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31st January 2024
Management
Established Wernicke’s encephalopathy
Pabrinex (B vitamins including thiamine with ascorbic acid) given intravenously (IV) is required to treat Wernicke’s encephalopathy – oral thiamine is only suitable for long-term maintenance in those who are alcohol-dependent. The BNF current dosing guidelines recommends two to three pairs of Pabrinex three times a day for up to five days as treatment for established Wernicke’s encephalopathy.
Prophylaxis of Wernicke’s encephalopathy
Prophylaxis dose is 1 pair once a day intramuscularly (IM) for 5-7 days. Dose reduction can be used after this period, but oral preparations of thiamine are not suitable as an acute treatment. Literature suggests Korsakoff’s syndrome should also be treated with the same dosing of IV Pabrinex; however, the effects of this condition are often more chronic, and for some, long-term care provision is often needed, alongside standard oral thiamine maintenance. Physiotherapy and support with alcohol abstinence are also often required.
Medications to support abstinence
Those who successfully manage to abstain from alcohol may be offered additional medication to help them remain sober long-term. NICE guidance currently advises use of either acamprosate (1st line), naltrexone (alternative 1st line, not if concomitant opioid use) or, if needed, disulfiram. These treatments are summarised in the table below:
| Medication | Indication | Cautions/contraindications |
|---|---|---|
| Acamprosate | 1st line for reducing alcohol cravings. It can be taken for up to 6 months or longer if helpful to aid abstinence. Can cause abdominal pain, nausea, and diarrhoea. It should be discontinued if alcohol consumption continues for up to 6 weeks after starting the medication. | Cannot be given to those with severe hepatic or renal impairment or those breastfeeding. Advised to avoid in pregnancy unless necessary. |
| Naltrexone | Also 1st line – it is an opioid-receptor antagonist, so stops opioid-based analgesia from working effectively and reduces alcohol cravings. | Cannot be given to those who are currently opioid dependents, advised to avoid during breastfeeding and in severe hepatic impairment. Reduced dosing may be needed in renal impairment. Advised to avoid in pregnancy unless necessary. |
| Disulfiram | 2nd line – blocks the metabolism of alcohol after consumption. Usually started 1 day or more after the last alcoholic drink. It reacts with alcohol and causes nausea, flushing and dizziness, which is designed to discourage further alcohol intake. | Cannot be used in those with active cardiovascular disease, prior stroke, hypertension, or psychosis. Should be avoided in the first trimester as acetaldehyde (the metabolite of alcohol breakdown) may be a teratogen. |
Source: Adapted from: NICE. Disulfiram [Internet]. NICE. 2022 [cited 2022Dec3]. Available from: https://bnf.nice.org.uk/drugs/disulfiram/#indications-and-dose, NICE. Alcohol problem drinking: Acamprosate [Internet]. NICE. 2022 [cited 2022Dec3]. Available from: https://cks.nice.org.uk/topics/alcohol-problem-drinking/prescribing-information/acamprosate/ and NICE. Naltrexone hydrochloride [Internet]. NICE. 2022 [cited 2022Dec3]. Available from: https://bnf.nice.org.uk/drugs/naltrexone-hydrochloride/#drug-action
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