Thiamine for refeeding syndrome

During refeeding syndrome, the demand for thiamine increases which can lead to a depletion of stores.

Thiamine replacement is thus indicated to prevent complications from thiamine deficiency such as the development of Wernicke’s encephalopathy which can progress to Korsakoff’s syndrome.

Products and availability

Issues affecting Pabrinex

Pabrinex, which contains thiamine, has been previously used for refeeding syndrome. However, intramuscular Pabrinex has been discontinued, and intravenous Pabrinex is affected by a long term supply issue. Supplies will not be available after August 2024.

There are no other licensed parenteral alternatives to Pabrinex intravenous and intramuscular injections.

Intravenous thiamine

Intravenous thiamine is an alternative to Pabrinex that can be used in some patients where indicated, although no product with a marketing authorisation currently exists in the UK.

Actions

Organisations should undertake a number of actions to ensure Pabrinex stock is preserved and thiamine is used appropriately.

Review local protocols

Identify and review any local protocols for refeeding syndrome and amend these as necessary.

Conserve current Pabrinex stock

Current stock should be used only for life-threatening conditions.

Use oral thiamine and vitamin B first

Oral thiamine and vitamin B compound strong should be used first where supplementation is clinically indicated and appropriate.

Use intravenous thiamine if high risk

If the oral or enteral route is not available, prescribe intravenous thiamine at the lowest clinically suitable dose and course length for patients at high or extremely high risk of refeeding syndrome. Determine risk based on NICE CG32 as follows:

High risk

Patient has 1 or more of the following:

• BMI less than 16 kg/m²
• unintentional weight loss greater than 15% within the last 3 to 6 months
• little or no nutritional intake for more than 10 days
• low levels of potassium, phosphate or magnesium before feeding

Or patient has 2 or more of the following:

• BMI less than 18.5 kg/m²
• unintentional weight loss greater than 10% within the last 3 to 6 months
• little or no nutritional intake for more than 5 days
• a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

Extremely high risk

Patient has the following:

• BMI less than 14 kg/m² with negligible nutrition for more than 15 days

Doses of intravenous thiamine

Where intravenous thiamine is indicated, the following doses can be used.

Adults and children over 10 years

• give 200-300mg once daily prior to starting parenteral nutrition
• continue for at least 2 more days (total course of 3 days); or 4 more days (total course of 5 days) in higher-risk patients

Children

Under 6 years of age

• give 100mg once daily prior to starting parenteral nutrition
• continue for at least 2 more days (total course of 3 days); or 4 more days (total course of 5 days) in higher-risk patients

6-10 years of age

• give 150mg once daily prior to starting parenteral nutrition
• continue for at least 2 more days (total course of 3 days); or 4 more days (total course of 5 days) in higher-risk patients

Update history