What vitamins are at risk of depletion in a patient with chronic alcohol use, such as Ropati, and what are the potential complications of their deficiency?

From the Guidelines

In patients with chronic alcohol use, such as Ropati, it is crucial to replenish thiamine (B1), folate (B9), and B12, as well as magnesium to prevent severe complications. The primary concern in chronic alcohol use is the depletion of these essential nutrients due to impaired absorption and increased excretion. Thiamine deficiency is particularly critical, as it can lead to Wernicke-Korsakoff syndrome, characterized by confusion, ataxia, and memory problems that can become permanent if not treated promptly 1. Folate deficiency can cause megaloblastic anemia and neurological symptoms, while B12 deficiency leads to peripheral neuropathy and cognitive impairment. Magnesium depletion, common in alcoholism, can cause tremors, seizures, and cardiac arrhythmias.

Key Nutrients to Replenish

• Thiamine (B1): critical to prevent Wernicke-Korsakoff syndrome
• Folate (B9): essential to prevent megaloblastic anemia and neurological symptoms
• B12: necessary to prevent peripheral neuropathy and cognitive impairment
• Magnesium: important to prevent tremors, seizures, and cardiac arrhythmias

According to the espen micronutrient guideline, patients with chronic alcohol consumption are at high risk of thiamine deficiency, and IV thiamine 250 mg is required to manage encephalopathy 1. The easl clinical practice guidelines on nutrition in chronic liver disease also support the importance of assessing and supplementing vitamin D levels in patients with chronic liver disease, particularly in those with advanced disease 1. However, in the context of chronic alcohol use, the primary focus should be on replenishing thiamine, folate, B12, and magnesium.

Supplementation Recommendations

• Thiamine administration should begin immediately, with particular emphasis on administering it before glucose to prevent precipitating acute Wernicke's encephalopathy
• Folate, B12, and magnesium supplementation should also be initiated promptly to prevent deficiency-related complications
• Vitamin D supplementation may be considered, but it is not the primary concern in patients with chronic alcohol use.

From the FDA Drug Label

The need for vitamin B12 is increased by pregnancy and lactation. Deficiency has been recognized in infants of vegetarian mothers who were breast fed, even though the mothers had no symptoms of deficiency at the time. Colchicine, para-aminosalicylic acid and heavy alcohol intake for longer than 2 weeks may produce malabsorption of vitamin B12. Thiamine is distributed in all tissues. The highest concentrations occur in liver, brain, kidney and heart When thiamine intake is greatly in excess of need, tissue stores increase two to three times. If intake is insufficient, tissues become depleted of their vitamin content. Body depletion of vitamin B 1 can occur after approximately three weeks of total absence of thiamine in the diet.

With Ropati's alcohol use, we are concerned about replenishing Vitamin B12 and Thiamine (Vitamin B1).

• Vitamin B12 deficiency can lead to permanent degenerative lesions of the spinal cord if left untreated for more than 3 months.
• Thiamine (Vitamin B1) deficiency can occur after approximately three weeks of total absence of thiamine in the diet, and heavy alcohol intake can contribute to its depletion. Potential complications of chronic depletion include:
• Permanent nerve damage
• Incapacitating and irreversible damage to the nerves of the spinal cord
• Increased risk of carcinoma of the stomach in patients with pernicious anemia 2
• Body depletion of thiamine can occur after total absence of thiamine in the diet 3

From the Research

Vitamins of Concern

• Folate: Carbamazepine has been shown to reduce serum folate levels 4, 5
• Vitamin B12: Carbamazepine has been associated with lower vitamin B12 levels in some studies 4, 5

Potential Complications of Chronic Depletion

• Hyperhomocysteinemia: Low folate and vitamin B12 levels can lead to elevated homocysteine plasma levels, which is a risk factor for various health problems 4
• Hematologic changes: Carbamazepine therapy has been linked to changes in basic hematologic parameters, including decreased white blood cell count and red blood cell count, and increased mean erythrocyte volume (MCV) 5
• Neurological problems: Folate and vitamin B12 deficiencies can cause neurological symptoms such as weakness, fatigue, and numbness or tingling in the hands and feet

Interaction with Alcohol Use

• Alcohol use can exacerbate the depletion of folate and vitamin B12, increasing the risk of complications 4
• Chronic alcohol consumption can also lead to impaired liver function, which can affect the metabolism of carbamazepine and other medications 6