Transcript Alternative Vitamin Repletion in Alcohol

Parenteral Vitamin
Repletion in Alcohol
Use Disorder
Vicki P. Cheng, Cory Taylor
UCI Internal Medicine Residency
Cost-Conscious Medicine Series
Acute Concerns in Alcohol
Use Disorder

Alcohol Withdrawal

CNS Hyperstimulation
• Disorientation
• Hallucinosis
• Delirium Tremens

High Sympathetic Tone
• Tremors, Diaphoresis
• Tachycardia, HTN, fever
Acute Concerns in Alcohol
Use Disorder

Wernicke Encephalopathy
An acute condition
 Untreated or exacerbated

• Can include Korsakoff psychosis
• Can lead to coma, death

Chronic undertreatment leads to:
• Wernicke disease – permanent deficits
• Korsakoff dementia – permanent deficits
Wernicke Encephalopathy

Thiamine deficiency

Most often in chronic alcoholics
• Also seen in other states of
malabsorption, nutritional deficiency

Requirements increase with
• Metabolic rate
• Blood-glucose loading
Wernicke Encephalopathy

Presentation*
Triad: encephalopathy, ataxia,
occulomotor dysfunction
 Diagnosis is clinical and difficult

• Triad present in < 20%
• Encephalopathy in 80% but overlaps with
withdrawal and dementia

Can be precipitated or exacerbated by
IV glucose administration
Thiamine Repletion

Parenteral repletion
To treat Wernicke Encephalopathy*
 To avoid precipitation of Wernicke
Encephalopathy*

• NPO status for medications
• Concern for ETOH
enteropathy/malabsorption
• Efficacy is questionable, not well studied
Thiamine Prophylaxis Issues

Deficiency is rare, even in alcohol use

A tribute to ubiquitous fortification
Krishel S, SaFranek, Clark RF. Intravenous vitamins for alcoholics in the emergency department: a
review. J Emerg Med. 1998;16(3):419-424.

Banana Bag Order Set


Does not provide for treatment of
Wernicke Encephalopathy
May obscure existence of subclinical
disease
Thiamine Prophylaxis Issues

What is the goal:
Avoid any pathologic or clinical
development of wernickean injury?
 Avoid iatrogenic precipitation of
wernickean injury?*


May benefit from cultural paradigm
shift
Objective
Routine IV multivitamin and folate in alcohol
abuse is costly and not supported by
evidence
Faine B, Nunge M, Denning G, Nugent A. Implementing evidence-based changes in emergency
department treatment: alternative vitamin therapy for alcohol-related illnesses. Ann Emerg Med.
2012;59:408-412.

To study current utilization of parenteral
vitamin therapy routes on the Medicine
Wards at UC Irvine
Methods
Chart Review
 Subjects: All Inpatients on Medicine Teams A-G at UCI Medical Center,
2 days (1 day 2013, 1 day 2016) with Diagnosis/Active Problem
(n=55+75 = 130)





Alcohol Use Disorder (2+2)
Encephalopathy (1+1)
GI Bleed (1+1)
Pancreatitis
Seizure, Epilepsy

Intervention:
1L IVF solution with thiamine 100mg inj, multivitamin 10mL inj, folic acid
1mg inj, 1 bag daily x 3 days.
May discontinue if tolerating PO.

Comparison:
Thiamine 100mg PO daily
Folic Acid 1mg PO daily
Multivitamin (Tab-a-vite) 1 tab PO daily

Outcome: Appropriate or Inappropriate Route (Tolerating diet?)
Results
Patient
Name
PO
thiamine
PO
folate
PO
MVI
History of
Delirium
Tremens?
Diagnosis
Tolerating
PO?
IV banana
bag
1
AUD
Yes, hepatic
X2 (12/7)
7-Dec
7-Dec
7-Dec Yes
2
Upper GI
Bleed
No, NPO
x2 (12/5-6)
7-Dec
7-Dec
7-Dec Unknown
3
AUD
Yes, regular
Self
reported
“seizures”
4
Upper GI
Bleed
No, NPO
Yes
2 of 4 patients concurrently receiving both IV and PO vitamins
Additional Results
Banana bag
PO
thiamine
PO
folate
PO
MVI
History of
Delirium
Tremens?
No
No
No
No
No
No
Upper GI Bleed
No
No
No
No
No
No
3.2
Alcohol
Withdrawal
Yes, regular
No
Yes
Yes
Yes
No
4.2
Encephalopathy
with heavy
ETOH history
No, NPO
Yes
Yes
Yes
Yes
Yes
Patient
Name
Diagnosis
Tolerating
PO?
1.2
AUD
2.2
Conclusion
Multivitamins
Average Patient Cost
per day Folate 1mg
Total
IV
PO (1 tab)
$43.25
$0.04
$47.28
$0.05
$90.53
$0.09