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Letters |

Thiamine Before Glucose to Prevent Wernicke Encephalopathy: Examining the Conventional Wisdom

Jason B. Hack, MD; Robert S. Hoffman
JAMA. 1998;279(8):583-584. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-8-jbk0225.
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To the Editor.—In his letter, Dr Marinella1 claims, "Thiamine should be administered prior to a glucose load because cases of Wernicke encephalopathy have been reported after glucose administration in thiamine-deficient patients." The reference that supports this statement describes only 4 patients.2 The first was a 27-year-old woman with weight loss for more than 6 months, gastrointestinal symptoms for 3 days, and the onset of dizziness and blurring of her vision. She had tachycardia, confusion, ataxia, absent deep tendon reflexes, and horizontal nystagmus. After treatment with 3 L of 5% dextrose for more than 24 hours, her symptoms worsened. The second patient was a 79-year-old woman with schizophrenia, anorexia, weight loss, horizontal nystagmus, absent deep tendon reflexes, and a temperature of 33°C; the diagnosis was septicemia. After 2 L of dextrose, she developed bilateral sixth nerve palsies, disorientation, and coma. The third patient was a 45-year-old woman with end-stage renal failure who began peritoneal dialysis and lost 6.3 kg in 6 months. Her peritoneal dialysis fluid was switched to hypertonic glucose 48 hours prior to the development of disorientation, nystagmus, and a sixth nerve palsy. The fourth patient, a 36-year-old alcoholic man, developed renal failure secondary to rhabdomyolysis and required hemodialysis. Five days after the initiation of a 20% dextrose infusion he developed nystagmus, bilateral sixth nerve palsies, areflexia, hypotension, and disorientation. All patients improved with thiamine administration.


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