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 vitamin A, D, E, K, and magnesium to prevent potential complications like Wernicke-Korsakoff syndrome, megaloblastic anemia, and neurological problems. According to the most recent guideline on micronutrient supplementation 1, patients with chronic alcohol consumption are at high risk of thiamine deficiency, which can lead to severe and potentially irreversible neurological damage. The guideline recommends administering IV thiamine 250 mg to manage encephalopathy, especially in patients with poor absorption due to chronic alcohol ingestion.

Key Vitamins and Minerals to Replenish

• Thiamine (B1): critical to prevent Wernicke-Korsakoff syndrome, characterized by confusion, ataxia, and memory problems that can become permanent if untreated 1
• Folate (B9) and B12: deficiencies can cause megaloblastic anemia, neurological symptoms, peripheral neuropathy, and cognitive impairment
• Vitamin A: deficiency affects night vision and immune function
• Vitamin D: deficiency impacts bone health, and supplementation is recommended for patients with chronic liver disease, particularly those with advanced disease or non-alcoholic fatty liver disease 1
• Vitamin E and K: deficiencies can cause neurological problems and bleeding disorders, respectively
• Magnesium: deficiency may manifest as muscle cramps, arrhythmias, and seizures

Supplementation Recommendations

• Supplementation with a B-complex vitamin and multivitamin is recommended, with particular attention to administering thiamine before glucose to prevent precipitating Wernicke's encephalopathy 1
• Vitamin D supplementation is advised for patients with chronic liver disease, aiming to reach a serum vitamin D level above 30 ng/ml 1
• Parenteral thiamine supplementation is mandatory if Wernicke’s encephalopathy is suspected, and generous supplementation is recommended for patients with chronic alcohol use 1

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, an antiepileptic drug, has been shown to reduce serum levels of folate 4.
• Vitamin B12: Certain antiepileptic drugs, including carbamazepine, have been associated with lower vitamin B12 levels 4.

Potential Complications of Chronic Depletion

• Hyperhomocysteinemia: Reduced folate or vitamin B12 serum levels can lead to elevated homocysteine plasma levels, which is a risk factor for various health issues 4.
• Increased mean corpuscular volume (MCV): Folate or vitamin B12 levels below the reference range have been linked to higher MCV and homocysteine plasma levels 4.
• Neural tube defects: Although the concern about an association between pre-conception dolutegravir and neural tube defects has been resolved, folate and vitamin B12 play a crucial role in neural tube development 5.

Interaction with Dolutegravir

• Carbamazepine, a CYP450 3A4 inducer, can reduce the blood levels of dolutegravir, potentially making Triumeq less effective in treating HIV infection 6, 7.

Replenishment and Monitoring

• Vitamin supplementation for 3 months has been shown to restore normal vitamin levels, reduce MCV, and decrease homocysteine plasma levels in patients with folate or vitamin B12 deficiency 4.
• Close monitoring of patients taking carbamazepine and dolutegravir is necessary to prevent adverse drug interactions and ensure effective treatment of HIV infection 6, 7, 8.