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