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 – thiamine

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INITIAL
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at-risk asymptomatic hospitalized adults
1st line – 

thiamine

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

Although rare, anaphylaxis and anaphylactoid reactions can occur when thiamine is given parenterally.[1][13]​​​​ It is therefore recommended that intravenous thiamine is administered in the hospital (with facilities for cardiopulmonary resuscitation).[7]

Refeeding can be a risk factor for precipitating Wernicke encephalopathy. Thiamine should be given before initiating oral, enteral, or parental feeding (including intravenous dextrose therapy) in patients identified as being at risk for refeeding syndrome.[20]

There are insufficient data from randomized controlled trials to recommend standard doses for the treatment of vitamin B1 deficiency.[67]​ Dosing regimens are therefore based on consensus expert opinion. An example of a suitable dose regimen is presented here.[1]​ However, dose regimens vary and you should consult your local guidelines or drug information source for more information.

Primary options

thiamine (vitamin B1): 100 mg intravenously three times 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 be measured and replacement therapy initiated per standard protocols.[20]​​

adult on alcohol withdrawal program

1st line – thiamine

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INITIAL
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adult on alcohol withdrawal program
1st line – 

thiamine

Prophylactic oral thiamine should be offered to patients who misuse alcohol before and during medically assisted alcohol withdrawal.[66]

Refeeding can be a risk factor for precipitating Wernicke encephalopathy. Thiamine should be given before initiating oral, enteral, or parental feeding (including intravenous dextrose therapy) in patients identified as being at risk for refeeding syndrome.[20]

There are insufficient data from randomized controlled trials to recommend standard doses for the treatment of vitamin B1 deficiency.[67]​ Dosing regimens are therefore based on consensus expert opinion. An example of a suitable dose regimen is presented here.[1]​ However, dose regimens vary and you should consult your local guidelines or drug information source for more information.

Primary options

thiamine (vitamin B1): 100-200 mg orally once daily for 3-5 days

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ACUTE

symptomatic adults

1st line – thiamine

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ACUTE
|
symptomatic adults
1st line – 

thiamine

High-dose intravenous thiamine should be given for 3 days and the clinical response assessed.

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.

If there is no clinical improvement, high-dose intravenous thiamine should be discontinued. Oral thiamine may be continued at lower doses in these patients.

Although rare, anaphylaxis and anaphylactoid reactions can occur when thiamine is given parenterally.[1][13]​​​ It is therefore recommended that intravenous thiamine is administered in the hospital (with facilities for cardiopulmonary resuscitation).[7]

Refeeding can be a risk factor for precipitating Wernicke encephalopathy. Thiamine should be given before initiating oral, enteral, or parenteral feeding (including intravenous dextrose therapy) in patients identified as being at risk for refeeding syndrome.[20]

There are insufficient data from randomized controlled trials to recommend standard doses for the treatment of vitamin B1 deficiency.[67]​ Dosing regimens are therefore based on consensus expert opinion. Examples of suitable dose regimens are presented here and depend on the indication.[1]​ However, dose regimens vary and you should consult your local guidelines or drug information source for more information.

Primary options

thiamine (vitamin B1): Wernicke encephalopathy: 200-500 mg intravenously three times daily for 2-7 days, followed by 250 mg once daily for 3-5 days; berberi: 100-200 mg intravenously three times daily for 2-3 days followed by maintenance therapy; other cause of proven deficiency: 200 mg intravenously three times daily; refeeding syndrome: 300 mg intravenously before initiating nutrition therapy, followed by 200-300 mg once daily for at least 3 days; maintenance therapy: 50-100 mg orally once daily

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 per standard protocols.[20]​​

symptomatic children and infants

1st line – thiamine

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ACUTE
|
symptomatic children and infants
1st line – 

thiamine

There are no established doses for thiamine replacement in children with symptomatic vitamin B1 deficiency, 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; 3-6 weeks of oral therapy should then be given.

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

There are insufficient data from randomized controlled trials to recommend standard doses for the treatment of vitamin B1 deficiency.[67]​ Dosing regimens are therefore based on consensus expert opinion. However, dose regimens vary and you should consult your local guidelines or drug information source for more information.

Primary options

thiamine (vitamin B1): consult specialist for guidance on dose

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.​​​​[68]

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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