Vitamin Prophylaxis and Treatment of Wernicke-Korsakoff Encephalopathy

Introduction

The guidance applies to all alcohol use disorders; hazardous, harmful and dependent.

Figure 1 – Assessing for Wernicke's encephalopathy

Assess for Wernicke's encephalopathy

Does the patient have any of the following signs / symptoms: confusion, decreased consciousness, nystagmus, ataxia, opthalmoplegia, hypothermia / hypotension

↓

If Yes - Presumptive diagnosis of Wernicke's encephalopathy (if symptoms otherwise unexplained). See Box A below for management.

If No - Assess risk of Wernicke's encephalopathy. See Box B below for management.

Box A - Presumptive diagnosis of Wernicke's encephalopathy and management

This requires urgent treatment.

Day 1-2

Day 3-5

Day 6 onwards

Pabrinex^® IV 2 pairs of vials three times a day

Magnesium - check serum level urgently and give IV replacement if deficient. See hypomagnesaemia guideline.

Pabrinex^® IV / IM 1 pair of vials three times a day

Change to thiamine oral 50mg four times a day or continue with Pabrinex^® IV / IM at the discretion of the medical team

Box B - Assessment of risk of Wernicke's encephalopathy and management

Check magnesium in all patients and correct deficiency.
Risk factors include: weight loss (MUST=1), poor diet or vomiting for <5 days, alcoholic liver disease, presents with seizures, age ≤18 or ≥65 years.
Severe risk factors are severe weight loss (MUST≥2), poor diet or vomiting for >5 days.

No risk factors	1 risk factor	≥2 risk factors or any single severe risk factor
Thiamine oral 50mg four times daily	Pabrinex^®IV / IM 1 pair of vials three times a day for 24 hours then change to thiamine oral 50mg four times daily	Pabrinex^® IV / IM 1 pair three times a day for 48 hours then change to thiamine oral 50mg four times daily

Important notes

If oral thiamine is indicated but a patient is unable to take medicine by mouth then consult with ward clinical pharmacist. Nasogastric administration may be possible or Pabrinex^® IM (1 pair of vials once daily) are alternatives.
Intravenous Pabrinex^® should be administered over 30 minutes.
Anaphylaxis is a rare complication of IV Pabrinex^® administration and even more uncommon with IM administration. Monitor patient for wheeze, tachycardia, breathlessness and skin rash. Facilities for the administration of adrenaline and other resuscitation should be available (see Management of Anaphylaxis).
Further vitamin supplementation as clinically indicated by responsible medical team in the context of a general nutritional assessment.
Discontinuation of oral thiamine should be considered for patients who have been abstinent for 3 months and who have an adequate dietary intake.

Guideline reviewed and last updated November 2020