Approach
The mainstay of treatment is thiamine replacement therapy. In addition to the treatment of patients with symptoms of vitamin B1 deficiency (i.e., Wernicke encephalopathy, wet beriberi, or dry beriberi), thiamine supplementation should be considered in all patients at high risk of deficiency.
Vitamin B1 deficiency is a clinical diagnosis, and as the presenting symptoms are nonspecific, thiamine replacement therapy should be initiated immediately based on any suspicion of the deficiency. Treatment should not be delayed while awaiting the results of further investigations to exclude other diagnoses.
There are insufficient RCT data to recommend standard doses for the treatment of vitamin B1 deficiency.[55] Dosing regimens are therefore based on consensus expert opinion. As oral thiamine is poorly absorbed, it should be given intravenously in the hospital setting or intramuscularly in the community.[56] Because refeeding can be a risk factor for precipitating Wernicke encephalopathy, thiamine should always be given before feeding or intravenous glucose therapy is initiated.
Treatment of symptomatic or at-risk asymptomatic hospitalized adults
High-dose intravenous thiamine should be given for 3 days and the clinical response assessed. If there is no clinical improvement, treatment should be discontinued. If there is evidence of clinical improvement, intravenous thiamine should be continued at a lower dose for a further 5 days, or until clinical improvement ceases.
All asymptomatic adults at high risk of vitamin B1 deficiency should be considered for 3 days of high-dose intravenous thiamine.
Anaphylaxis and anaphylactoid reactions can occur when thiamine is given parenterally.[7] It is therefore recommended that intravenous thiamine is administered in the hospital with the availability of CPR facilities and epinephrine.[57]
Magnesium, potassium, and phosphate levels should also be measured and replacement therapy initiated as required.[7]
Supplementation during community alcohol withdrawal programs
Prophylactic oral thiamine should be offered to harmful or dependent drinkers before and during a planned medically assisted alcohol withdrawal.[53]
Treatment of symptomatic children and infants
Vitamin B1 deficiency in infants and children is extremely rare in the Western world. Infants (both breastfed and bottle-fed) with symptomatic vitamin B1 deficiency should be treated with a slow intravenous infusion of thiamine followed by 7 days of intramuscular thiamine and 3 to 6 weeks of oral therapy thereafter. Bottle-fed infants should receive formula milk fortified with thiamine in addition to the above thiamine supplementation. Mothers of breastfed infants with vitamin B1 deficiency should also be treated with 7 weeks of oral thiamine.[5]
There are no established doses for thiamine replacement in children with symptomatic vitamin B1 deficiency in the literature, but it may be appropriate to treat young children with the same dosing regimen as that given to infants.
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