The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the editor

Editor, – I refer to the article 'The management of the heavy drinker in primary care' (Aust Prescr 2002;25:70-3). This article is excellent in its succinct coverage of alcohol problems in general practice. However, I do feel that there is an under emphasis on the risk of acute thiamine deficiency even in the general practice population.

In our unit we have recently admitted two male patients with signs of Wernicke's encephalopathy. These patients were both in their mid-forties and had no previous history of detoxification for alcohol dependence. Both patients had been transferred from other hospitals where they had been treated for alcohol withdrawal. The first patient had been a postoperative inpatient for five days before his transfer and had been treated for an acute confusional state with symptomatic medications. He improved within an hour of his first intramuscular injection of thiamine.

The second patient presented to a local hospital after having been hit by a car while intoxicated. Once he was medically stable he was transferred to our Drug and Alcohol Unit and was found to have a combination of confusion, ataxia, nystagmus as well as other cerebellar signs. He was so unwell he was transferred back to the local hospital but he recalls 'waking up' in the ambulance after a single 100 mg injection of thiamine.

The point is that this is an extremely serious but easily treatable condition. I would suggest that in Box 2 of Professor Whelan's article the use of thiamine be reiterated and if there is any doubt whatsoever about oral absorption or nutritional status that intramuscular thiamine be given daily for at least three days.

Kevin McNamara
Drug and Alcohol Unit
Palm Beach/Currumbin Hospital
Gold Coast, Qld

Author's comments

Professor Greg Whelan, the author of the article, comments:

Dr McNamara rightly brings to our attention the importance of thiamine given prophylactically in the management of alcohol withdrawal.

The patients described by him are also seen in our hospital's Accident and Emergency service. All patients admitted with a history of heavy alcohol consumption, whether in alcohol withdrawal or not, are given an intravenous 'cocktail' of glucose and multivitamins, including thiamine.

The article in Australian Prescriber is aimed at producing guidance for general practitioners who manage patients in primary care, not in hospital. As noted, these patients are given thiamine 100 mg. Our practice is to give this orally unless we are concerned about absorption.