Intramuscular and intravenous thiamine can be used to prevent complications of alcohol dependence such as Wernicke’s encephalopathy.
Developed with colleagues
· This page was developed with colleagues outside SPS
This content is being published by SPS to support the current supply issue with Pabrinex. It was developed with a number of colleagues from the expert reference group for UK clinical guidelines on alcohol treatment from the Office for Health Improvement and Disparities.
There are no other licensed parenteral alternatives to Pabrinex intravenous and intramuscular injections.
Thiamine
Intravenous or intramuscular thiamine is an alternative to Pabrinex that can be used in people at high risk of Wernicke’s encephalopathy, although no product with a marketing authorisation currently exists in the UK.
Organisational 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 alcohol dependence and amend these as necessary.
NICE CG100 recommends to offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers if they:
are malnourished or at risk of malnourishment or
have decompensated liver disease
and in addition:
they attend an emergency department or
are admitted to hospital with an acute injury or illness
People at high risk of Wernicke’s encephalopathy can have a range of conditions, including:
significant weight loss
poor diet
low BMI (<18)
other signs of malnutrition
memory disturbance
peripheral neuropathy
previous history of Wernicke’s encephalopathy
Consider offering prophylactic parenteral thiamine to people at high risk following the dosing below.
Community setting doses
give intramuscular thiamine 200 to 300mg once daily for at least 3 days
Hospital setting doses
give intramuscular or intravenous thiamine 200 to 300mg once daily for 3 to 5 days with daily review and monitoring for emergent signs of Wernicke’s encephalopathy
Treating Wernicke’s encephalopathy
Identifying symptoms
People with any of the additional symptoms below require treatment for Wernicke’s encephalopathy.
impaired eye movements (ophthalmoplegia)
unsteady walking (ataxia)
confusion
Hospital setting doses
give intravenous thiamine 300 to 500mg three times a day for 3 to 5 days with daily review
if the individual is still symptomatic after 5 days of treatment, then give intravenous thiamine 300mg to 500mg once daily for a further 3 to 5 days for as long as clinical improvement continues
other causes for their confusion should be explored
Evidence behind the recommendations
Office for Health Improvement and Disparities (OHID) and DHSC convened a group of 11 expert clinicians (drawn mainly from the clinical reference group for the UK clinical guidelines on alcohol treatment) chaired by Dr Mike Kelleher (Consultant Addiction Psychiatrist) National Clinical Advisor for alcohol and drugs to OHID (DHSC).
A consensus on recommendations for intramuscular and intravenous thiamine was reached based on reviewing the available evidence, national/international guidelines, clinical experience and consultations with international specialists.
Park et al. Comparative Pharmacokinetic Analysis of Thiamine and Its Phosphorylated Metabolites Administered as Multivitamin Preparations. Clinical Therapeutics 2016. DOI: 10.1016/j.clinthera.2016.08.009
Thomson A, Guerrini I, Marshall E J. Wernicke’s Encephalopathy: Role of thiamine. Nutrition issues in Gastroenterology, Practical Gastroenterology June 2009: Series #75 XXXIII(6) pages 21- 30.