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Letters |

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

Mark A. Marinella, MD
JAMA. 1998;279(8):583-584. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-8-jbk0225.
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In Reply.—I agree with Drs Hack and Hoffman that patients with suspected Wernicke encephalopathy should receive parenteral rather than oral thiamine. They correctly note that patients who consume significant quantities of alcohol often do not adequately absorb oral thiamine from their intestinal tract.1 Since the classic clinical triad of ophthalmoplegia, confusion, and ataxia is uncommon (less than 10% of patients), Wernicke encephalopathy should be considered in any patient presenting with a confusional state, and parenteral thiamine should be administered.2 Patients with marginal thiamine reserves may develop overt Wernicke encephalopathy if administered a glucose load; hence, I agree with the traditional recommendation that, if possible, thiamine should be given prior to a glucose load.2,3 I agree with Hack and Hoffman that glucose should not be withheld from a patient while awaiting thiamine. However, if a fingerstick glucose test reveals no hypoglycemia, thiamine should be administered before glucose, if possible. In addition, patients with suspected thiamine deficiency should also receive concurrent magnesium as this acts as a cofactor for transketolase activity.2


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