Thiamine Substitution in Alcohol Use Disorder: A Narrative Review of Medical Guidelines

Abstract

Aims: Patients with alcohol use disorder (AUD) frequently suffer from cognitive deficits ranging from mild symptoms to most severe forms. Wernicke encephalopathy (WE), caused by thiamine deficiency, is a potentially fatal syndrome characterized by the clinical triad of ophthalmoplegia, ataxia, and confusion. WE frequently presents in patients with AUD and, if left untreated, can progress to Wernicke-Korsakoff syndrome, which constitutes severe anterograde amnesia, confabulation, and behavioral abnormalities. Due to oftentimes indistinct clinical presentation, WE remains undiagnosed in up to 80% of cases. We conducted a review of current treatment guidelines for AUD in order to identify recommendations for the use of thiamine. Methods: Three different keyword combinations (“alcohol treatment guideline,” “alcohol withdrawal guideline,” and “alcohol treatment recommendation”) were entered in PubMed and Scopus, additional guidelines were searched screening the online sites of the respective agencies or societies. In total, 14 guidelines were included. Results: Thiamine was mentioned in all but one of the reviewed publications. Specifications on application modalities and indications varied considerably. While the majority of reviewed guidelines recommended parenteral thiamine only for patients at high risk for WE, some gave no information regarding the application form or dosage. Conclusion: Substitution of parenteral thiamine in individuals with suspected WE is a well-established treatment regimen. However, suggestions according to guidelines vary widely. Furthermore, hardly any evidence-based recommendations exist on a more general use of thiamine as a preventative intervention in individuals with AUD. Further research is of utmost importance to raise awareness for this potentially undervalued problem.

High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder

“…Furthermore, hardly any evidence-based recommendations exist on a more general use of thiamine as a preventative intervention in individuals with alcohol use disorder. [ 13 ] There are very few studies that have evaluated the dose and duration of thiamine for WKS, but higher doses may result in a greater response. [ 6 14 ] With thiamine administration rapid improvement is seen in eye movement abnormalities (improve within days or weeks) and ataxia (may take months to recover), but the effects on memory, in particular, are unclear.…”

Perioperative Management of Alcohol Withdrawal Syndrome

“…Thiamine therapy is safe and results in rapid clinical improvement of acute Wernicke's encephalopathy [17]. Therapeutic dosage recommendations vary from 50 mg/ day for 3 days (US guidelines) up to 500 mg every 8 h for 3-5 days followed by dosage tapering until clinical improvement (British and German guidelines) [18]. For prophylaxis, low-dose substitution is recommended for hospitalized AUD patients (100 mg/day) if they appear to be malnourished, but not routinely for all asymptomatic AUD patients.…”

“…Neuropathological correlates are lesions in the periventricular region, diencephalon, midbrain, hypothalamus, and DOI: 10.1159/000507595 cerebellar vermis. Autopsy studies suggest signs of Wernicke's encephalopathy in 0.4-2.8% of the population and in 12.5% of persons with AUD [18]. As in AWS, symptom variability and other overlapping manifestations of the primary hospitalization disease, such as traumatic brain injury, sepsis, or stroke, can complicate the diagnosis.…”

Micronutrient Deficiencies in Medical and Surgical Inpatients

“…Some categories of patients, such as chronic, alcohol consumers, which are largely prevalent in western countries, being present in nearly 30% of hospital admissions, are at higher risk of thiamine deficiencies—these patients are at particularly high risk of refeeding syndrome and its worst neurologic complication, the Wernicke encephalopathy. A recent review of the literature confirmed the importance of administering intravenous thiamine to these patients in order to prevent severe sequelae [107]. The recommended doses ranged from 50–100 mg/day to 250–500 mg 3 times a day.…”