Thiamine: A Simple Solution to Reverse Wernicke Syndrome

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Thiamine: A Simple Solution to Reverse Wernicke Syndrome
Thiamine: A Simple Solution to Reverse Wernicke Syndrome

There is a particular type of brain damage resulting from a simple vitamin deficiency that, if not treated promptly, can become permanent. Up to 25% of untreated cases lead to death.1 The condition is called Wernicke encephalopathy, and it is caused by a lack of thiamine (vitamin B1), which is required for the normal breakdown of glucose.

The good news is that there is a fast, inexpensive, and highly effective way to reverse the symptoms. “Wernicke encephalopathy represents a medical emergency that demands timely and effective replacement of thiamine,” Gregory Day, MD, a behavioral neurology fellow at the Knight Alzheimer Disease Research Center at the Washington University School of Medicine in St. Louis, told Neurology Advisor. Unfortunately, this quick fix  is underused and often misused.

When thiamine is lacking, the body uses a less efficient means of breaking down glucose, of which lactic acid is a byproduct. “The subsequent build-up of lactic acid contributes to neuronal death in susceptible brain areas,” Day explained. “Damage to these brain area results in the clinical syndrome of Wernicke encephalopathy, with core findings including altered mental status, eye movement abnormalities, and ataxia.”

The condition is highly unlikely to affect individuals who eat a normal diet, as there are many natural food sources of thiamine, and it is also added to most fortified grain products sold in North America. “Additionally, the body maintains a three week supply of thiamine in the liver,” said Day. Some of the individuals most at risk of Wernicke encephalopathy are those with chronic alcohol use (since it can interfere with the body's absorption and storage of thiamine), eating disorders, and medical conditions that cause frequent vomiting or limit oral absorption. \

Patients who are admitted to hospitals have an especially high risk of developing the disorder for several reasons: illness, malnourishment, and an increased metabolism, where they may use up their body's thiamine stores and are likely to be administered glucose or intravenous fluids containing it.  “The breakdown of glucose requires thiamine – thus, providing glucose without thiamine can worsen thiamine deficiency and can trigger Wernicke encephalopathy,” said Day.

Day co-authored a study during his neurology residency at the University of Toronto, published ahead of print in February 2015 in the Journal of Hospital Medicine, which investigated how thiamine was prescribed to over 32,000 inpatients at 14 academic hospitals in Canada.2 He and his colleagues were surprised to find that, though the importance of prescribing thiamine via parenteral means is widely stated in various published guideline documents, thiamine was prescribed to inpatients by the oral route in 42.4% of cases.

“This is even more surprising considering that most patients develop thiamine deficiency due to an impaired ability to absorb or maintain oral thiamine intake,” he said. “It simply isn't possible to provide enough thiamine via the oral route, or to provide it fast enough to correct an existing brain thiamine deficiency. Ultimately IV administration of high doses is the only way to reliably accomplish this.”

A study from the April 2014 issue of the Canadian Journal of Surgery reviewed the use of thiamine prophylaxis in 1,000 male patients admitted to a level 1 trauma center, where there tend to be high rates of alcohol use among injured patients.1 The findings show that only 44% of patients with elevated blood alcohol levels received thiamine prophylaxis. Research published last year in the Journal of Addiction Medicine found similar results at a U.S. teaching hospital.3 Of 217 patients with alcohol use disorders, a significant percentage of them were not prescribed thiamine, and among those who were, almost all were prescribed the less effective oral thiamine – even high-risk patients.

“Wernicke encephalopathy is clearly underappreciated,” Chad G. Ball, MD, co-author of the April 2014 study, and a professor of surgery and oncology at the University of Calgary and Foothills Medical Center, told Neurology Advisor. “The incidence is high enough, and the treatment cheap enough, that perhaps we should be giving it to all intoxicated folks. It costs only pennies, so it can be delivered in almost any environment or cost structure.” As a result of the findings at his trauma center, they have changed their policy to make it routine practice to screen all injured patients for alcohol intoxication and administer thiamine accordingly.

Day also advocates the better-safe-than-sorry approach: it can't hurt but it could definitely help. He recommended the following guidelines to ensure proper treatment: First, consider a diagnosis of Wernicke encephalopathy for all patients with a history of nutritional deficiency and for those with a recent change in mental state, oculomotor abnormalities, or cerebellar dysfunction.

“Treat first, ask questions later. If your patient meets the above criteria, provide treatment while continuing to consider alternative diagnoses,” he said. All patients who are treated for possible deficiency should receive parenteral thiamine. “It's the only way to ensure absorption, and the only way to quickly reverse brain-thiamine deficiency.” Following these rules will certainly result in unnecessary thiamine administration for some patients, but considering that it is cheap and has almost no side effects, Day believes that “inadvertently enriching the blood of a thousand patients who do not have thiamine deficiency is far superior – and more cost effective – than missing the opportunity to effectively reverse thiamine deficiency in the one patient with Wernicke encephalopathy.” 

References

  1. Blackmore C, Ouellet JF, Niven D, Kirkpatrick AW, Ball CG. Prevention of delirium in trauma patients: Are we giving thiamine prophylaxis a fair chance? Canadian Journal of Surgery; 2014; 57(2): 78–81.
  2. Day GSLadak SCurley KFarb NAMasiowski PPringsheim T…, Martin Del Campo C. Thiamine prescribing practices within university-affiliated hospitals: A multicenter retrospective review. Journal of Hospital Medicine; 2015; doi: 10.1002/jhm.2324. [Published online ahead of print.]
  3. Isenberg-Grzeda E, Chabon BNicolson SE. Prescribing thiamine to inpatients with alcohol use disorders: how well are we doing? Journal of Addiction Medicine; 2014; 8(1):1-5.

 

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