Today will be our review quiz for the eating disorders theme. Take a few minutes and check your learning.
1) Which of the following are not recommended admission criteria for patients with anorexia nervosa?
a) Heart rate < 50
b) Blood pressure < 80/60
c) Cardiac arrhythmia
d) BMI < 15 or weight <70% of ideal body weight
2) For which eating disorder is fluoxetine considered the first-line medication option?
a) Anorexia nervosa
b) Bulimia nervosa
c) Avoidant/restrictive food intake disorder (ARFID)
d) Rumination disorder
3) A patient repeatedly regurgitates their food, sometimes spitting it out, and sometimes re-swallowing it. This has been going on for three months. What is the most likely diagnosis?
a) Anorexia nervosa, purging type
c) Avoidant/restrictive food intake disorder (ARFID)
d) Rumination disorder
From day #145
Heart rate < 50
General approach: The primary initial goal in the treatment of anorexia nervosa is to improve their nutritional status. This involves a supervised weight gain schedule with close monitoring. Many patients may be treated as an outpatient with an interdisciplinary approach (psychiatrist, primary care, dietician, therapist). Mental health treatment should be focused on psychotherapy as opposed to medication management. Other treatment options include intensive outpatient, partial hospitalization programs, residential programs, and medical or psychiatric hospitalization depending on severity.
Hospitalization: There are no clear-cut evidence-based criteria for hospitalization, however the following are suggested based upon clinical practice guidelines: BMI <14 or 70% ideal body weight; unstable vital signs (HR < 40, BP < 80/60, orthostatic hypotension); cardiac dysrhythmia; marked dehydration; or serious medical complications of malnutrition (e.g., electrolyte imbalance, hypoglycemia, syncope, cardiovascular/hepatic/renal compromise requiring medical stabilization, refeeding syndrome). Other considerations include rapid weight loss, severe binging and purging, safety concerns, or failure to respond to outpatient treatment.
Refeeding syndrome: If severely malnourished patients are refed too quickly it may lead to dangerous electrolyte and fluid shifts. Typically occurs within the first five days of refeeding. Look for fluid retention (edema) and ↓ levels of phosphorus, magnesium, and calcium. Complications include arrhythmias, hypotension, respiratory failure, rhabdomyolysis, delirium, seizures, and sudden death. Replace electrolytes and slow the feedings.
From day #147
Pharmacotherapy for bulimia nervosa: Fluoxetine is the only FDA approved medication for the treatment of bulimia nervosa (in adults) and should be considered as the first-line medication option. The effective dose is typically higher than average depression treatment (60-80 mg/day). Other SSRIs (e.g. sertraline, citalopram, escitalopram) have also demonstrated efficacy for reducing the frequency of binge eating and purging. Early response (at ~3 weeks) is a strong predictor of overall response. TCAs may be considered as second-line antidepressant treatment. Antidepressants may be considered for treatment of BN in adolescents, but they have little evidence and are not licensed for this practice. Other medications to consider that have reasonable evidence includes topiramate (↓ frequency of binge eating) and lisdexamfetamine (↓ frequency of binge eating; approved in binge-eating disorder). There is ongoing research on opioid antagonists given the relationships between feeding and the endogenous opioid system. Other medications that have been used with some benefit include SNRIs, lamotrigine, zonisamide, acamprosate, and sodium oxybate. Avoid bupropion due to its potential side effect to lower the seizure threshold.
Pharmacotherapy for anorexia nervosa: There are no FDA approved medications for the treatment of anorexia nervosa, and there are few controlled trials to guide treatment. There is very limited evidence for the use of any pharmacological interventions other than those to correct metabolic deficiencies and the treatment of co-morbid conditions. It has been suggested that neurochemical changes in starvation may partially explain medication non-response. Antidepressants, including SSRIs, have not been effective in improvement of weight gain or eating disorder pathology although one small trial found that fluoxetine may reduce the risk of relapse after weight restoration. Mirtazapine has been used to assist with weight gain, depressive symptoms, and reduction of obsessional thinking with some success, however data is limited to case studies. Bupropion is contraindicated due to seizure risk. Antidepressants are commonly used to treat comorbid conditions (depression, anxiety, OCD, etc.), however these conditions may improve/resolve with weight restoration alone. Among antipsychotic medications, olanzapine is the best supported. Olanzapine is the only medication suggested to have a positive effect on weight restoration and may also reduce agitation and other comorbid symptoms. Only prolactin-sparing antipsychotics should be considered (↑ prolactin can further increase the risk of bone loss and osteoporosis). Many other medications have been or are currently being studied with varying levels of quality and success (dronabinol, cyproheptadine, naltrexone, zinc, etc.). Medications should be used with caution due to increased risk of QTc prolongation, arrhythmia, electrolyte disturbances, and seizures. ECG monitoring should be undertaken if the prescription of any medicine that may compromise cardiac functioning is essential.
Avoidant/Restrictive Food Intake Disorder (ARFID): Weight restoration based on BMI growth charts. Psychological treatments are emerging for this disorder to include CBT for ARFID (CBT-AR) and Family-Based Therapy (FBT). Treatment focuses on nutritional rehabilitation in stages ("volume before variety"). Patients who are underweight are encouraged to eat larger volumes of preferred food in the early stages of treatment, before increasing dietary variety in later stages. The key intervention is structured and systematic exposure to the patient's most relevant concerns such as sensory sensitivity, fear of aversive consequences, or lack of interest in food and eating. Case reports and small case series have described the use of mirtazapine or lorazepam to decrease anxiety related to eating; and olanzapine to reduce cognitive rigidity in beliefs about food and to promote weight gain. Future RCTs are needed to evaluate the efficacy of these medications for the resolution of ARFID symptoms.
Rumination Disorder: Diaphragmatic breathing is the first-line treatment for rumination syndrome. It works by initiating a competing mechanism to the acquired, unperceived contractions of the abdominothoracic muscles. Diaphragmatic breathing should be initiated after completion of a meal or with signs of incoming regurgitations. Referral to a behavioral therapist for additional behavioral strategies and CBT for rumination disorder (CBT-RD) can be used as adjuncts. Generally, pharmacotherapy for rumination syndrome should be reserved for patients who fail initial management with behavioral therapy. A small crossover study demonstrated improved outcomes with baclofen (counteracts transient lower esophageal sphincter (LES) relaxations by increasing the basal LES pressure, thereby limiting regurgitation episodes). Buspirone may play a role due to its positive gastric fundus relaxation properties, however there are no specific studies in this population. Expert review considered a trial of buspirone for rumination syndrome in refractory cases as reasonable.
From day #149
Repeated regurgitation of food for ≥ 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
Not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).
Does not occur exclusively during the course of other eating disorders.
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