Thiamine supplementation was not included as a recommendation in the 2019 “Office management of alcohol withdrawal” onsert that arrived with the November 2019 issue of Canadian Family Physician,1 despite the fact that individuals with alcohol use disorder are often nutritionally depleted.2 Thiamine supplementation reduces the risk of developing Wernicke syndrome, Korsakoff syndrome, and beriberi.3 Physicians working with patients with alcohol use disorders should have a high index of suspicion for Wernicke syndrome, particularly if the patient shows evidence of ophthalmoplegia, ataxia, or confusion.4
Although more research is needed on the dose, duration, and route of thiamine administration, there is growing agreement that patients with Wernicke syndrome, or who are at a high risk of developing Wernicke syndrome, should be managed with parenteral thiamine.5 Moreover, oral thiamine supplementation might prevent or improve thiamine-deficient states.6 Although past studies showed reduced gastrointestinal absorption of oral compared with intramuscular thiamine,7–9 the benefits of oral supplementation in preventing thiamine deficiency might outweigh the low risk.
The 2017 update of the National Institute for Health and Clinical Excellence evidence-based guidelines recommends prescribing prophylactic oral thiamine to individuals with alcohol dependence.10 Similarly, the British Association for Psychopharmacology suggests giving oral thiamine to individuals with alcohol dependence who might not be eating healthy diets.5 Further, an article on outpatient management of alcohol withdrawal recommended routine prescriptions of thiamine at 100 mg daily and folic acid at 1 mg daily.11
In the management of patients with alcohol dependence, physicians should have a high index of suspicion for thiamine-deficient states, especially Wernicke-Korsakoff syndrome. Given the potential benefit of preventing thiamine deficiency, oral thiamine supplementation is a consideration in the office management of alcohol use disorders and alcohol withdrawal.
Footnotes
Competing interests
None declared
References
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