A SURVEY OF THE CURRENT CLINICAL PRACTICE OF PSYCHIATRISTS AND ACCIDENT AND EMERGENCY SPECIALISTS IN THE UNITED KINGDOM CONCERNING VITAMIN SUPPLEMENTATION FOR CHRONIC ALCOHOL MISUSERS

Louise C. Hope*, Christopher C. H. Cook and Allan D. Thomson1

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


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Although it is well known that B-vitamin deficiencies directly affecting the brain are common in alcohol misuse, no concise guidelines on the use of vitamin supplements in alcohol misusers currently exist in the UK. The purpose of this study was to assess current practice and opinion among UK physicians. Questionnaires were completed by a total of 427 physicians comprising Accident and Emergency (A&E) specialists and psychiatrists, with a response rate of 25%. The main findings were that vitamin deficiency was perceived as being uncommon amongst alcohol misusers (<25%) and there was no consensus as to which B vitamins are beneficial in treatment or the best method of administration of B-vitamin supplementation. The majority of psychiatrists favoured oral administration for prophylaxis against the Wernicke–Korsakoff syndrome in chronic alcohol misusers and parenteral therapy in patients with signs of Wernicke–Korsakoff syndrome. Whilst only just over half the A&E specialists expressed a preference, most favoured parenteral therapy in both cases. Most respondents did not currently have a unit policy/protocol on the management of vitamin supplementation in chronic alcohol misusers. Overall, the findings suggest that there is wide variation in current practice and highlight the need for guidelines in this area.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Deficiencies in B vitamins directly affecting the brain are common in alcohol misuse (Cook and Thomson, 1997Go). Various consequences of these B-vitamin deficiencies on the central and peripheral nervous systems have been highlighted, including behavioural changes, peripheral neuropathy, and the Wernicke–Korsakoff syndrome (Cook et al., 1998Go).

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., 1982Go; Thomson and Pratt, 1992Go). 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., 1986Go). 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., 1985Go). Further, there is evidence that this condition is frequently not treated appropriately with parenteral B-complex vitamins (Thomson and Cook, 1997Go).

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, 1995Go) and in the USA (Wrenn et al., 1989Go; Wrenn and Slovis, 1992Go).

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 Wernicke–Korsakoff syndrome (Brown et al., 1983Go; Harper et al., 1986Go; Tallaksen et al., 1992Go).

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.


    METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Questionnaires were sent out in January 1997 to 1598 UK physicians believed to be involved in the treatment of chronic alcohol misusers. Addresses were obtained from three sources: the Directory of Acute Medical Services, The Royal College of Psychiatrists, and the contact list of Link Pharmaceuticals, manufacturers of vitamin supplements. It was requested that forms be returned by the 3 March 1997 to ensure inclusion in the results, and a freepost envelope was enclosed for this purpose. The questionnaire was designed to elicit current practice, involvement, and opinion about the treatment and management of vitamin supplementation in chronic alcohol misusers. Questions focused on: (1) information regarding medical speciality; (2) current involvement in the treatment of chronic alcohol misusers; (3) where vitamin therapy would normally be initiated; (4) involvement with alcohol detoxification programmes; (5) the number of alcohol misusing patients seen per week; (6) existence of a unit policy/protocol on the management of vitamin supplementation; (7) the initial route of administration of B-vitamin therapy used for chronic alcohol misusers; (8) initial route of administration of B-vitamin therapy in patients with Wernicke's encephalopathy; (9) which B vitamins are viewed as beneficial; (10) the percentage of alcohol misusers considered on initial contact to have/likely to have a serious B-vitamin deficiency; (11) whether parenteral B complex vitamins were always used when a patient presented with certain symptoms; (12) any reasons that would cause responding clinicians to restrict the use of either oral or parenteral B-vitamin supplementation; and (13) whether they would like to receive a concise review and guidelines on the use of parenteral B vitamins in alcohol misusers.

A copy of the questionnaire can be obtained on request from the first author.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Of the total of questionnaires sent, 28% (447) were returned, 20 of these were excluded from the analysis, since they had not been completed or had been returned as non-applicable. Of the remaining 427, 60% (257) of the respondents described themselves as psychiatrists and 32% (136) as specializing in Accident and Emergency medicine (A&E), with the rest (8%, 34 cases), stating their speciality as other areas. Due to the small number involved, or the fact that their specialist area fell outside the scope of alcohol misuse, the last group of responses were not included in the analysis. Therefore, a total of 393 respondents were included, representing a response rate of approximately 25% and all the following figures are based on these respondents' replies. A summary of these respondents' involvement with the treatment of alcohol misusers is given in Table 1Go.


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Table 1. Details of respondents' involvement in the treatment of alcohol misusers and detoxification programmes
 
Table 1Go shows that the majority of respondents are currently involved in treating alcohol misusers (93% of psychiatrists, 76% of A&E specialists), although only the majority of psychiatrists are also involved with detoxification programmes (86 vs 8% of A&E specialists). For both specialities, it would appear that most do not currently have a unit policy/ protocol on the management of vitamin supplementation in chronic alcohol misusers (34% of psychiatrists and 13% of A&E specialists). A large proportion of respondents indicated that they would like to receive a concise review and guidelines on the use of parenteral B vitamins in alcohol misusers (96% of psychiatrists, 90% of A&E specialists).

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. 1Go, 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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Fig. 1. The route of B-vitamin therapy initiated in chronic alcohol misusers and patients with Wernicke's encephalopathy.

 
There was wide variation in reasons given for why the use of either oral or parenteral B-vitamin supplementation would be restricted. Twenty-eight per cent of both specialities stated that they knew of no reasons for restricting oral supplementation, although fewer stated this in respect of parenteral therapy (10% of psychiatrists and 13% of A&E specialists). However, non-response rates for this question were quite high (28% of psychiatrists and 6% of A&E specialists in respect of oral supplementation, 16 and 52% respectively for parenteral therapy), though it is not clear if these non-responses can be viewed as reflecting the opinion of ‘no reason' for restricting that form of supplementation. However, a large proportion of psychiatrists (70%), and a few A&E specialists (18%), mentioned either ‘allergy' or ‘anaphylaxis' as reasons for restricting the use of parenteral B vitamins.

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%).


    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Overall, the results of the survey confirm that there is a wide variation in the management and treatment of chronic alcohol misusers in the UK. Although the response rate was low, the sample size is relatively large and the results do provide interesting information regarding current practice and opinion. Furthermore, the low response rate may further reflect the confusion that surrounds this area.

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., 1998Go). 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., 1993Go).

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., 1987Go, 1996Go). 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, 1979Go; Harper et al., 1986Go) and 12.5% of alcoholic patients similarly examined (Torvik et al., 1982Go). 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 Wernicke–Korsakoff 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., 1998Go). 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 Wernicke–Korsakoff 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., 1985Go; Harper et al., 1986Go). 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 Wernicke–Korsakoff 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.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The authors would like to thank Link Pharmaceuticals for their help in producing and distributing the questionnaires and collating the data, and, in particular, Neil Hodson for his efforts in the data analysis. We would also like to thank all those who took part in the survey. L. H. was supported by a generous grant from the Henry Smith Charities.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Brown, L. M., Rowe, A. E., Ryle, P. R., Majumdar, S. K., Jones, D., Thomson, A. D. and Shaw, G. K. (1983) Efficacy of vitamin supplementation in chronic alcoholics undergoing detoxification. Alcohol and Alcoholism 18, 157–166.[ISI]

Committee on Safety of Medicines (1989) Parentrovite and allergic reactions. Current Problems 24, 1.

Cook, C. C. H. and Thomson, A. D. (1997) B-complex vitamins in the prevention and treatment of Wernicke– Korsakoff syndrome. British Journal of Hospital Medicine 57, 461–465.[ISI][Medline]

Cook, C. C. H., Hallwood, P. M. and Thomson, A. D. (1998) B-vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol and Alcoholism 33, 317–336.[Abstract]

Green, M., Setchell, J., Hames, P., Stiff, G., Touquet, R. and Priest, R. (1993) Management of alcohol abusing patients in Accident and Emergency departments. Journal of the Royal Society of Medicine 86, 393–395.[Abstract]

Harper, C. (1979) Wernicke's encephalopathy: a more common disease than realised. Journal of Neurology, Neurosurgery and Psychiatry 42, 226–231.[Abstract]

Harper, C. G., Giles, M. and Finlay-Jones, R. (1986) Clinical signs in the Wernicke–Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. Journal of Neurology, Neurosurgery and Psychiatry 49, 341–345.[Abstract]

O'Brien, P. (1995) Parenteral vitamin therapy in alcoholism. Psychiatric Bulletin 19, 788.

Reuler, J. B., Girard, D. E. and Cooney, T. G. (1985) Wernicke's encephalopathy. New England Journal of Medicine 312, 1035–1039.[ISI][Medline]

Tallaksen, C. M. E., Bell, H. and Bøhmer, T. (1992) The concentration of thiamin and thiamin phosphate esters in patients with alcoholic liver cirrhosis. Alcohol and Alcoholism 27, 523–530.[Abstract]

Thomson, A. D. and Cook, C. C. H. (1997) Parenteral thiamine and Wernicke's encephalopathy: the balance of risks and perception of concern. Alcohol and Alcoholism 32, 207–209.[Abstract]

Thomson, A. D. and Pratt, O. E. (1992) Interaction of nutrients and alcohol: absorption, transport, utilization and metabolism. In Nutrition and Alcohol, Watson, R. R. and Watzl, B. eds, pp. 75–99. CRC Press, Boca Raton, FL.

Thomson, A. D., Jeyasingham, M., Pratt, O. E. and Shaw, G. K. (1987) Nutrition and alcoholic encephalopathies. Acta Medica Scandinavica Supplementum 717, 55–65.[Medline]

Thomson, A. D., Heap, L. C. and Ward R. J. (1996) Alcohol-induced malabsorption in the gastrointestinal tract. In Alcohol and the Gastrointestinal Tract, Preedy, V. R. and Watson, R. R. eds, pp. 203–218. CRC Press, Boca Raton, FL.

Torvik, A., Lindboe, C. F. and Rogde, S. (1982) Brain lesions in alcoholics. A neuropathological study with clinical correlations. Journal of Neurological Sciences 56, 233–248.[ISI][Medline]

Waller, S., Thom, B., Harris, S. and Kelly, M. (1998) Perceptions of alcohol-related attendances in Accident and Emergency departments in England: a national survey. Alcohol and Alcoholism 33, 354–361.[Abstract]

Wrenn, K. D. and Slovis, C. M. (1992) Is intravenous thiamine safe? American Journal of Emergency Medicine 10, 165.[ISI][Medline]

Wrenn, K. D., Murphy, F. and Slovis, C. M. (1989) A toxicity study of parenteral thiamine hydrochloride. Annals of Emergency Medicine 18, 867–870.[ISI][Medline]