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Pharmacy-based intervention in Wernicke's encephalopathy

  • Ed Day (a1), Rhiannon Callaghan (a2), Tarun Kuruvilla (a3), Sanju George (a1), Kerry Webb (a1) and Peter Bentham (a1)...
Abstract
Aims and method

Clinical audit methodology was used to compare the treatment of alcohol misusers at risk of Wernicke's encephalopathy in an acute medical setting, and to assess the impact of providing information about best practice to prescribing doctors. All patients prescribed thiamine during an admission to an acute hospital trust over a 6-month period were identified, and data about their treatment episode were collected retrospectively. Hospital pharmacists then provided all prescribers with a flowchart summarising current prescribing guidelines, and prescribing patterns were re-audited 6 months later.

Results

Over two audit periods, half of the patients prescribed thiamine whose case notes we examined had symptoms suggestive of Wernicke's encephalopathy, and another 30% were at high risk. Prescribing adhered to hospital guidelines only in 14% of cases, with the pharmacy-led intervention associated with a small but significant increase in the number of patients receiving adequate treatment for Wernicke's encephalopathy.

Clinical implications

Wernicke's encephalopathy is relatively common in alcohol-dependent individuals admitted to hospital, and it is easily and cheaply managed. However, even when potential cases are identified, prescribing guidelines are followed in a minority of cases, even with prompting by a hospital pharmacist. This may be related to the limited research base concerning the optimum dosing schedule of thiamine, or fears about possible anaphylaxis when using parenteral preparations.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Ed Day (e.j.day@bham.ac.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Victor, M, Adams, RD, Collins, GH. The Wernicke-Korsakoff Syndrome and Related Neurological Disorders Due to Alcoholism and Malnutrition. Davis Company, F. A., 1989.
2 Thomson, AD, Cook, CCH, Guerrini, I, Sheedy, D, Harper, C, Marshall, EJ. Wernicke's encephalopathy: ‘plus ca change, plus c'est la meme chose’. Alcohol Alcohol 2008; 43: 180–6.
3 Harper, CG, Giles, M, Finlay-Jones, R. Clinical signs in the Wernicke-Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry 1986; 49: 341–5.
4 Torvik, A. Wernicke's encephalopathy – prevalence and clinical spectrum. Alcohol Alcohol 1991; 26 (suppl 1): 381–4.
5 Harper, C, Fornes, P, Duyckaerts, C, Lecomte, D, Hauw, J-J. An international perspective on the prevalence of the Wernicke-Korsakoff syndrome. Metab Brain Dis 1995; 10: 1724.
6 Cook, CCH, Hallwood, PM, Thomson, AD. B vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol Alcohol 1998; 33: 317–36.
7 Thomson, AD, Marshall, J. The treatment of patients at risk of developing Wernicke's encephalopathy in the community. Alcohol Alcohol 2006; 41: 159–67.
8 Cook, CCH. Prevention and treatment of Wernicke-Korsakoff syndrome. Alcohol Alcohol 2000; 35 (suppl 1): 1920.
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13 Royal College of Physicians. Alcohol – Can the NHS Afford It? Royal College of Physicians, 2001.
14 Day, E, Bentham, P, Callaghan, R, Kuruvilla, T, George, S. Thiamine for Wernicke-Korsakoff syndrome in people at risk from alcohol misuse. Cochrane Database Syst Rev 2004; issue 1: CD004033.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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Pharmacy-based intervention in Wernicke's encephalopathy

  • Ed Day (a1), Rhiannon Callaghan (a2), Tarun Kuruvilla (a3), Sanju George (a1), Kerry Webb (a1) and Peter Bentham (a1)...
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eLetters

Don't forget the patient

Ruth V Reed, Specialty Registrar in Psychiatry
26 June 2010

Day et al.’s study of thiamine prescribing was interesting and valuable. The results given in the abstract report only the small positivechange in the post-intervention group, rather than reflecting the mixed picture of positive and negative change in the appropriateness of prescribing which are outlined more fully in the body of the paper. It is concerning and disappointing that such a clear and ostensibly easy-to-use flowchart did not produce the degree of change in practice that one might reasonably have hoped, and still left the significant majority of patientsapparently receiving suboptimal treatment.

The authors highlight the role of clinician-dependent factors, such as incomplete history taking on admission, lack of knowledge and disproportionate concern with rare adverse reactions. I would argue that the relative failure of an information-giving intervention to produce realimprovements in clinical practice should encourage us to look more deeply at the patient-related factors which may act as barriers to the delivery of ‘optimal’ treatment.

From my own clinical experience, I would suggest that factors such aspatient concordance, cooperativeness and capacity are major determinants of the feasibility of delivering what, on paper, would be best practice. Patients with chronic alcohol misuse not uncommonly have comorbid psychiatric conditions or personality styles which affect their compliancewith the relatively unpleasant treatments of cannulation and intramuscularinjection. Acute confusion, noted in around one third of this sample, would often impair the capacity to consent to treatment. The risks, to staff and the patient alike, of attempting to administer thiamine parenterally to an uncooperative individual are considerable, and must be evaluated in any best-interests decision-making process. Such patient-related factors may explain the preference amongst treating professionals to take the route of oral medication despite the provision of advice to the contrary, particularly in less clearly-defined cases.

I look forward to seeing further exploration of factors impacting upon the delivery of treatment in future studies.
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Conflict of interest: None Declared

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Choice is not always good

Michael G�, consultant psychiatrist
21 June 2010

In Forth Valley we were similarly dismayed about the high rates of missed Wernicke’s encephalopathy and subsequent Korsakoff’s dementia in patients admitted to our hospitals who (also) abuse alcohol. The approachwe have chosen differs slightly from the one described by Day et al. It is based on the following principles:

1.The group of patients at risk of developing Wernicke’s encephalopathy should receive parenteral vitamin B preparations (as per NICE guideline).2.Incidents of anaphylaxis with parenteral Vitamin B preparations are vanishingly low in comparison to most medications prescribed on a daily basis in hospitals.3.There is no evidence that a patient who occasionally receives parenteral Vitamin B preparations without needing them comes to any harm.4.If busy clinicians are faced with a complicated decision making tree they resign (mentally) and make no decision.

As a result of this, we targeted the emergency department to increasethe detection rate of heavy drinkers. We then developed a local, very colourful, standard Chlordiazepoxide fixed dosing regime, which includes the prescription of parenteral Thiamine as per NICE guideline. Most importantly the entire prescription chart requires one signature, only, from one doctor.

The essence of this approach is quite obviously the deprivation of choice for clinicians and patients. As a result of this we are likely to over-prescribe parenteral Vitamin B. It would be very surprising indeed if our approach would not help to reduce the rate of Korsakoff’s dementia.
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Conflict of interest: None Declared

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