Supplementation for Patients with Alcohol Withdrawal Syndrome

A few years ago, I came across this article that contains recommendations for vitamin and mineral supplementation for patients with alcoholism. Our small community hospital sees a lot of patients with alcoholism. It seems to be becoming more prevalent or maybe we are just more mindful of it, perhaps both. The has specific insights as to what to recommend and dose for these types of patients. I would suggest you read the article, and I will give my summary of what I found to be the most useful in my day to day assessments.

Things to Remember

1. There are very few high quality studies that investigate the optimal dosing of deficient nutrients for AWS
2. Strategies and protocols for repletion vary from institution to institution because there are so few studies.

This means, many PCP are doing supplementation generally based on where they went to school or what the culture of the facility is. It varies from PCP to PCP or facility to facility.

Nutrients Needed for Supplementation

1. Thiamine
2. Folic Acid
3. Magnesium
4. Phosphorus

These are many of the same nutrients we evaluate for Refeeding Syndrome.

Thiamine

Historically the dose has been 100 mg IV daily and should be given prophylactically for AWS. Thiamine should be given as soon as possible as Wernecke’s Encephalopathy (WE) can develop when glucose is administered. Repletion should last for 2-3 days./

Thiamine should be the first thing given for any patient that is thought to be malnourished, The incidence of WE is large. A patient that has had very poor intake for several weeks, due to alcoholism, hyperemesis graviderum, the flu, etc, should be given thiamine. There is a danger of developing WE if these patients are given IVF with dextrose and are deficient in thiamine. Evaluating thiamine levels is unnecessary, just give them thiamine. There is very little chance that a patient will have too much thiamine.

Folic Acid

We should stick to providing at or below the upper recommended limits of 1 mg per day. Adverse effects from higher dosages have been noted. Interestingly, the bioavailability of oral folic acid when taken without food or alcohol is 100%. Symptoms of deficiency include weakness, sob, skin and hair changes and if is often coupled with B12 deficiency.

Magnesium

This deficiency is found in 30% of AWS patients. If a patient is symptomatic (tremors, arrhythmias, positive Trousseau’s sign) then IV supplementation should be given at 8-12 mg in the first 24 hours and then 4-6 mg daily for 3 days. . Asymptomatic depletion, ie low serum magnesium levels, oral magnesium can be provided. Renal function should be considered and those with reduced function should receive 25-50% less

Phosphorus

Deficits in phosphorus usually become apparent when glucose is administered or the patient is fed. IV phosphorus should be used if levels of serum phosphorus are less than 1 mg/dl. 1.5 mmol/kg/day of IV phosphorus should be given at that time and then the patient can transition to oral supplementation of 1.3-1.5 mmol/kg/day.

Summary

These are the things I have found most useful in the article to remember, other that appreciating the dosing recommendations.

1. Orders and protocols for repletion vary from institutions and between PCPs due to lack of trials.
2. Thiamine should be given in any patient you feel may be malnourished because of the prevalence of WE.
3. Thiamine replacement should be given IV 2-3 times per day in those who are at risk for or have a deficiency.
4. Pay attention to serum magnesium and phosphorus levels as the patient progresses
5. 1 mg of Folic Acid likely provides adequate repletion.
6. A daily MVI is reasonable to provide remains vitamin and mineral needs, while the patient is or has been treated for other deficiencies.

Please give the article some attention, it is worth reviewing if you a a dietitian who works with a lot of patients who have alcoholism.