Thiamine dosing in patients with suspected alcohol withdrawal syndrome

 

Tiffany Somereville, PharmD candidate, Class of 2018

Joshua Patterson, PharmD candidate, Class of 2018

Tyler Young, PharmD candidate, Class of 2018

Valana Vannoy, PharmD, PGY1 Pharmacy Practice Resident, Phoebe Putney Memorial Hospital

Anthony Hawkins, PharmD, BCCCP, Clinical Assistant Professor, University of Georgia College of Pharmacy

 

Background

 

Approximately 20% of patients admitted to the hospital suffer from alcohol dependency; many of which will experience acute withdrawal syndrome while receiving care for other conditions.1 In providing supportive and preventative care for these patients, a major cause of concern continues to be the dosing of thiamine in alcohol-induced thiamine deficiency.2

Thiamine is an essential dietary nutrient and is heavily utilized as a cofactor in reactions essential to the catabolism of carbohydrates.2 For patients with alcohol dependency, excessive consumption of alcohol disrupts the diffusion of thiamine from the gastrointestinal tract, putting the patient at risk for developing numerous neurological issues, most notably Wernicke's encephalopathy. It has been shown that both alcohol and thiamine utilize diffusion in the small intestines as its method of transport into the bloodstream. Excess ethanol overloads the diffusion process, thereby slowing the rate of absorption in the intestines. This impairs the conversion of thiamine to its useable form and causes the accumulation of ethanol in the body.2-4

 

Presentation

 

Alcohol withdrawal typically presents as a 'cluster of symptoms' which usually occurs after a person significantly reduces or stops long-term alcohol consumption.The patient can present with autonomic dysreflexia, anxiety, agitation, tremors, and irritability. If the withdrawal is severe enough, the patient's symptoms may worsen to include seizures, delirium tremens, and hallucinations. These symptoms can begin to manifest after only a few hours of alcohol abstinence5.

Another condition that can present during alcohol withdrawal is Wernicke's syndrome, due to an acquired thiamine deficiency. Wernicke's is characterized by three conditions: ataxia, confusion, and opthalmoplegia. However, it is important to note that these three symptoms are rarely seen all at once. This leads to Wernicke's often going unrecognized, undiagnosed, and improperly treated. If left untreated, Wernicke's syndrome can progress into permanent memory loss and neurologic damage.6

 

Treatment

 

Generally, treatment is focused on symptomatic and supportive care. It is important to keep the patient comfortable and as relaxed as possible. Sedation with benzodiazepines and fluid replacement are often utilized.

To prevent the development of neurological disorders such as Wernicke's encephalopathy, thiamine has historically been administered at 100mg daily as a standard ingredient included in a banana bag.7 This dose was arbitrarily chosen over half a century ago with no supportive evidence. Recent evidence states that less than 20% of patients with Wernicke's encephalopathy achieve complete recovery with this commonly prescribed dose.3,7 This subtherapeutic thiamine dosing results in severe sequelae, with more than 80% of patients suffering permanent neurologic impairments.3 If Wernicke's encephalopathy is suspected, higher doses of up to 500mg of intravenous thiamine every eight to twelve hours are now recommended for three to five days.2,3 Benefits of the neurological preservation by these higher doses outweigh the risks associated with any adverse effects associated with thiamine.1

The earlier thiamine supplementation is initiated, the more likely severe neurological complications can be avoided. Some studies suggest that initiation of therapy within two hours is optimal. Oral thiamine is not recommended in critically ill patients due to the rate limited absorption of thiamine which is further decreased in alcoholics. However, continuation of oral thiamine in the outpatient setting of 100mg daily for 30 days after the acute withdrawal phase is recommended.6

Due to the supporting evidence of the inadequacy of traditional thiamine dosing strategies, it is recommended for patients suffering from alcohol withdrawal to receive intravenous thiamine 500 mg two to three times daily for 3 to 5 days.3,7 Subsequent tapering strategies should be individualized to the clinical response of the patient.

June 10, 2016, from

http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Nursing-Care-of-Patients-with-Alcohol-Withdrawal-Syndrome.aspx

 

2.       Hoyumpa, AM, Jr. (2012) Mechanisms of Thiamin Deficiency in Chronic Alcoholism. The American Journal of Clinical Nutrition. 33(12): 2750-61. http://ajcn.nutrition.org/content/33/12/2750.abstract

 

3.       Kattimani, S., & Bharadwaj, B. (2013). Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry Journal, 22(2), 100-108. http://doi.org/10.4103/0972-6748.132914

 

4.       Thiamin - Health Professional Fact Sheet. (2016). Retrieved June, 2016, from https://ods.od.nih.gov/factsheets/Thiamin-HealthProfessional/

 

5.       Sachdeva, A., Choudhary, M., & Chandra, M. (2015). Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. Journal of Clinical and Diagnostic Research: JCDR, 9(9), VE01-VE07. http://doi.org/10.7860/JCDR/2015/13407.6538

 

6.       Talbot, P. A. (2011). Timing of Efficacy of Thiamine in Wernicke's Disease in Alcoholics at Risk. Journal of Correctional Health Care, 17(1), 46-50. doi:10.1177/1078345810385913