• 
• 

Three Part Question

In [Adult patients presenting to the ED due to alcohol] is [vitamin B supplementation in all patients] required to [prevent wernickes encephalopathy]?

Clinical Scenario

A patient presents to the emergency department whom you believe to be a chronic alcohol abuser. Your worried he may be at risk of wernickes encephalopathy and wonder whether you should give him prophylactic Vitamin B supplementation

Search Strategy

Using the OVID interface;
medline 1996-06/07 :
[exp Wernicke Encephalopathy or wernickes encephalopathy.mp or wernicke encephalopathy.mp or exp Thiamine Deficiency or exp Alcohol Amnestic Disorder/ or exp Korsakoff Syndrome] AND [vitamin B.mp or exp Thiamine or thiamine.mp or riboflavin.mp or exp Riboflavin or pyridoxine.mp. or exp Pyridoxine] and [exp Ethanol or exp Alcoholic Intoxication or exp Alcoholism] AND limit to (humans and english language)
Cochrane Database of Systematic Reviews 2nd quarter 2007:
[exp Wernicke Encephalopathy or wernickes encephalopathy.mp or wernicke encephalopathy.mp or exp Thiamine Deficiency or exp Alcohol Amnestic Disorder/ or exp Korsakoff Syndrome] AND [vitamin B.mp or exp Thiamine or thiamine.mp or riboflavin.mp or exp Riboflavin or pyridoxine.mp. or exp Pyridoxine] AND limit to (humans and english language)
Embase 1996 to 2007 week 26:
[exp Wernicke Encephalopathy or wernickes encephalopathy.mp or wernicke encephalopathy.mp or exp Thiamine Deficiency or exp Alcohol Amnestic Disorder/ or exp Korsakoff Syndrome] AND [vitamin B.mp or exp Thiamine or thiamine.mp or riboflavin.mp or exp Riboflavin or pyridoxine.mp. or exp Pyridoxine] and [exp Ethanol or exp Alcoholic Intoxication or exp Alcoholism] AND limit to (humans and english language)

Search Outcome

Medline found 58 papers, Cochrane found 3 papers and Embase found 148 papers.
1 paper was found to be relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Day E et al 2004 England	2 studies met inclusion criteria Ambrose (2001) and Nichols unpublished. Total of 177 patients with a history of chronic alcohol abuse.	Systematic Review/ Meta Analysis	Ambrose assessed patient on day 3 using the delayed alternation test. Nichols used a range of cognitive function tests.	Ambrose (2001) showed significant difference in favour of 200mg/day dose compared to 5mg/day dose (MD -17.90, 95% CI -35.4 to -40.0, p=0.04).	Nichols unpublished contained insufficient data for full analysis. Ambrose (2001) use delayed alteration test as outcome measure. Reliability of test not known. Methodological shortcomings in design.

Comment(s)

The use of Thiamine has been advocated for many years but there is very little evidence available about the best use of Thiamine in the alcoholic patient. Only one published RCT has been conducted. It appears that if you suspect Wernickes Encephalopathy then a dose of 200mg or greater would be necessary to improve the outcome but again the evidence is poor. Due to this lack of evidence it would be best to follow advice given in the current guidelines from the Royal college of Physicians related specifically to the prevention of wernickes encephalopathy produced by Thomson AD et al.

Clinical Bottom Line

If you suspect a patient is at risk of Wernickes Encephalopathy, The Royal college of Physicians guidelines advise: Two pairs of vials of Pabrinex 1 and 2 diluted in 100 ml of crystalloid should be given i.v. over 30 min, initially in A&E.

References

1. Day E et al Thiamine for Wernicke Korsakoff syndrome in people at risk from Alcohol Abuse Cochrane Database of Systematic Reviews 2004, issue 1 Art No: CD004033