Kent Institute of Medicine and Health Sciences, University of Kent at Canterbury, Canterbury, Kent CT2 7PD and
1 Department of Gastroenterology, Greenwich District Hospital, London SE10, UK
Received 2 November 1998; in revised form 22 February 1999; accepted 30 March 1999
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ABSTRACT |
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INTRODUCTION |
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One of the most serious consequences of thiamine (B1) deficiency is Wernicke's encephalopathy, which, if untreated or treated inadequately, can lead to premature death or permanent brain damage (Korsakoff's psychosis). Research has shown that the prevalence of this condition is often underestimated (Torvik et al., 1982; Thomson and Pratt, 1992
). There is also evidence that the triad of symptoms originally described by Wernicke in 1881, namely confusion, ataxia, and ophthalmoplegia, are not invariably present (Harper et al., 1986
). Indeed, it is now believed that Wernicke's encephalopathy can evolve as a series of minor episodes of subclinical encephalopathies in which all of the classic features are absent (Reuler et al., 1985
). Further, there is evidence that this condition is frequently not treated appropriately with parenteral B-complex vitamins (Thomson and Cook, 1997
).
Despite evidence indicating the importance of parenteral administration, the use of parenteral B-complex vitamins has altered over the past 6 years for two main reasons. First, there was a 9-month gap in 1992 when Parentrovite was not available in the UK due to manufacturing problems and secondly because of the previous warnings by the Committee on Safety of Medicines (CSM, 1989) of adverse effects following parenteral administration. Nevertheless, reports of adverse reaction to parenteral therapy have been rare, both in the UK (O'Brien, 1995) and in the USA (Wrenn et al., 1989
; Wrenn and Slovis, 1992
).
No formal dose-ranging, placebo-controlled studies have been conducted on the use of parenteral B-complex vitamins in alcohol misuse. Data are extremely limited on dosage and duration of therapy, with dosage recommendations largely based on data from uncontrolled trials and empirical clinical practice. Research has shown that low-dose parenteral therapy does not appear to be effective in preventing morbidity and mortality associated with WernickeKorsakoff syndrome (Brown et al., 1983; Harper et al., 1986
; Tallaksen et al., 1992
).
From the research outlined, it can be seen that, despite the knowledge of possible B-vitamin deficiency in chronic alcohol misusers and the likely consequences of inadequate or no treatment, there remains concern as to whether correct prophylaxis or treatment is prescribed in practice. The purpose of this research was to establish the current practice in management of vitamin supplementation in chronic alcohol misusers in the UK by surveying physicians involved in such treatment.
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METHODS |
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A copy of the questionnaire can be obtained on request from the first author.
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RESULTS |
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The majority of both specialities indicated that, on initial contact of alcohol misusers, they considered less than 25% to have, or likely to have, serious B-vitamin deficiency. However, there was a fairly high percentage of non-responses from the A&E specialists (30%).
There was a large variation in responses to the question of which B vitamins respondents regarded as beneficial in the treatment of chronic alcohol abusers, although the majority considered thiamine (B1) as important (88% of psychiatrists, 54% of A&E), with less than half of each speciality regarding the other vitamins specified (B6, nicotinamide, and B2) as beneficial. Again, a large non-response rate was recorded for the A&E specialists (42%).
Subjects also indicated which route of administration they would use when initiating B-vitamin therapy in chronic alcohol misusers and for patients whom they thought had Wernicke's encephalopathy. As shown in Fig. 1, the majority of psychiatrists favoured oral administration if treating chronic alcohol misusers (66 vs 9% preferring parenteral or 20% both), but for patients with Wernicke's encephalopathy, the majority favoured parenteral administration (76 vs 7% oral and 4% both). The majority of A&E specialists who stated a preference favoured the parenteral route of administration for both chronic alcohol misusers and patients with Wernicke's encephalopathy (35 and 53% respectively vs 14 and 2% oral, 10 and 0% both). Again, a large non-response rate for the A&E specialists was noted (40 and 45% respectively).
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Respondents were also asked to indicate whether they always used parenteral B-complex vitamins in a chronic alcohol misuser presenting with confusion, ataxia or ophthalmoplegia. There was a large variation in responses, with no consensus for either speciality. Nevertheless, it would appear that few would require all three symptoms to be present (approximately 21% of psychiatrists and 10% of A&E specialists), although slightly more indicated that they would use this route of administration if two or three symptoms were present (26% of psychiatrists and 9% of A&E specialists). A small percentage stated that they would always use parenteral B complex vitamins in chronic alcoholic patients presenting with confusion (psychiatrists 19%, A&E specialists 4%), ataxia (psychiatrists 19%, A&E specialists 6%) or ophthalmoplegia (psychiatrists 22%, A&E specialists 9%).
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DISCUSSION |
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Of particular interest is the difference in practice and views between the two specialities of psychiatry and A&E. Throughout the questionnaire, there was a high level of non-response by the A&E specialists, possibly suggesting either a lack of knowledge or experience. However, the majority stated that they were currently involved in treating alcohol misusers, albeit few stated they were involved in detoxification programmes. Given the transitory patient contact in the A&E setting, and that the main purpose for the contact may only be indirectly linked to alcohol misuse, with patients more likely to be acutely ill, the opportunity for provision of treatment may be limited. Indeed, few A&E departments have established detection procedures or intervention practices and the problem is either unrecognized or ignored (Waller et al., 1998). Nevertheless, research has shown that the number of patients with alcohol problems attending A&E departments is approximately 10 000/year in England and Wales (Green et al., 1993
).
The results also highlight that, despite the research evidence, vitamin deficiency is not considered to be likely for most alcohol misusers seen. However, research has shown reduced circulating levels of the vitamins thiamine (B1), pyridoxine (B6), and riboflavine (B2) in alcoholics (Thomson et al., 1987, 1996
). This under-estimation of vitamin deficiency, highlighted in the current survey, is a serious concern bearing in mind the possible consequences of no or inadequate treatment. Indeed, post-mortem examination in general hospitals has identified brain damage in around 1.5% of patients (Harper, 1979
; Harper et al., 1986
) and 12.5% of alcoholic patients similarly examined (Torvik et al., 1982
). No overall consensus was found regarding the benefit of B vitamins in treatment, with wide variation in responses for both specialities, and a high proportion of non-responses for the A&E specialists. However, despite the apparent confusion, it is encouraging to note that the majority of both specialities, though not all, recognized thiamine (B1) as important, particularly since deficiency in this B vitamin has been linked to the serious condition of WernickeKorsakoff syndrome. Unfortunately, the current study was unable to establish current practice regarding dosage levels given in treatment. This question therefore needs to be addressed in any future research.
The results did highlight a difference in practice regarding the route of administration of B-vitamin therapy between the specialities, which is particularly interesting. For psychiatrists, oral administration was the preferred route for chronic alcohol misusers, yet parenteral therapy was more likely to be used for those with Wernicke's encephalopathy. In contrast, parenteral administration was the preferred route in both cases for A&E specialists, though there were a large proportion of non-responses for this group, and other research suggests that that such treatment is not frequently performed (Waller et al., 1998). These results appear to confirm the suggestion by O'Brien (1995), that the recommendations by the CSM have been misinterpreted, especially by psychiatrists, causing oral vitamin supplementation to be prescribed even in alcoholics at high risk of Wernicke's encephalopathy. The majority of psychiatrists, and a small proportion of A&E specialists, were aware of possible allergic and anaphylactic reactions to parenteral therapy. Coupled with the perceived non-urgency of treatment of chronic alcohol misusers, this could explain the psychiatrists' preference for using oral administration for chronic alcoholic users and parenteral therapy when the patient is considered to be at risk of Wernicke's encephalopathy.
With regard to the treatment of the condition of the WernickeKorsakoff syndrome, few respondents indicated that they required all three of the classic signs to be present before administering parenteral B complex vitamins, suggesting an awareness of current research findings (Reuler et al., 1985; Harper et al., 1986
). Since the question employed in the current survey was not satisfactory, future research needs to clarify this further. However, there was no clear consensus as to which symptoms would lead to such treatment being initiated. These findings suggest that the prevalence of WernickeKorsakoff syndrome is likely to be underestimated.
In conclusion, it can be seen that wide variation and apparent confusion in current practice and understanding of vitamin supplementation in chronic alcohol misuse was found among those physicians who participated in the survey. Clearly there is a need for consensus in the treatment and management of chronic alcohol misusers bearing in mind the possible consequences of no or inadequate treatment. The findings therefore suggest a need for clear guidelines and education on all aspects of vitamin deficiency in this vulnerable population which should be made available to all involved in their treatment. The differences in specialities' understanding and knowledge of this area need to be taken into consideration in any future guidelines or education provided.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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REFERENCES |
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