Thiamine in the management of alcohol use disorders

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.

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