Hi All
I'm in a bit of a quandry, as I am trying to write a protocol for alcohol detox and not sure what way to go on the subject of giving i.m. Pabrinex (injectable Thiamine - one of the B vitamins) in the community. On the one hand, historically the BNF has always cautioned against doing it, quoting a risk of anaphylaxis, (potentially life-threatening allergic response) On the other hand, we have the Maudsley Prescribing Guidelines which say the risk is very small at 1 in 5 million, far lower than many other drugs which are given in the community with no such cautions attached, and they say with the risk of Wernicke's so high and the efficacy of oral thiamine so questionable that it should be 'considered'.
All the people I've asked on this so far have been in secondary care, and they may have more access to specialist resources whih allow them to give the Pabrinex in clinical settings, but they have tended towards the cautious approach. I feel it's time I asked primary care practitioners what they do - has anybody given Pabrinex in the community? If you only do it sometimes, how do you decide when/on whom? Have you written prescribing/administration protocols? Have you encountered anaphylaxis with Pabrinex?
Thanks for your replies

Susi,

something at the back of my mind tells me an ANSA member uses Pabrinex in community. Might be an idea to send a mail to Malcolm.

Hi Susi

I worked for the Maudsley in a primary care based team for 7 years. We never used pabrinex in communiy alcohol detoxes -always suggested GPs prescribed thiamine and vitamin b compound strong. Seemed to be effective.
A local GP (for her MSC Addiction research) took bloods from 'street drinkers' prior to detox and, if I remember rightly, found that none of her patients had remarkably low thiamine levels.
It is also an idea to prescribe thiamine/vit b prophylactically to 'heavy drinkers'.

I prescribe thiamine and vit B strong, and our local inpt detox unit give oral thiamine too.

So do i .. though I think I am a bit vague about doses. I have taken this oportunity to look them up, (because Emis has started flashing at me that vitamin B co strongcontains thiamine too, but I see it is only 5mg per tab.)

I have tended to prescribe Vitamin B co strong x1 daily and Thiamine 100mg x2 daily, but from the BNF it looks as though that is rather stingy on the vitamin B co.

Like Jane I prescribe it prophylactically for chronic drinkers if i can presuade them to take them now and then, but I have never prescribed the IM version in primary care. i suppose we could if the cost/benefit was proved, as we do have "facilities for treatment of anaphlaxis" to cover baby clinic and travel imms etc.

If as you say "they say with the risk of Wernicke's so high and the efficacy of oral thiamine so questionable that it should be 'considered'".

Please let us know what you decide.

I agree with the comments about vit B co. strong along with thiamine being the mainstay of primary care management of chronic alcohol use.I have never prescribed this preparation and would suggest that any primary care physician would be on very sticky ground prescribing it for use in the community. In secondary care the situation is very different. I would suggest that to include injectable thiamine as any intervention in primary care would be a mistake.

On closer examination of the question-you seem to be asking whether injectable thiamine should be part of your protocol for community alcohol detox. The answer is no it should not. Full stop. It is not licensed for community detox and there are clear warnings of the dangers.

that's an interesting question - i have understood that oral preparations are usually poorly absorbed in heavy drinkers, but IM Pabrinex in community carries a small but significant risk ( unless administered somewhere with staff & means to treat anaphylaxis). However am I right in thinking that Wernickes encephalopathy ( although very alarming ) is reversible with Pabrinex, and patients are usually treated with this in A & E or on admission to Secondary care ? And how common is it ? Also interesting to see that thiamine levels were not greatly reduced in one study. Just wondering what the recent UK Review of effectiveness of Treatments for Alcohol Dependence say ? I will get on to the NTA site & find out .....

P. 134 of the review ( found on nta website under publications - alcohol ) states that around 80% of Wernickes are subclinical, ( doesn't say how common it is overall though ) and it is essential to treat possible cases in order to prevent irreversible brain damage ( ie Korsakoff's syndrome ). On a more general note ( not detox ) lower risk, otherwise healthy drinkers can have oral preparations, but those who are drinking more heavily and are malnourished should be given IM / IV Pabrinex 250mg for 3 - 5 days. Tretament for strongly suspected Wernickes is 500mg Pabrinex IM / IV for 3 - 5 days.
Their conclusions are : 1. High dose parenteral thiamine is an effective treatment for Wernicke's encephalopathy ( evidence level I ) 2. Consideration should be given, as a harm reduction measure, to prescribing vitamin supps at any stage of change where nutritional deficiencies are likely ( evidence level IV )... what do you make of that ?

Good question!!! And thanks for thinking of review of evidence which I'm embarassed to say had slipped my mind. i hope you didn't have to read the other 133 pages before you got to this one!

I make of it... a controversial area lacking in supporting evidence for either policy really, and crying out for a bit of research. And as it happens a local consultant would be willing and is keen to supervise some research into exactly this, as convinced we should be giving more im for exactly reasones Gill has stated. So if anyone out there is giving i.m. Pabrinex in the community already and would be interested in having a formal evaluuation of their pracrice please get in touch!

Will get back to yu on prevalence - I've read it somewhere...

no problem, I have coincidentally looked up a few things in this document recently, but ? read the other 133 pages - you know me better than that - i used the index....

Some research would be good, I agree. I've prescribed community detoxes for many malnourished drinkers with oral thiamine alone. I am interested to know how NICE know that 80% of Wernicke's is subclinical - what does this mean? It certainly is not common in clinical practice.
I think its worth saying that people need assessment before deciding on a community detox and if there is intercurrent illness, significant liver disease, history of previous stormy detoxes etc it should not be done.
I have also read (but cannot recall where) that splitting the dose of thiamine to 100mg tds improves absorption, so this is our usual practice.
Some answers about Vit B co Strong would be useful too - as Judith says it contains v little thiamine and I wonder how beneficial it is during the course of a detox when thiamine is being given? I use it more for harm reduction in those contunuing to drink, at a dose of 2 tds.

http://alcalc.oxfordjournals.org/cgi/reprint/37/6/513
This article may help to answer some of these questions.
The 80% figure as I understand it is from autopsy finidng on brains of known drinkers but some of the changes they classified as Wernicke's I am told are not pathognomonic as such. Sorry i don't know the ref for this offhand will let you know if I lay hands on it.

Hi Susi,
I came across this discussion today, having had the same concerns a few months ago re chronic alcholics with poor nutrition. I also did a literature search, same results as you, and came to the conclusion that oral supplementation is a waste of time in the malnourished street drinkers we tend to pick up at our outreach clinics. We discussed this as a practice ( 4 GPwSIs ) and are following the protocol used by our local A+E, if we see patients with clinical features of Wernicke's or at very high risk. We are treating with 3 doses usually a week apart, though A+E give these much more quickly. So far 3 patients treated by me and I think 2 by one of my partners, have had no ill effects. The remarkable thing has been the effects on appetite and cognition, both of which patients have been volunteering has been dramatic.
Having contacted the local alcohol liaison nurses, when drawing up the protocol, I was e-mailed by a rep. for pabrinex, who was keen to meet up but subsequently failed to contact me, so currently only in-house audit going on.
Some of the replies on the discussion forum made me hesitate, but I still feel the benefits far outweigh the risks for this group of patients.

Hi Helen
thanks so much for this post. Just a couple of queries - are you giving iv? and what is the settiing? ie would you be able to treat anaphylaxis if it occurred?
many thanks again and welcome to the forum
Susi

i'll reply on helen's behalf since we're at the same (windmill)practice; you give it IM- it is a whopping 5+2ml- 2 vials mixed together & up your bum; remarkably few complaints of sore arse-i guess most i've given it too have been rather pissed at the time- dubious consent u may say but if we waited for them to be sober...anyway helen & i were discussing only this am & feel benefits far outweigh any risks (anaphylaxis 1 in a v large number eg 500 000 & unlikely in any of our lifetimes- but even if it happned- hey could with anything we dish out here- we have the shock boxes...); it seems we may well be kidding ourselkves that oral vit b partic for malnourished drinkers is doing any good at all. what other experience or lit searchers out there?

Hi Stephen many thanks for this its really good to get a feel for what its like doing it. helen mentioned you'd done about 5 of these as a practice so far - what sort of time period does that come under? ie would you have enough patients to do research? (no idea how many you need by the way but with the knowledge of the number of opatients and the length of time I can at least ask the question!
If anyone else is also giving im pabrinex in community please get in touch, it would be great to use the forum to build a picture of actual clinical practice

Hi Susi,
5 patients in last couple of months. Unlike Stephen I have found a few do object to the sore bottom a 5ml IM injection causes, so some have only attended for first one and refused subsequent dose - actually often those still drinking. Patients really committed to stopping seem to stick the 3 weekly injections.
The IV preparation is the old parvolex and I haven't given since house jobs - this was the one with the quoted high rate of anaphyllaxis. The rate for the IM pabrinex is quoted by the manufacturers as 1 in 1 million.
Research not my thing but willing to collaborate if it means a meaningful number of patients to draw conclusions re feasibility and risk/ benefit - as I said before so far so good
If anyone wants a copy of our protocol e-mail me at
helen.sperry@gp-c84683.nhs.uk

Helen

Brings back memories of the old 7ml parentrovite injections we used to give in inpatient detox; very strong smell!

This is so helpful many thanks to all. The latest news on my detox protocol is that the local district nursing service have agreed in rinciple, so long as workload does not become to onerous. so I'll put it in - but now find myslef with another challenge - do i advocate Pabrinex for all, or only for the ones most at risdk? And is anybody using good crieteria for risk that works for them?

the other bit of news is that apparently therea re some really good protocols on the SCAN website but i don't have access - they are going to request the writer to let me see them - if so iwill check with him how far they can go.

helen, thanks for your offer to participate I will email the releavant person and copy you in.

thanks again to all - keep 'em coming!!