2. About Me
Dietetic Intern
Coordinated Program in Dietetics
Purdue University
Pre and post presentation questionnaires
Disclosure: no relevant financial or nonfinancial
relationships to disclose.
4. Goal
To educate clinical nutrition staff of the benefits of
initiation of thiamin supplementation for heart failure
patients as a routine part of the initial nutrition
assessment
Currently there are no hospital guidelines for thiamine
supplementation initiation
5. Objectives
Understand the benefits of thiamine supplementation in
the hospital setting
Determine when a patient may be at a higher risk for
thiamine deficiency based off medical history and food
recall
Recognize mediations that can have an adverse effect
on thiamine levels
Understand dosing for thiamine deficiency
7. Introduction
Thiamine (thiamin), Vitamin B1
Water soluble
Energy, metabolism, growth & cell development
Coenzyme & non-coenzyme functions
Synthesis of pentose
Used in the Krebs cycle for NADH production
Membrane and nerve conduction
Synthesized in large intestine, unknown amount
8. Dietary Intake
Meats - Pork
Whole grains, enriched & fortified - cereals, brown rice
Harmful: heating, pH>8, anti-thiamine factors
Two forms: free form & phosphorylated form (TPP or TDP)
Image: http://www.namrata.co/wp-content/uploads/2012/08/T1.bmp
9. Absorption & Storage
Most effective upper jejunum
Phosphorylated form
Hydrolyzed before absorption
Dietary sources: active transport
Pharmacological doses: passive diffusion
Low intake absorption increases
No noticeable storage
40% is stored in muscle
Half-life is 9.5 to 18.5 days, regular supply
Adult: 25-30mg, 80% is TPP form
10. Recommended Dietary Allowance
for Thiamine
Age Male Female Pregnant or lactating
Birth – 6 months 0.2mg 0.2mg
7-12 months 0.3mg 0.3mg
1-3 years 0.5mg 0.5mg
4-8 years 0.6mg 0.6mg
9-13 years 0.9mg 0.9mg
14-18 years 1.2mg 1.0mg 1.4mg
19-50 years 1.2mg 1.1mg 1.4mg
51+ years 1.2mg 1.1mg
11. Usual Intake
Deficiency is rare due to many fortified and enriched foods
U.S. population with intake below EAR – 6%
Average dietary intake:
Men – 1.95mg/d Women – 1.39mg/d
Average dietary & supplements intake:
Men – 4.89mg/d Women – 4.9mg/d
12. Toxicity
No upper levels established
Lack of toxicity
Rapid decline in absorption – intake >5mg
Water soluble
Intravenous thiamine supplement
Headaches, convulsions, cardiac arrhythmias, anaphylactic shock
Administration should be dispersed over 30 minutes
13. Supplements
Multivitamin – 1.5mg of thiamine – 100% of DV
Forms: Thiamine mononitrate & Thiamine hydrochloride
Stable & water soluble
World Health Organization (WHO) recommendations for adults
50-100mg/day 10mg/day 3-5mg/day Total time
Mild
deficiency
Oral, 1 week Oral, 6 weeks 7 weeks
Severe
deficiency
Intravenous,
1 week
Intravenous,
1 week
Oral, 6 weeks 8 weeks
14. Measurement
Offered with IU Health
Whole blood measurement
Direct measurement of
erythrocyte TPP
More sensitive than ETKA
Whole blood testing
90% of thiamine content of
whole blood is TPP form
Cost & time
Not offered with IU Health
Plasma blood measurement
<10% of thiamine is in plasma
Low specificity & sensitivity
Urinary Thiamine
excretion, not tissue storage
Erythrocyte transketolase
activity (ETKA) measurement
actual level of thiamine in tissue
15. “Serious and potentially irreversible
neurologic damage can occur with
untreated TD, practitioners should
treat the patient without laboratory
confirmation of deficiency and
monitor and evaluate resolution of
signs and symptoms.”
-Frank L, Thamin in Clinical Practice, JPEN (2015)
18. Early Symptoms
No specific threshold for serum thiamine that will indicate TD
Weight loss
Anorexia
Confusion
Short term memory loss
Muscle weakness
Enlarged heart
19. Symptoms of Wet Beriberi
Heart failure with high cardiac output
Edema in the lower extremities
Tachycardia or bradycardia
Lactic acidosis
Dyspnea
Heart hypertrophy and dilatation
Respiratory distress
Systemic venous hypertension
Bounding arterial pulsations
20. Shoshin Beriberi
Severe form of wet beriberi
Sudden onset of heart failure
Cardiovascular collapse
Metabolic acidosis
Severe hemodynamic instability
Can lead to death
21. Symptoms of Dry Beriberi
Brisk tendon reflexes
Peripheral neuropathy
Muscle weakness
Pain of upper and lower extremities
Gait ataxia
Convulsions
23. Wernicke’s Encephalopathy
Later stage of thiamine deficiency
Polyneuropathy
Ataxia
Ocular changes
Confusion
Short-term memory loss
Korsakoff psychosis
24. Populations At Risk For Deficiency
Alcohol dependence
Most common cause of thiamine deficiency
Ethanol reduces gastrointestinal absorption, liver stores, & phosphorylation
Inadequate intake of essential nutrients
Older adults
Possible reasons: low intake, chronic diseases, medications, low absorption
Risk of deficiency particularly high for elderly who reside in an institution
Diabetes
Thiamine plasma levels 76% lower in type 1 diabetics
Thiamine plasma levels 50-75% lower in type 2 diabetics
25. Populations At Risk For Deficiency
HIV/AIDS
Possible malnutrition due to catabolic state associated with AIDS
Thiamine deficiency under diagnosed
Post bariatric surgery
Risk for severe thiamine deficiency due to malabsorption
Genetic Beriberi
Rare, but occurs when body looses ability to absorb thiamine
Breastfed infants
If mother is lacking thiamine, infant will as well if milk is only source of nutrition
27. Medications
No known medical interactions
Certain medications can alter levels
Diuretics
Furosemide – Lasix
Most frequently prescribed diuretic
More than heart failure & lack of research
Chemotherapy
Fluorouracil – Adrucil
Used to stop or slow cancer cell growth
28. Furosemide
Mixed reviews as to if furosemide at various doses is significant
32 heart failure patients receiving 40mg/d or >80mg/d of furosemide.
>80mg/d resulted in 98% of patients with severe TD (24/25)
40mg/d resulted in 57% of patients with severe TD (4/7)
Thiamine deficiency occurs in a substantial proportion of CHF failure patients being
treated with furosemide
Furosemide may be inhibit TPP levels at the cellular level by inhibiting uptake
or blocking phosphorylation
29. Spironolactone & Furosemide
Spironolactone
Potassium sparing diuretic
Spironolactone & furosemide combined
Patients with heart failure who received both had
significantly higher thiamine levels compared to furosemide
alone
30. Prevalence of Thiamine Deficiency in
Hospitalized Patients with Congestive
Heart Failure
100 congestive heart failure patients (CHF) & 50 control subjects
CHF patents were on furosemide
Thiamine supplements, other supplements
Erythrocyte TPP measurements
Findings:
TD occurred 33% in CHF patients versus 12% in control
Multivitamin was found to have a significant association with better
thiamine status in CHF patients
Did not find a significant relationship between TD and furosemide
dose, urine volume, or urine thiamine excretion
Hanninen S, Darling P, Sole M, Barr A, Keith M. The Prevalence of Thiamin Deficiency in Hospitalized Patients
With Congestive Heart Failure. J Am Coll Cardiol. 2006; 47(2): 354-361.
31. Prevalence of Thiamine Deficiency
in Hospitalized Patients with Congestive
Heart Failure
TD was related to urine thiamine loss, non-use of thiamine
containing supplements, and preserved renal function
Increased urine thiamine excretion was the only significant
positive predictor of thiamine status
Decreased renal function was significantly associated with
better thiamine status in CHF patients
Decreased renal function prevents excessive thiamine loss,
preventing TD
Hanninen S, Darling P, Sole M, Barr A, Keith M. The Prevalence of Thiamin Deficiency in Hospitalized Patients
With Congestive Heart Failure. J Am Coll Cardiol. 2006; 47(2): 354-361.
32. Left Ventricle Ejection Fraction &
Thiamine
9 patients, diuretics – unknown what type
Congestive heart failure & left ventricle ejection fraction <40%
Thiamine (300mg) or placebo
28 days, 6 week washout period, cross over to second 28 day period
Left ventricle ejection fraction baseline for both groups was 29.5%
Result: Thiamine treatment resulted in an increase in LVEF of 3.9%
Thiamine supplementation has positive effects on cardiac function for
patients taking diuretic drugs for symptomatic CHF
Schoenenberger A, Schoenenberger-Berzins R, Maur C Suter P, Vergopoulos A, Erne P.
Thiamine supplementation in symptomatic chronic heart failure: a randomized, double-blind,
placebo-controlled, cross-over pilot Study. Clin Res Cardiol. 2012; 101:159–164.
34. Our Contributation
Be an advocate for early thiamine supplementation
Work towards early initiation of thiamine supplementation when patient is
placed on diuretics or at risk for deficiency
IU Methodist options:
Oral nutrition supplements
Enteral nutrition
Parenteral nutrition
Multivitamins
Thiamine supplements
35. Brief Review
RDA
Men: 1.2mg Women: 1.1mg Lactating or pregnant: 1.4mg
World Health Organization (WHO) recommendations for adults
50-100mg/day 10mg/day 3-5mg/day Total time
Mild
deficiency
Oral, 1 week Oral, 6 weeks 7 weeks
Severe
deficiency
Intravenous*,
1 week
Intravenous*,
1 week
Oral, 6 weeks 8 weeks
*Intravenous injection should be dispersed over 30+ minutes
36. Oral Nutrition Supplements
Product Mg/serving Servings per day to meet RDA
Ensure Clear 0.3 4
Ensure Complete 0.38 3.15
Glucerna 0.38 3.15
Nepro with Carbsteady 0.58 3
Consider: cumulative nutrition dose
37. Nutrition Support
Enteral Nutrition
Parenteral Nutrition
6mg thiamine per 10mL per day
Mg/L Product
1.7 Vivonex RTF
2.1 Vital High Protein
2.3 Jevity 1.2 &1.5. Osmolite 1.2, Promote
2.4 Nepro with Carbsteady
2.5 Vital AF 1.2
2.6 TwoCal
3 Impact Peptide 1.5, Osmolite 1.5, Vital 1.5
38. Multivitamins & Thiamine Supplements
Multivitamins – contain thiamine hydrochloride
Thiamine Supplements
Injection – 100mg/2mL
Oral tablets – 50mg & 100mg
Adult multivit w/ minerals 3mg per tablet
Pediatric multivitamin w/ minerals (Flintstones) 3mg per 2 tablets
Prenatal Vitamin 1.8mg per tablet
HD multivit, Adult or ocular multivit, Flintstones 1.5ng per tablet
CF & Bariatric multivitamin 1.5mg per 2 tablets
Liquid adult multivitamin 1.5mg per 15mL
Pediatric multivitamins – with or without iron 0.5mg per 1mL
39. Objectives Review
Understand the benefits of thiamine supplementation in
the hospital setting
Determine when a patient may be at a higher risk for
thiamine deficiency based off medical history and food
recall
Recognize mediations that can have an adverse effect
on thiamine levels
Understand dosing for thiamine deficiency
40. References
Thiamine. Medline Plus. https://www.nlm.nih.gov/medlineplus/druginfo/natural/965.html.
Updated March 17, 2015. Accessed April 20, 2016.
Beriberi. Medline Plus. https://www.nlm.nih.gov/medlineplus/ency/article/000339.htm. Updated
August 17, 2014. Accessed April 20, 2016.
Thiamin. National Institutes of Health. https://ods.od.nih.gov/factsheets/Thiamin-
HealthProfessional/. Updated February 11, 2016. Accessed April 20, 2016.
Hanninen S, Darling P, Sole M, Barr A, Keith M. The Prevalence of Thiamin Deficiency in
Hospitalized Patients With Congestive Heart Failure. J Am Coll Cardiol. 2006; 47(2): 354-361.
Schoenenberger A, Schoenenberger-Berzins R, Maur C Suter P, Vergopoulos A, Erne P.
Thiamine supplementation in symptomatic chronic heart failure: a randomized, double-blind,
placebo-controlled, cross-over pilot Study. Clin Res Cardiol. 2012; 101:159–164.
Frank L. Thiamin in Clinical Practice. JPEN. 2015; 39(5): 503-520.
Sica D. Loop Diuretic Therapy, Thiamine Balance, and Heart Failure. Congest Heart Fail. 2007;
13(4): 244-247.
Katta N, Balla S, Alpert M. Does Long-Term Furosemide Therapy Cause Thiamine Deficiency in
Patients with Heart Failure? A Focused Review. AM J MED. 2016.
Rieck J, Halkin H, Almog S, et al. Urinary loss of thiamine is increased by low doses of
furosemide in healthy volunteers. J Lab Clin Med. 1999; 134: 238-243
Heating foods can decrease thiamin content and since it is water soluble, a significant amount of the vitamin can be lost when the cooking water is discarded.
Anti-thiamine factors: raw fish – thiaminases. Polyhydrophenols - tannic & caffeic acids found in coffee, tea, betel nuts, blueberries, black currents, Brussels spouts, & red cabbage
Plant sources contain free thiamine
Animal sources >95% is phosphorylated form
Lesser amount: duodenum & ileum
Mild – all oral doses
Severe – intravenous weeks 1 and 2, oral weeks 3-9
The plasma or serum thiamine level does not accurately represent body thiamine status because it contains only a fraction of the total body thiamine.
Indirect measurement
Measure erythrocyte
transketolase activity (ETKA)
Uses TPP
Influenced by other factors
Healthy individual: 0-15%
Marginal deficiency: 15-25%
Deficiency: >25%
Measuring ETKA – actual level of thiamine tissue levels. FYI- We do not have this lab available to check in Cerner.
Urinary thiamine
Measure of thiamine excretion but not tissue storage
Adequate intake: >100mcg/d
Insufficient intake: <100mcg/d
Extremely low intake:<40mcg/d
Urine thiamine levels provide information about thiamine intake, but not about the tissue stores
Plasma measurement
<10% of blood thiamine is in the plasma
Suffers from low specificity & sensitivity
Affected by disease states
Sepsis, CABG, trauma
Renal replacement therapy
Decreases
Hepatic injury
Increases
Supplemental thiamine can cure beriberi, but depending on the severity of the damage, it may be past the point of no return
Tachycardia – Rapid heart beat
Bradycardia – slow heart beat
Example of Supplemental thiamine can cure beriberi, but depending on the severity of the damage, it may be past the point of no return
Can cause heart failure, but it will reach a point that the damage has been done.
Ataxia - the loss of full control of bodily movements.
Without treatment, 20% of people with wernickes die
The rest develop korsakoff’s psychosis
See sticky note
Autopsies of 380 people with AIDS (not HIV), 10% had wernicke’s encephalopathy.
blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output of urine
Due to the lack of research on thiamine deficiency associated with bumetanide and torsemide, little is known about their relationship.
Most frequently prescribed diuretic
Furosdemine intake must be marginal
Loop: blocking the absorption of sodium, chloride, and water from the filtered fluid in the kidney tubules, causing a profound increase in the output of urine
Potassium sparing diuretic - interfering with the sodium-potassium exchange in the distal convoluted tubule in the kidneys
Excluded those who were being treated with thiamine supplements (200mg/d) for alcohol abuse
Control group were subjects that were age(+/- 5 years) and of the same gender and were excluded if they were taking any thiamine supplements or had disease that may affect thiamine status.
Some patients were also on spironlactone and metalazone
Suggesting that increased urine thiamin excretion independently predicts better thiamin status
Since studies in healthy adults suggest that urine thiamin excretion is positively correlated with dietary thiamin intake and blood thiamin concentrations, our urinary thiamin excretion may simply reflect the amount of thiamin consumed in the diet and supplements
No vitamin supplements, renal failure, or fertile women
