4.10.4.4 Vitamin supplementation

Click here for parenteral prophylaxis.

Oral Prophylaxis

Low risk of Wernicke’s Encephaopathy (WE)

ChoiceDrugDosage
1st choiceThiamine (vitamin B1) tablets 100mg,Dose: Oral: 100mg three times daily. Single doses above 100mg do not enhance oral absorption and should be avoided

Prescribing Notes

  • Refer to local trust protocol.
  • Oral thiamine can be considered for those at low risk (mild alcohol dependence with an adequate diet).
  • Oral thiamine is indicated for less severe cases while receiving detoxification treatment for 5 to 7 days. Patients who resume drinking or continue to drink and are at risk of malnourishment should be given oral thiamine 50mg or 300mg daily, according to local protocol, on a long-term basis.
  • Clients undergoing community detoxification should also be considered for parenteral prophylaxis with Pabrinex® because oral thiamine is not adequately absorbed and there is considerable doubt about the usefulness of oral replacement. However, parenteral administration of thiamine is not always possible in the community setting. In this case, low-risk drinkers without neuropsychiatric complications and with an adequate diet should be offered oral thiamine: a minimum of 300mg daily during assisted alcohol withdrawal and periods of high alcohol intake.

Parenteral Prophylaxis

ChoiceDrugDosage
1st choices

Parenteral vitamins B and C (Pabrinex®), Intramuscular High Potency injection

Each No. 1 ampoule contains: 5ml ampoule Thiamine Hydrochloride BP 250mg, Riboflavin (as Phosphate Sodium BP) 4mg, Pyridoxine Hydrochloride BP 50mg

Each No. 2 ampoule contains: 2ml ampoule Ascorbic acid BP 500mg, Nicotinamide BP 160mg

Method of administration: See SmPC, local trust protocol

Refer to table below for doses

Or

Parenteral vitamins B and C (Pabrinex®) Intravenous High Potency injection Each No. 1 ampoule contains: 5ml ampoule Thiamine Hydrochloride BP 250mg, Riboflavin (as Phosphate Sodium BP) 4mg, Pyridoxine Hydrochloride BP 50mg

Each No. 2 ampoule contains: 5ml ampoule Ascorbic acid BP 500mg, Nicotinamide BP 160mg, Anhydrous Glucose BP 1000mg

NB Doses refer to 5ml ampoules.10ml No. 1 and 10ml No. 2 ampoules are also available

Method of administration: See SmPC, local trust protocol

Refer to table below for doses

 

 

IndicationDose*
Prophylaxis (Moderate-high risk of WE)1 pair of ampoules IV or IM once daily for 5 days (refer to table above for details on method of administration)
Treatment (Suspected or confirmed WE)2 pairs of ampoules IV three times daily for 5 days followed by 1 pair of ampoules IV or IM once daily for 3-5 days depending on response (refer to table above for details on method of administration)
*Some recommendations outside SPC (Reference Maudsley 2015)

Prescribing Notes

  • Refer to local alcohol withdrawal protocols and SmPC for Pabrinex® for further information.
  • The following patients should be considered to be at moderate-high risk of Wernicke’s Encephaopathy (WE):
    • patients who are alcohol dependent where there is evidence of malnutrition, physical illness or complicated withdrawal
    • patients who show evidence of malnourishment or are at risk of malnourishment
    • decompensated liver disease
    • attending the emergency department or are admitted to hospital with acute illness or injury
    • omelessness
    • hospitalised for co-morbidity of another alcohol issue
  • Offer parenteral thiamine to people with suspected WE. Maintain a high level of suspicion for the possibility of WE, particularly if the person is intoxicated. Parenteral treatment should be given for a minimum of 5 days, unless WE is excluded. Oral thiamine treatment should follow parenteral therapy.
  • A presumptive diagnosis of WE should be made if any of the following signs are present: confusion, ataxia, ophthalmoplegia / nystagmus, memory disturbance, hypothermia and hypotension, coma/unconsciousness. The classic triad of ophthalmoplegia, ataxia and confusion is rarely seen.
  • Pabrinex® should usually be administered in hospitals or health centres where facilities for treating anaphylaxis are available.
  • Although IV Pabrinex® remains the treatment of choice in patients whom a presumptive diagnosis of WE has been made, or for whom the diagnosis is clear, IM Pabrinex® is typically given as prophylaxis for in-patients undergoing medically assisted withdrawal.
  • Avoid IM injections in the presence of coagulopathy, in patients with very low muscle mass and if more than once daily dosing is required.
  • IM thiamine preparations have a lower incidence of anaphylactic reactions than IV preparations, at 1 per 5 million pairs of ampoules of Pabrinex® – far lower than many frequently used drugs that carry no special warning in the BNF. However, this risk has resulted in fears about using parenteral preparations and the inappropriate use of oral thiamine preparations. Given the nature of WE, the benefit to risk ratio favours parenteral thiamine. BNF guidance/CSM advice states that facilities for treating anaphylaxis should be available. This includes the need for staff to be trained in the management of anaphylaxis and administration of adrenaline (epinephrine) IM.
  • Patients with associated cognitive impairment should continue to receive Pabrinex® until the improvement in their condition plateaus.