Ravipal Singh, PharmD, BCCCP
Emergency Medicine Pharmacist
John Muir Health – Walnut Creek Medical Center
Walnut Creek, CA
There is a movement away from prescribing a banana bag when treating patients with acute alcohol intoxication or at risk for alcohol withdrawal. This has been covered in detail in multiple FOAM posts and literature . This post will not discuss Wernicke’s encephalopathy, malnourished patients, prevention vs. treatment thiamine doses nor dosing frequency. We are going to zero in on how to get the liquid from the thiamine vial into the patient’s IV line.
It’s important to highlight a possible exception with respect to IV thiamine administration rate. A 2003 controlled study compared the effects of varied infusion rates in 12 healthy individuals when 150 mg of thiamine was given IV over either 1 hour or 24 hours. As expected, although the rapid infusion produced a higher peak concentration, the slower infusion increased the AUC of thiamine pyrophosphate (thiamine’s active metabolite) slightly by 10% (P < 0.08) and decreased the urinary elimination from 83.6% of the dose to 57.6%, suggesting a benefit for slower administration rates when treating severe thiamine deficiency syndromes. Therefore, longer infusion times are a consideration when treating Wernicke’s encephalopathy since bolusing increased renal elimination of the drug .
Storing a thiamine 200 mg/2 mL vial in the automated dispensing cabinet to be given IV push is easier from an operations standpoint. It decreases total aggregate workload for both pharmacy and nursing and potentially decreases waste. Making a piggyback to bedside administration is labor-intensive. This involves compounding in the IV room, delivering to the RN who has to get tubing, smart pump, program the pump, and tend to any pump alarms during the infusion. There’s also the possibility of getting a missing medication or damaged bag message, which restarts the whole process.
The purpose of this post is to explore if thiamine IV push (IVP) is safe. The heart of the issue is while thiamine has a good safety profile, concerns exist because of anaphylaxis reports.
Let’s explore some data.
Thiamine Anaphylaxis Case Reports:
- Before the 1970s, especially in 1940s, there were multiple reports of serious reactions to thiamine and then curiously, at least in the USA, no further cases were reported for 20 years, until the 1992 Tufts-New England Medical Center case report [3,4,5].
- 1992 Tufts-New England Medical Center ED (Boston): 32 yo male with alcohol intoxication, slipped on ice resulting in shoulder injury, otherwise in good health. Given thiamine 100 mg IV push. Within 2 minutes, complains of nausea, at 5 minutes intensely erythematous, hypotensive, bilateral inspiratory and expiratory wheezes, no upper airway stridor, no urticaria. Got epinephrine subcutaneous and adjuncts. Recovered and discharged next day .
- 1995 Belgium: 86 yo female, found at home, lying on the floor, history of alcohol abuse. Admitted to geriatric ward for possible alcohol withdrawal. Thiamine 250 mg intramuscular administered. 2 hours after injection, throat tightness, shortness of breath, hypotensive, barely palpable femoral pulses. Subcutaneous epi given, 10 minutes later, epi 0.5 mg IV given, subsequent ECG did not show MI. After 30 minutes, became unconscious, intubated, transferred to ICU, given fluid, started on dopamine drip, vital signs deteriorated over 2 hours, patient died in asystole. CPR not performed .
- 2000 Lincoln Medical Center (New York): 51 yo woman h/o diabetes, chronic alcoholism, anxiety found by EMS in acute confusional state. EMS gave 25 g D50W and thiamine 100 mg IV (assuming IV push). On arrival to hospital 20 minutes later, in respiratory arrest and was intubated. Next morning, patient was extubated. 2.5 hours later, a routine thiamine infusion started. Within moments, patient complained of shortness of breath, warmth, and tightness of throat, BP 83/40, oxygen sat dropped to 70%, then reintubated. Extubated next day and discharged 2 days later with advice to avoid thiamine .
- 2013 Denmark: 44 yo alcohol-intoxicated male with NKA c/o diffusely located chest and abdominal pain. ECG at admission showed sinus rhythm with no signs of ischemia. Thiamine 300 mg IV given (unknown if pushed or infused). Had received thiamine on several previous occasions without complications. No other drugs were given. Shortly after, patient found unresponsive with abnormal rattling respiration. CPR started, patient in PEA. ROSC at 15 minutes. Transfered to ICU, discharged in good health after 14 days. A serum tryptase obtained after 1 and 24 hours from thiamine administration, confirmed the diagnosis of anaphylaxis .
Data Supporting IVP Thiamine:
Let’s go back 30 years! In 1989, a study out of Grady Memorial Hospital ED was published in Annals of Emergency Medicine .
- Prospective evaluation of the safety of thiamine given as a 100 mg IV push, usually over 10 seconds or less, to patients at risk for thiamine deficiency or who needed fluids for other reasons
- Over 6 month period, 989 consecutive patients, 1,070 doses administered IVP
- 795 men (80%); 194 women (20%); ages ranged 16 – 80 years
- 80% of cases, alcoholism was at least partially the reason for thiamine administration
- 49 patients on cardiac monitors at the time of the study, no arrhythmias noted
- 12 adverse reactions (1.1%) reported
- minor reactions consisting of transient (lasted seconds to minutes) local irritation seen in 11 patients (1.02%)
- 1 major reaction (0.093%) consisting of generalized pruritis
- The authors commented that “After a review of the literature, it seems that any prejudice against IV thiamine dose in favor of other parenteral routes is unwarranted because anaphylactoid reactions seem to occur with equal frequency in IV, IM, or subcutaneous injections.”
- Thiamine 100 mg IVP may be administered without undue concern. Intradermal test doses before administration are not warranted.
A few years later these same authors wrote a rebuttal to the 1992 case report that the Tufts-New England case should not be a plea for excessive caution in administering thiamine to patients at risk for Wernicke’s encephalopathy . They wrote:
- We estimate that during our 15 years in Atlanta, parenteral thiamine was administered at least 10,000 times per year.
- During 1980s, almost all thiamine was given IVP.
- Similar data came from 2 other large inner city EDs. Both Bellevue Hospital in New York City and Denver General Hospital have given at least 10,000 IV thiamine injections per year over the past 10 years without incident (personal communications they had with Drs. Lewis Goldfrank and John Marx, 1991).
- The chance of an allergic reaction is below what is reported for penicillin and contrast media.
Common Practices from Around the Country
I reached out to several authors and practitioners regarding IV thiamine administration at their hospitals, and the responses are summarized below.
University of Kentucky Medical Center
- Doses ≤ 200 mg are given as IV push.
- Nursing administration guide is to push 200 mg over 2 minutes – no further dilutions required.
- How long has your institution been doing this? Probably 6-8 months now. When the thiamine shortage really started to impact us, we decreased our empiric dosing in ICUs from 500 mg IV q8h (IV infusion) to 200 mg IV q8h IV push.
- Any ADRs seen? None that I’m aware of (not formally evaluated in MUE or anything though)
Brigham and Women’s Hospital (Boston)
- Pushing up to and including 250 mg of thiamine about 9 years.
- In process of publishing their work.
- Research snapshot published in Jan 2019 Critical Care Medicine .
Objective: Evaluate the incidence of anaphylaxis and IV site reactions associated with IV push thiamine in adult inpatients.
Methods: single-center, retrospective chart review of all adult patients who received 100 mg, 200 mg, 250 mg, and 500 mg IV push thiamine between June 1, 2015 – July 31, 2017.
- 8530 administrations in 2591 patients
- 5494 peripheral administrations; 1641 centrally; remainder – unknown
|Thiamine IV push DOSE||# of doses|
- No anaphylactic or anaphylactoid reactions were observed.
- 24 (0.28%) infusion site reactions noted in 19 patients.
- Phlebitis noted 11 times (grade one:2; grade two: 3; ungraded: 6)
- Infiltration noted 13 times (grade two: 1; grade three: 3; ungraded: 9)
- Further assessment of the reactions with Naranjo Nomogram classified:
- 18 reactions – possible likelihood caused by IVP thiamine
- 6 reactions – probable likelihood caused by IVP thiamine
- IV push thiamine not associated with any anaphylactic events
- Low incidence of IV site reactions
- IV push thiamine in doses ranging from 100 mg to 250 mg may be considered safe for administration
- A signal that thiamine 500 mg IV push dose may be safely administered
University of North Carolina Medical Center
- Yes, we push all doses of 100 and 200mg IV thiamine. We have always pushed 100mg doses for as long as I have been at UNC, which is 30 years. We started pushing 200mg doses in April of 2013. It’s pushed and not diluted. I am not aware of any issues since the MUE was completed. This is our normal practice and we do it daily.
- In process of publishing work.
- abstract PDF available on the internet – Google Search “University of North Carolina and thiamine”–> Evaluation of the safety of intravenous thiamine administration in a large academic medical center .
Due to high utilization of thiamine IVP for 200 mg doses within the institution, they sought to evaluate the safety of this practice compared to administration by infusion.
- Single-center, retrospective cohort study performed from June 2017 to October 2017
- Included patients at least 18 years old and received one dose of IV thiamine 200 mg or greater
- 2 groups: 200 mg IVP (n = 100) or 200 mg or greater as an IV infusion (n = 100)
- On average, included patients were 55 years old and male
- Most common reasons for admission: altered mental status (12%); alcohol withdrawal (9.5%); cirrhosis (3.5%)
- Patients received average of 2000 mg of thiamine and 7 total doses
- 50% received 200 mg IVP only
- 30% received IV infusion only
- 20% received both IV infusion and IVP
- Adverse reactions possibly due to thiamine administration occurred in 4 patients (2%)
- 1 received 200 mg thiamine via IV infusion
- 3 received 200 mg via IV push
- no significant difference (p=0.640) in rate of adverse reactions between IVP and IV infusion administrations
- reactions noted included shortness of breath and/or wheezing and abdominal pain
- Anaphylaxis, hypersensitivity, syncope, and cardiac arrest were not observed in the patient population studied
- No patients developed shock which could be attributed to thiamine administration
- Data supports administering thiamine doses 200 mg or less as an IV push
- Given lack of robust safety data, authors recommended to continue to dilute thiamine doses greater than 200 mg and infuse over 30 minutes
Abbott Northwestern Hospital (Minneapolis, Minnesota)
- Doses ≤ 200 mg are given as IV push
- How long has your hospital been doing this? At least as long as I have been here, which is 14 years
- Any specific administration or dilution comments: Give as slow IV push over 2-5 minutes
- Have not seen any ADRs, and we have not conducted any specific MUE
- This process is for all Allina sites. Abbott Northwestern is the largest of the Allina Hospitals.
Grady Health System (Atlanta)
- Been giving thiamine IV push for > 15 years.
- Doses ≤ 100 mg can be given IV push.
SHARP Grossmont Hospital (San Diego)
- Most of our patients are getting either thiamine IV push, or a thiamine-folate IVPB, if unable to take PO.
- Our hospital has been using a ton of IV push thiamine over the past couple years now – only for 100 mg (anything more requires IVPB), with the following order comments: “Give slow IV push over 5 minutes. Anaphylactoid/hypersensitivity reaction associated with rapid administration”. Not heard of any instances of adverse reaction since we switched to IVP.
Mercy Health Saint Mary’s (Grand Rapids, Michigan)
- 100 mg given IV Push.
- Responder been at this hospital x 2 years and 100 mg IV push has been there since
- Order comments: IV push to administer up to 20 mg/min. No dilution required.
- Not aware of any ADRs
University of Chicago Medical Center
- Up to 100 mg as IV push.
- Unsure how long this has been in practice, no anecdotal ADR, no MUE performed.
- Default administration instructions: Administer via IV push over 1-2 minutes
The data involving a large number of both IVP doses and patients without adverse reactions to thiamine IVP gathered from decades-old literature, new literature, and recent responses from practitioners around the USA strongly suggests that thiamine 100 mg IVP is reasonably safe, and 200 mg IVP may be considered safe, too.
Even though publications are in the works, conducting more studies or sharing an MUE abstract is encouraged because people tend to like recent data. Moreover, maybe your hospital has already been doing IVP thiamine for years without issue and it’s not even on your radar, but I’m sure there is another hospital on the cusp to make a decision to change from IVPB to IVP that would benefit from your experience. Never underestimate the power of sharing knowledge, you can literally help change and improve practice.
Reviewed and edited by: Craig Cocchio, Pharm.D, BCPS
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- Jean S, Tjugum S, Hedrick T, et al. Evaluation of the safety of intravenous thiamine administration in a large academic medical center. Accessed 18 July 2019, https://pharmacy.unc.edu/files/2018/05/Stephanie-Jean-REPS-abstract.pdf