid (only after B12 initiated) 2

4. Nutritional support: Protein intake 1.2-1.5 g/kg/day and caloric intake 35-40 kcal/kg/day 2

High-Risk Patients Requiring Aggressive Intervention

High-risk features include: malnutrition, severe withdrawal symptoms, active vomiting, alcoholic gastritis, or any neurological symptoms 1

For these patients:

• Intravenous thiamine 100-300 mg daily (not oral) 1
• Consider parenteral administration of other water-soluble vitamins 3
• Increase protein to 1.5 g/kg/day and calories to 40 kcal/kg/day 2

Critical Pitfalls to Avoid

Never delay thiamine administration while waiting for laboratory results in high-risk patients - the risk of Wernicke's encephalopathy is too great 1

Do not rely on standard multivitamins alone - they typically contain only 1-2 mg of thiamine, which is insufficient to correct established deficiency 1

Never give glucose before thiamine - this can precipitate acute Wernicke's encephalopathy 1

Do not treat folic acid deficiency before B12 - this masks B12 deficiency and can cause irreversible neurological damage 2

Do not discontinue B12 supplementation once levels normalize - maintenance therapy is required for life 2

Duration and Monitoring

Thiamine: Continue for 2-3 months minimum after withdrawal symptoms resolve; consider lifelong supplementation for those with persistent risk factors or poor nutritional intake 1

B12: Lifelong supplementation required 2

Other vitamins: Continue supplementation as long as nutritional intake remains inadequate or alcohol use disorder persists 3, 5

Cost consideration: The cost of empiric oral supplementation is less expensive than laboratory measurements to establish individual micronutrient deficiencies before replacement 3