Prescribing Thiamine to Inpatients With Alcohol Use Disorders

Abstract

This is the first study to report on the prescribing of thiamine to inpatients with AUD at an American teaching hospital. It serves to confirm what many already suspected: that more education is needed to improve the diagnostic challenges of WKS, the detection of risk factors for WKS, and the adequate dosing of thiamine for prevention and treatment of WKS.

A Case of Chronic Wernicke’s Encephalopathy: A Neuropsychological Study

“…Given that the prognosis of WE is known to depend on the speed of compensating the deficiency in thiamine (14) and the severe chronic cognitive disturbance associated with chronic WE observed in the present study, our results indicate that an active treatment policy is needed to avoid severe chronic neuropsychiatric symptoms. Current treatment standards suggest that parenteral (intravenous or intramuscular thiamine should be given 200 up to 500 mg three times daily until symptoms of acute WE resolute (32).…”

Thiamine Prescribing Practices for Adult Patients Admitted to an Internal Medicine Service

“…Although no prospective studies have compared different durations of thiamine administration, the EFNS guidelines suggest that treatment be continued until symptoms resolve, whereas the RCP guidelines suggest completing 3 days of treatment and, if a response is noted, completing an additional 5 days of treatment or continuing treatment until clinical improvement ceases. 11,12,23 In the study presented here, the median durations of IV thiamine were 3 days for those who received low-dose treatment and 5 days for those who received high-dose treatment. Treatment duration tended to be longer for the subset of patients in whom a diagnosis of WE was being considered, but this difference was not statistically significant.…”

“…1 Overall, about 93% of the total prescriptions were for 100 mg of thiamine, and 75% of these 100-mg prescriptions were ordered as once daily. 1 In a retrospective study of thiamine prescribing practices for 217 patients with alcohol-use disorder conducted in a large US teaching hospital, 23 a regimen of thiamine 100 mg orally daily was prescribed for about 70% of the patients. Interestingly, for the subset of 124 patients (57%) identified as being at high risk because they presented with alcohol intoxication, withdrawal, or delirium tremens, no statistically significant association was revealed between risk status and receipt of high-dose thiamine (defined as doses ≥ 200 mg IV).…”

“…Interestingly, for the subset of 124 patients (57%) identified as being at high risk because they presented with alcohol intoxication, withdrawal, or delirium tremens, no statistically significant association was revealed between risk status and receipt of high-dose thiamine (defined as doses ≥ 200 mg IV). 23 There is no consensus on the appropriate duration of thiamine treatment for patients with suspected WE. Although no prospective studies have compared different durations of thiamine administration, the EFNS guidelines suggest that treatment be continued until symptoms resolve, whereas the RCP guidelines suggest completing 3 days of treatment and, if a response is noted, completing an additional 5 days of treatment or continuing treatment until clinical improvement ceases.…”

Unpeeling the Evidence for the Banana Bag: Evidence-Based Recommendations for the Management of Alcohol-Associated Vitamin and Electrolyte Deficiencies in the ICU

“…WE may mask itself as a "wolf in sheep's clothing" within the context of ICU delirium, a ubiquitous condition in critical care, and may delay appropriate treatment (33). Even in the context of modern day care, failures to appropriately identify and utilize appropriate doses of thiamine to treat WE remain documented (34)(35)(36). Given the difficulty of diagnosis, the poor prognosis associated with delayed recognition and inadequate treatment of WE, and minimal drug-drug interactions and adverse effects of thiamine, these authors believe the risk-benefit favors taking thiamine out of the banana bag and administering at treatment doses of 200-500 mg every 8 hours for at least 72 hours or until WE is ruled out.…”