1. Parenteral Vitamin Repletion in Alcohol Use Disorder Vicki P. Cheng, Cory Taylor UCI Internal Medicine Residency Cost-Conscious Medicine Series

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

3. 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 Acute Concerns in Alcohol Use Disorder

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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?)

11. Results Patient NameDiagnosis Tolerating PO? IV banana bag PO thiamine PO folate PO MVI History of Delirium Tremens? 1AUDYes, hepaticX2 (12/7)7-Dec Yes 2 Upper GI BleedNo, NPOx2 (12/5-6)7-Dec Unknown 3AUDYes, regular Self reported “seizures” 4 Upper GI BleedNo, NPO Yes 2 of 4 patients concurrently receiving both IV and PO vitamins

12. Additional Results Patient NameDiagnosis Tolerating PO?Banana bag PO thiamine PO folate PO MVI History of Delirium Tremens? 1.2AUDNo 2.2Upper GI BleedNo 3.2 Alcohol WithdrawalYes, regular NoYes No 4.2 Encephalopathy with heavy ETOH historyNo, NPOYes

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