BNF Recommendations for the treatment of Wernicke's encephalopathy: Lost in translation?

Abstract

We agree with Thomson and Marshall (2013) that the current prescribing of thiamine replacement therapy for Wernicke's Encephalopathy (WE) is ambiguous. In response to their article, we also advocate that any consensus on accurate thiamine treatment for WE should receive sufficient international attention, since too many patients with WE are currently inaccurately treated leading to unnecessary cases of Korsakoff's syndrome. WE is a neurologic disease caused by thiamine (vitamin B1) deficiency. Most patients with WE have a background of chronic alcoholism and self-neglect (Sechi and Serra, 2007). Importantly, WE is also a life-threatening condition associated with a classic triad of acute neurological symptoms resembling delirium: confusion, ataxia and eye-movement disorders (McCormick et al., 2011; Wijnia and Oudman, 2013). Usually, but not necessarily, patients will develop Korsakoff's syndrome characterized by chronic amnesia (Kopelman, 2002). Slingedael offers a long-stay facility for patients with Korsakoff's syndrome in Rotterdam, The Netherlands. For triage purposes, confused alcoholic patients with probable Wernicke–Korsakoff's syndrome related cognitive disorders are visited by our physicians and psychologists, usually when they are inpatients of general or psychiatric hospitals in the Rotterdam region (∼1.2 million inhabitants). In daily practice, we see very disappointing results with respect to the quantity of patients that have been appropriately treated with parenteral thiamine after admission to general or psychiatric hospitals. In fact, up to 90% of the confused alcoholics that have been visited by members of our team did not receive parenteral thiamine or received parenteral thiamine just once. This while current Dutch recommendations state that confused inpatients at risk of developing WE should receive 250 mg i.m. or i.v. for at least 3 to 5 days; up to 500 mg i.v. for patients that have presumed WE (Van den Brink and Jansen, 2009). Implementations of the guidelines have been documented (Laurent and van der Schrieck - de Loos, 2009). Therefore, we suggest that besides the clarity of the guidelines for treatment of WE also successful propagation for treatment guidelines is necessary to prevent the detrimental effects of unsuccessfully treated WE, namely Korsakoff's syndrome.