According to the 2020 American Society of Addiction Medicine (ASAM) Clinical Practice Guideline on Alcohol Withdrawal Management, alcohol withdrawal can cause significant morbidity in patients, particularly those in the critical care setting, and intensive care unit (ICU) admission may warrant prophylactic interventions to reduce the risk of developing withdrawal-related complications. Patients in the ICU should be closely monitored for worsening signs and symptoms, as well as for the development of Wernicke encephalopathy (WE), a potentially severe consequence of thiamine (vitamin B1) deficiency. Traditionally, multivitamin infusions, often referred to as “banana bags,” have been administered to ICU patients to prevent WE. However, studies examining the effectiveness of the standard ICU protocol have suggested that the banana bag approach may not adequately address the risk, particularly when signs and symptoms are masked or mimicked by other illnesses. These findings have led to recommendations to abandon routine banana bag administration in favor of targeted therapy, specifically providing patients with 200-500 mg of intravenous (IV) thiamine every eight hours, magnesium sulfate at 64 mg/kg, and IV folate at 400-1,000 mcg for those exhibiting signs or symptoms suggestive of WE. Importantly, when patients also receive glucose, thiamine can be administered before, after, or concurrently with glucose to prevent precipitating or worsening deficiency. [1]
A 2016 review article evaluated vitamin and electrolyte deficiencies in critically ill patients with chronic alcohol use disorder (AUD) and identified thiamine as the most critical nutrient to assess and replace promptly. Based on pharmacokinetic data, standard banana bags are unlikely to optimize thiamine delivery to the central nervous system. Folic acid and magnesium may warrant supplementation, but evidence supporting their routine use is weaker, and there is no evidence for multivitamin administration. For patients admitted to the ICU with symptoms that may mimic or mask WE, the authors recommended abandoning the banana bag in favor of targeted therapy: 200-500 mg IV thiamine every eight hours, magnesium sulfate 64 mg/kg (4-5 g for most adults), and IV folate 400-1,000 mcg during the first day of admission. When alcoholic ketoacidosis (AKA) is suspected, dextrose-containing fluids are preferred over normal saline. The review also emphasized that critically ill patients with chronic AUD are often deficient in thiamine, folate, and magnesium, and typical banana bag formulations do not adequately address the neurological risks associated with these deficiencies. While evidence for nutrients other than thiamine is limited, empiric therapy is often justified due to the difficulty of diagnosing WE or Korsakoff syndrome and the severe consequences of delayed treatment. Ultimately, clinicians should weigh the potential benefits, risks, and costs of supplementation for each patient using the available literature as guidance. For an overview of recommendations for supplementation in critically ill patients with AUD, please refer to Table 1. [2]
A 2020 article highlighted that thiamine supplementation was not included in the 2019 Canadian Family Physician guidance on office management of alcohol withdrawal, despite the well-established risk of nutritional deficiencies in individuals with alcohol use disorder. The authors emphasized that thiamine supplementation reduces the risk of Wernicke syndrome, Korsakoff syndrome, and beriberi, and that clinicians should maintain a high index of suspicion for Wernicke syndrome, particularly in patients presenting with ophthalmoplegia, ataxia, or confusion. While optimal dosing, duration, and route of administration remain uncertain, there is increasing consensus that patients with confirmed or high-risk Wernicke syndrome should receive parenteral thiamine. Oral thiamine may also play a role in preventing or improving thiamine-deficient states; although gastrointestinal absorption is lower than with intramuscular administration, the potential preventive benefit and low risk support its use. Consistent with this, the 2017 update of the National Institute for Health and Clinical Excellence guidelines recommends prophylactic oral thiamine for individuals with alcohol dependence, and the British Association for Psychopharmacology similarly advises oral thiamine in those with poor nutritional intake. Additional outpatient guidance has recommended routine thiamine 100 mg daily with folic acid 1 mg daily. Overall, the article supports routine consideration of thiamine supplementation in the office-based management of alcohol use disorders and alcohol withdrawal, given the serious consequences of unrecognized thiamine deficiency and the potential benefit of prevention. Of note, the use of banana bag formulations was not described within the article. [3]
Lastly, a 2020 review delves into the efficacy of vitamin supplementation for addressing alcoholism and alcohol-related health complications. This comprehensive examination highlights research findings derived from both clinical and basic studies that elucidate the impact of vitamin deficiencies on physiological systems, primarily focusing on the liver and brain. Animal models, particularly rodents, were frequently employed to investigate the effects of vitamin depletion, utilizing behavioral experiments that simulate cognitive, learning, memory, and motivational parameters. These foundational studies offer support for existing hypotheses concerning the detrimental impact of vitamin deficiencies in individuals with alcohol use disorder. Although clinical studies remain scarce, those available generally assess the outcomes of vitamin supplementation within structured treatment programs. The review underscores the significance of deficiencies in specific vitamins, such as retinoids (vitamin A), thiamine (B1), and niacin (B3), which are recurrently explored in the context of alcoholism. Despite promising findings regarding individual vitamins and their combinations, the review stresses the necessity for more extensive clinical research to validate these results and calls for more standardized supplementation and treatment protocols. This exploration affirms the potential of vitamin supplementation in enhancing the understanding and treatment of alcoholism, although it acknowledges the current predominance of basic research over clinical applications. [4]