eMedicine Specialties > Emergency Medicine > Psychosocial
Anorexia Nervosa: Treatment & Medication
Updated: Aug 21, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Prehospital care of a patient with anorexia nervosa includes stabilization for any life-threatening conditions (eg, shock, cardiac arrhythmias) and basics such as airway, breathing, and circulatory support as needed.
Emergency Department Care
Emergency care of anorexia nervosa should include a basic medical evaluation as well as urgent or timely outpatient psychiatric evaluation.
- Basic tests include physical and mental status evaluation, CBC, chemistry, calcium, magnesium, phosphorus, urinalysis, HCG in women, and electrocardiogram.
- Metabolic abnormalities should be corrected as needed, with oral or parenteral treatment depending on the patient's mental status and decision to cooperate.
- Life-threatening or potentially lethal abnormalities require admission. Indications for hospitalization include the following:
- Bradycardia or other cardiac dysrhythmias
- Severe electrolyte abnormalities, especially of potassium, sodium, and phosphorus levels
- Altered mental status or suicidality
- Extremely low body weight
- Failure of outpatient treatment
Consultations
Most cases of anorexia nervosa encountered in the emergency department will be appropriate for outpatient management if close, planned follow-up is arranged prior to discharge.
- Consultation with the pediatrician or primary care physician is necessary to arrange follow-up. Urgency of follow-up depends on the patient's condition and how soon they will need their laboratory studies reevaluated.
- Psychiatric consultation in the emergency department should be considered for patients expressing suicidality, psychosis, or severely disordered thinking.
- Outpatient psychiatric follow-up is necessary and may be arranged either from the ED or by the primary care provider.
Medication
Medical therapy in the emergency department consists of electrolyte repletion and stabilization.
Multiple studies have failed to show an overall benefit for pharmacologic treatment of anorexia nervosa with psychiatric medications. However, most patients who recover will be treated with a multidisciplinary approach including medication, psychotherapy, nutritional counseling, and frequent medical evaluations. The most common class studied is SSRIs, which have been shown to be beneficial in patients with bulimia nervosa but not anorexia. However, since many patients with anorexia have concurrent mood disorders, medication may be of benefit.
Electrolyte repletion
Necessary in patients with profound malnutrition, dehydration, and purging behaviors.
May be repleted orally or parenterally, depending on the clinical state of the patient.
Potassium chloride
Essential for transmission of nerve impulses, contraction of cardiac muscle, maintenance of intracellular tonicity, skeletal and smooth muscles, and maintenance of normal renal function. Gradual potassium depletion occurs via renal excretion or GI loss or because of low intake. Depletion usually results from diuretic therapy, primary or secondary hyperaldosteronism, diabetic ketoacidosis, severe diarrhea (if associated with vomiting), or inadequate replacement during prolonged parenteral nutrition. Potassium depletion sufficient to cause 1 mEq/L drop in the serum potassium level requires a loss of approximately 100-200 mEq of potassium from the total body store.
Adult
Serum levels >2.5 mEq/L: 10 mEq IV over 1 h, then prn based on frequently obtained lab values; not to exceed 200 mEq/d
Serum levels <2.5 mEq/L: 40 mEq IV over 1 h, then prn based on frequently obtained lab values; not to exceed 400 mEq/d
Must dilute IV prior to administration
Pediatric
Emergent situation:
IV: 0.5-1 mEq/kg over 1-2 h initially; maximum dose not to exceed 40 mEq/dose
May repeat prn based on frequently obtained lab values; must dilute IV prior to administration; administer in ED or ICU with ECG monitoring
PO: 2-5 mEq/kg/d based on primary disease; sometimes requires up to 10 mEq/kg/d
Concurrent use with ACE inhibitors may result in elevated serum potassium concentrations; potassium-sparing diuretics and potassium-containing salt substitutes can produce severe hyperkalemia; inpatients taking digoxin, hypokalemia may result in digoxin toxicity; caution if discontinuing potassium administration in patients maintained on digoxin
Hyperkalemia, renal failure, and conditions in which potassium retention is present and those with oliguria or azotemia, crush injuries, severe hemolytic reactions, anuria, and adrenocortical insufficiency
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Do not infuse rapidly; high plasma concentrations of potassium may cause death due to cardiac depression, arrhythmias, or arrest; plasma levels do not necessarily reflect tissue levels; monitor potassium replacement therapy whenever possible by continuous or serial ECG; when a concentration > 40 mEq/L is infused, local pain and phlebitis may also follow
Calcium gluconate
Moderates nerve and muscle performance and facilitates normal cardiac function. Can be given IV initially, and calcium levels maintained with high calcium diet. Some patients require oral calcium supplementation. The 10% IV solution provides 100 mg/mL of calcium gluconate that equals 9 mg/mL (0.46 mEq/mL) of elemental calcium. One 10 mL ampule contains 93 mg of elemental calcium
Adult
100-300 mg elemental calcium IV diluted in 150 mL D5W over 10 min; initial rate of infusion should be 0.3-2 mg of elemental calcium/kg/h
Pediatric
2 mg/kg of elemental calcium IV (about 20 mg/kg of calcium gluconate 10%)
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; antagonizes effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in digitalized patients, respiratory failure, acidosis, or severe hyperphosphatemia
Potassium phosphate
For severe hypophosphatemia (<1 mg/dL), parenteral preparations of phosphate should be used for repletion. IV preparations are available as sodium or potassium phosphate (K2PO4). Response to IV serum phosphorus supplementation is highly variable and is associated with hyperphosphatemia, and hypocalcemia. The rate of infusion and choice of initial dosage should be based on severity of hypophosphatemia and presence of symptoms.
Serum phosphate and calcium should be monitored closely. For less severe hypophosphatemia (1-2 mg/dL), PO phosphate salt preparations can be used. PO preparations are available as sodium or potassium phosphate in capsule or liquid form. Neutra-Phos packets contain 250 mg of phosphorus/packet. Tablets contain either 250, 125.6, or 114 mg each. Liquid preparations available as 250 mg/75 mL.
Adult
8 mmol of K2PO4 q6h IV or 0.1 mmol/kg of K2PO4 or Na2PO4 q6h IV (32 mmol/24h) initially
Aggressive IV replacement: 15 mmol of K2PO4 over 6 h or 0.2-0.3 mmol/kg of K2PO4 or Na2PO4 over 6 h
For oral replacement, 250 mg as capsule, liquid, or packet tid/qid is generally adequate; for most patients, once phosphate stores are repleted, PO supplements are no longer required, as the diet has ample phosphate
Pediatric
0.25-0.5 mmol/kg IV over 4-6 h and repeat if symptomatic hypophosphatemia persists
Magnesium and aluminum-containing antacids or sucralfate can act as phosphate binders and decrease serum phosphate levels; potassium-sparing diuretics, ACE inhibitors, and salt substitutes may increase serum phosphate levels
Documented hypersensitivity; hyperphosphatemia, hypocalcemia, hypomagnesemia, hyperkalemia, or renal failure
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with renal insufficiency and metabolic alkalosis; admixture of phosphate and calcium in IV fluids can result in calcium phosphate precipitation
More on Anorexia Nervosa |
| Overview: Anorexia Nervosa |
| Differential Diagnoses & Workup: Anorexia Nervosa |
 Treatment & Medication: Anorexia Nervosa |
| Follow-up: Anorexia Nervosa |
| References |
| « Previous Page | Next Page » |
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington DC: American Psychiatric Association; 1994:539-545.
Wilfley DE, Bishop ME, Wilson GT, et al. Classification of eating disorders: toward DSM-V. Int J Eat Disord. Nov 2007;40 Suppl:S123-9. [Medline].
Becker AE, Grinspoon SK, Klibanski A, et al. Eating disorders. N Engl J Med. Apr 8 1999;340(14):1092-8. [Medline].
Bochereau D, Clervoy P, Corcos M, et al. [Eating disorders. Anorexia nervosa in adolescents]. Presse Med. Jan 16 1999;28(2):89-99. [Medline].
Bowers WA, Ansher LS. The effectiveness of cognitive behavioral therapy on changing eating disorder symptoms and psychopathology of 32 anorexia nervosa patients at hospital discharge and one year follow-up. Ann Clin Psychiatry. Apr-Jun 2008;20(2):79-86. [Medline].
Coxson HO, Chan IH, Mayo JR, et al. Early emphysema in patients with anorexia nervosa. Am J Respir Crit Care Med. Oct 1 2004;170(7):748-52. [Medline].
Forman S. Eating Disorders: epidemiology, pathogenesis, and clinical features. Up to Date [online]. 2005.
Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord. Dec 2003;34(4):383-96. [Medline].
Kaplan H, Sadock B. Synopsis of Psychiatry. 8th ed. Williams and Wilkins; 1998:720-727.
Kaye W. Neurobiology of anorexia and bulimia nervosa. Physiol Behav. Apr 22 2008;94(1):121-35. [Medline].
Lavelle JM. Adolescent emergencies. In: Fleischer GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins; 1993:1503-1526.
Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa. Arch Intern Med. Mar 14 2005;165(5):561-6. [Medline].
Nilsson EW, Gillberg C, Rastam M. Familial factors in anorexia nervosa: a community-based study. Compr Psychiatry. Nov-Dec 1998;39(6):392-9. [Medline].
Reinblatt SP, Redgrave GW, Guarda AS. Medication management of pediatric eating disorders. Int Rev Psychiatry. Apr 2008;20(2):183-8. [Medline].
Rosenblum J, Forman S. Evidence-based treatment of eating disorders. Curr Opin Pediatr. Aug 2002;14(4):379-83. [Medline].
Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. Aug 2002;159(8):1284-93. [Medline].
Stoving RK, Hangaard J, Hansen-Nord M, et al. A review of endocrine changes in anorexia nervosa. J Psychiatr Res. Mar-Apr 1999;33(2):139-52. [Medline].
Sylvester CJ, Forman SF. Clinical practice guidelines for treating restrictive eating disorder patients during medical hospitalization. Curr Opin Pediatr. Aug 2008;20(4):390-7. [Medline].
Vazquez M, Olivares JL, Fleta J, et al. Cardiac disorders in young women with anorexia nervosa. Rev Esp Cardiol. Jul 2003;56(7):669-73. [Medline].
Zimmerman M, Francione-Witt C, Chelminski I, Young D, Tortolani C. Problems applying the DSM-IV eating disorders diagnostic criteria in a general psychiatric outpatient practice. J Clin Psychiatry. Mar 2008;69(3):381-4. [Medline].
Further Reading
Keywords
anorexia, anorexia nervosa, eating disorder, self-starvation, binging, purging, malnutrition, severe weight loss, extreme weight loss, life-threatening weight loss, amenorrhea, intense fear of obesity, primary amenorrhea, secondary amenorrhea, denial of hunger, depression, obsessive-compulsive behavior, binge behavior, purge behavior, anxiety disorder, hypoglycemia, vitamin deficiencies, delayed puberty, anovulation, supraventricular dysrhythmias, ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, shock, congestive heart failure, hypokalemia, hypochloremic alkalosis, hyperaldosteronism, gastric dilation, gastric rupture, dental enamel erosion, palatal trauma, esophagitis, Mallory Weiss lesions, diminished gag reflex, substance abuse
