Pediatric Anorexia Nervosa Medication

  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Jan 18, 2012
 

Medication Summary

The use of medication in individuals with anorexia nervosa is limited to the treatment of medical complications. To treat osteopenia and to prevent further bone loss, daily dietary intake of calcium 1000-1500 mg and vitamin D 400 IU are recommended. Estrogen replacement (ie, oral contraceptives) has also been recommended for the treatment of osteopenia, although the benefits and minimal effective dose have not been established. Bisphosphonate therapy can be effective, but the patient should be closely monitored for osteonecrosis of the mandible.[57]

Generally, evidence of efficacy of medication treatment of eating disorders is weak or moderate, especially as side effects tend to limit long-term compliance compared with psychotherapies. Recent randomized controlled trials show statistically helpful effect sizes for medication treatment combined with cognitive behavior therapy. Generally, fluoxetine was helpful in patients with AN who had been stabilized with weight restoration. Psychotherapy with adjunctive low-dose olanzapine may be useful for AN during inpatient treatment, especially in the context of anxiety, obsessive eating-related ruminations, and treatment resistance due to failure to engage. Higher dose fluoxetine and/or topiramate may be helpful in BN. At this time, medication for weight loss in BN is not recommended due to significant adverse effects such as pulmonary hypertension or heart failure.[82, 83]

Pharmacotherapy should not be the only line of treatment and should be used with caution in suspected bipolar disorder but may be helpful for depression.[84]

DHEA

In anorexia nervosa, bone density is compromised, which can lead to an increase in fractures and early osteoporosis. The intake of calcium and other macronutrients that normally strengthen bone decreases because of poor nutrition. A study by Gordon et al using dehydroepiandrosterone (DHEA) 50 mg, 100 mg, and 200 mg reported decreased bone resorption, an increase in bone formation markers, and a possible association with resumption of menses (53%).[85] The study showed that the antiosteolytic and anabolic effects of DHEA were due to the androgenic effects on bone mass rather than the estrogenic effects, as was previously thought. Potential adverse effects include mild acne, insulin resistance, hirsutism, and decreases in cholesterol, high-density lipoprotein (HDL), and sex hormone binding globulin (SHBG) levels.

Limitations of the study by Gordon et al included the small size, a question of compliance, the self-reporting of activity levels and nutritional intake, and no clear response relationship between the DHEA doses of 50 mg, 100 mg, or 200 mg.[85]

Antidepressive agents

Antidepressive and neuroleptic agents, although not reported to be effective, have a limited use in patients who have adequate nutrition and mood changes associated with anorexia nervosa. Prolongation of the QT interval is a contraindication to tricyclic antidepressants because a prolonged QT may increase the risk of ventricular tachycardia and death.

SSRIs and SNRIs

In patients with anorexia nervosa who have attained 85% of their expected weight, fluoxetine has been used to stabilize recovery. Zinc and cyproheptadine have not been useful. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) may be more helpful for addressing concurrent obsessive-compulsive issues and, owing to the relative neutral effect on weight, may be more easily accepted by the patient. Some preliminary studies have examined the use of atypical antipsychotic medications to promote weight gain, but there are significant safety concerns due to the high likelihood of cardiac conduction abnormalities in this population.[84]

SSRIs are greatly preferred over the other classes of antidepressants.[86] Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered in the treatment of a child or adolescent with a mood disorder.

Precautions in the pediatric population

Use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality (both ideation and attempts) in pediatric patients being treated with antidepressant medications for major depressive disorder and other various conditions. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

In 2005, the FDA proposed that manufacturers change antidepressant labeling by adding a black-box warning regarding the increased suicidality risk in children and adolescents who use antidepressants. The labeling change also emphasized the need for appropriate monitoring and patient awareness via medication guides. 2 years later, the FDA also recommended updates on the black-box labeling of antidepressants regarding increased risk of suicidality in young adults aged 18-24 during initial treatment (generally the first 1-2 months).

A 2006 study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.[87] Nonetheless, caution in patients younger than 18 years and close supervision of the response to antidepressant medications in all populations is advised.[87] This is the largest study to date to address this issue.

The current evidence does not support an increased risk of suicide in patients with obsessive-compulsive disorder (OCD) or other anxiety disorders who are treated with SSRIs.

Precautions with gastrointestinal prokinetic agents

Part of the pathophysiology of anorexia nervosa is a delay in gastric emptying, which can perpetuate the disorder by limiting the quantity of food that can be eaten. Although a study of cisapride (Propulsid) did not show gastric-emptying enhancement, participants did report a greater improvement in subjective symptoms during a meal.[88] In 2000, however, cisapride use in patients with anorexia nervosa or bulimia was discouraged after cisapride was found to be associated with serious cardiac events (ie, serious arrhythmias associated with prolonged QTc) and the risk of cardiovascular-related events in patients with eating disorders.

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Electrolyte Supplements

Class Summary

These agents are used for the prevention and treatment of calcium deficiency that could result in osteopenia.

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Calcium carbonate

 

Calcium moderates nerve and muscle-performance by regulating action potential excitation threshold. It also improves bone density.

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Vitamins

Class Summary

Vitamins are used to meet necessary dietary requirements and are used in metabolic pathways, as well as DNA and protein synthesis.

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Ergocalciferol (Calciferol, Drisdol)

 

This is a vitamin D-2 analog that is converted in the liver to an active intermediate and then further converted to its most active form in the kidneys. It stimulates the absorption of calcium and phosphate from the small intestine and promotes the release of calcium from bone into blood. Because it is a precursor, a significant delay between dose administration and effect exists. The liver must be intact for the intermediate to be formed (calcidiol, 25-hydroxy vitamin D). Many drugs may affect this step. It has lipid storage, so overdoses may cause prolonged hypercalcemia.

To measure of its efficacy, assess the serum calcium concentration.

It is used as replacement therapy.

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Antidepressants

Class Summary

These agents have been reported to reduce binge eating, vomiting, and depression, and to improve eating habits although their impact on body dissatisfaction remains unclear.

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Fluoxetine (Prozac)

 

Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect in the reuptake of norepinephrine or dopamine. It may cause more gastrointestinal adverse effects than other SSRIs now currently available, which is the reason it is not recommended as a first choice.

It may be given as a liquid and a capsule. Fluoxetine can be given a single dose or in divided doses. The presence of food does not appreciably alter the levels of the medication. It may take up to 4-6 weeks to achieve steady-state levels of the medication because it has a long half-life (72 h). The long half-life is both an advantage and a drawback. If it works well, an occasional missed dose is not a problem; if problems occur, eliminating all active metabolites takes a long time.

The choice depends on adverse effects and drug interactions. Adverse effects of SSRIs seem to be quite idiosyncratic; thus, relatively few reasons exist to prefer one over another at this point if dosing is started at a conservative level and advanced as tolerated.

It is indicated for the treatment of binge-eating and self-induced vomiting in patients with moderate-to-severe bulimia nervosa. The antidepressant, anti–obsessive-compulsive, and antibulimic actions are presumed to be linked to inhibition of CNS neuronal uptake of serotonin.

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Contributor Information and Disclosures
Author

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Angelo P Giardino, MD, PhD, MPH  Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jennifer DA Liburd, MD, to the development and writing of the source article.

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