Vicki P. Cheng, Cory Taylor
UCI Internal Medicine Residency
Cost-Conscious Medicine Series

Acute Concerns in Alcohol
Use Disorder
 Alcohol Withdrawal
 CNS Hyperstimulation
• Disorientation
• Hallucinosis
• Delirium Tremens
 High Sympathetic Tone
• Tremors, Diaphoresis
• Tachycardia, HTN, fever

Acute Concerns in Alcohol
Use Disorder
 Wernicke Encephalopathy
 An acute condition
 Untreated or exacerbated
• Can include Korsakoff psychosis
• Can lead to coma, death
 Chronic undertreatment leads to:
• Wernicke disease – permanent deficits
• Korsakoff dementia – permanent deficits

Wernicke Encephalopathy
 Thiamine deficiency
 Most often in chronic alcoholics
• Also seen in other states of malabsorption, nutritional deficiency
 Requirements increase with
• Metabolic rate
• Blood-glucose loading

Wernicke Encephalopathy
 Presentation*
 Triad: encephalopathy, ataxia, occulomotor dysfunction
 Diagnosis is clinical and difficult
• Triad present in < 20%
• Encephalopathy in 80% but overlaps with withdrawal and dementia
 Can be precipitated or exacerbated by
IV glucose administration

Thiamine Repletion
 Parenteral repletion
 To treat Wernicke Encephalopathy*
 To avoid precipitation of Wernicke
Encephalopathy*
• NPO status for medications
• Concern for ETOH enteropathy/malabsorption
• Efficacy is questionable, not well studied

Thiamine Prophylaxis -
Issues
 Deficiency is rare, even in alcohol use
 A tribute to ubiquitous fortification
Krishel S, SaFranek, Clark RF. Intravenous vitamins for alcoholics in the emergency department: a review. J Emerg Med. 1998;16(3):419-424.
 Banana Bag Order Set
 Does not provide for treatment of
Wernicke Encephalopathy
 May obscure existence of subclinical disease

Thiamine Prophylaxis -
Issues
 What is the goal:
 Avoid any pathologic or clinical development of wernickean injury?
 Avoid iatrogenic precipitation of wernickean injury?*
 May benefit from cultural paradigm shift

Objective
Routine IV multivitamin and folate in alcohol abuse is costly and not supported by evidence
Faine B, Nunge M, Denning G, Nugent A. Implementing evidence-based changes in emergency department treatment: alternative vitamin therapy for alcohol-related illnesses. Ann Emerg Med.
2012;59:408-412.
 To study current utilization of parenteral vitamin therapy routes on the Medicine
Wards at UC Irvine

Methods
Chart Review
 Subjects: All Inpatients on Medicine Teams A-G at UCI Medical Center,
2 days (1 day 2013, 1 day 2016) with Diagnosis/Active Problem
(n=55+75 = 130)





Alcohol Use Disorder (2+2)
Encephalopathy (1+1)
GI Bleed (1+1)
Pancreatitis
Seizure, Epilepsy
 Intervention:
1L IVF solution with thiamine 100mg inj, multivitamin 10mL inj, folic acid
1mg inj, 1 bag daily x 3 days.
May discontinue if tolerating PO.
 Comparison:
Thiamine 100mg PO daily
Folic Acid 1mg PO daily
Multivitamin (Tab-a-vite) 1 tab PO daily
 Outcome: Appropriate or Inappropriate Route (Tolerating diet?)

Results
1
2
Patient
Name Diagnosis
AUD
Upper GI
Bleed
3 AUD
Tolerating
PO?
IV banana bag
Yes, hepatic X2 (12/7)
No, NPO x2 (12/5-6)
PO thiamine
PO folate
7-Dec
7-Dec
7-Dec
7-Dec
PO
MVI
7-Dec
7-Dec
History of
Delirium
Tremens?
Yes
Unknown
Yes, regular
Self reported
“seizures”
4
Upper GI
Bleed No, NPO
2 of 4 patients concurrently receiving both IV and PO vitamins
Yes

Additional Results
Patient
Name Diagnosis
1.2
2.2
AUD
Tolerating
PO?
No
Upper GI Bleed No
Banana bag
PO thiamine
PO folate
PO
MVI
No
No
No
No
No
No
No
No
History of
Delirium
Tremens?
No
No
3.2
4.2
Alcohol
Withdrawal Yes, regular No
Encephalopathy with heavy
ETOH history No, NPO Yes
Yes
Yes
Yes
Yes
Yes No
Yes Yes

Conclusion
Multivitamins
Average Patient Cost per day Folate 1mg
Total
IV
$43.25
$47.28
$90.53
PO (1 tab)
$0.04
$0.05
$0.09