Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

at-risk asymptomatic hospitalized adults

1st line – intravenous thiamine

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INITIAL
|
at-risk asymptomatic hospitalized adults
1st line – 

intravenous thiamine

All asymptomatic adults at high risk of vitamin B1 deficiency should be considered for 3 days of high-dose intravenous thiamine.

High-dose intravenous thiamine should be given for 3 days.

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]

Because refeeding can be a risk factor for precipitating Wernicke encephalopathy, thiamine should always be given before feeding or intravenous glucose therapy is initiated.

Primary options

thiamine (vitamin B1): 300 mg orally once daily

Consider – magnesium, potassium, and/or phosphate replacement

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INITIAL
|
at-risk asymptomatic hospitalized adults
Consider – 

magnesium, potassium, and/or phosphate replacement

Treatment recommended for SOME patients in selected patient group

Magnesium, potassium, and phosphate levels should also be measured and replacement therapy initiated as required.[7]

Primary options

magnesium sulfate

OR

potassium chloride

outpatient on alcohol withdrawal program

1st line – oral thiamine

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INITIAL
|
outpatient on alcohol withdrawal program
1st line – 

oral thiamine

Prophylactic oral thiamine should be offered to harmful or dependent drinkers before and during a planned medically assisted alcohol withdrawal.[53]

Because refeeding can be a risk factor for precipitating Wernicke encephalopathy, thiamine should always be given before feeding or intravenous glucose therapy is initiated.

Primary options

thiamine (vitamin B1): 300 mg orally once daily

ACUTE

symptomatic adults

1st line – intravenous thiamine

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ACUTE
|
symptomatic adults
1st line – 

intravenous thiamine

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.

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]

Because refeeding can be a risk factor for precipitating Wernicke encephalopathy, thiamine should always be given before feeding or intravenous glucose therapy is initiated.

Primary options

thiamine (vitamin B1): 500 mg intravenously three times daily for 3 days, followed by 250 mg once daily for 5 days or until clinical improvement ceases

Consider – magnesium, potassium, and/or phosphate replacement

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ACUTE
|
symptomatic adults
Consider – 

magnesium, potassium, and/or phosphate replacement

Treatment recommended for SOME patients in selected patient group

Magnesium, potassium, and phosphate levels should also be measured and replacement therapy initiated as required.[7]

Primary options

magnesium sulfate

OR

potassium chloride

symptomatic children and infants

1st line – intravenous thiamine

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ACUTE
|
symptomatic children and infants
1st line – 

intravenous thiamine

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.

Infants (both breast-fed 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. Three to six weeks of oral therapy should then be given.

Intravenous dose is given by slow infusion to reduce risk of anaphylaxis.

Primary options

thiamine (vitamin B1): 25-50 mg intravenously for the first dose, followed by 10 mg intramuscularly once daily for 7 days, followed by 3-5 mg orally once daily for 3-6 weeks

Consider – treatment of mother

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ACUTE
|
symptomatic children and infants
Consider – 

treatment of mother

Treatment recommended for SOME patients in selected patient group

In cases of breast-fed infants with vitamin B1 deficiency, the mother should also be treated with 7 weeks of oral thiamine.[5]

Primary options

thiamine (vitamin B1): 10 mg orally once daily for 7 days, followed by 3-5 mg orally once daily for 6 weeks

Consider – thiamine-fortified formula milk

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ACUTE
|
symptomatic children and infants
Consider – 

thiamine-fortified formula milk

Treatment recommended for SOME patients in selected patient group

Bottle-fed infants should receive formula milk fortified with thiamine in addition to the above thiamine supplementation.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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