Which diagnoses are most often associated with EDOs
Schizophrenia
Anxiety disorders
Obsessive compulsive disorders
Substance use disorders
Anorexia nervosa has a predominantly female disorder with a mean age of onset of 15 years old
Patients with Anorexia Nervosa (AN) and a psychiatric comorbidity have higher lower( higher, lower ) mortality rates than those without
Comorbid disorders for Anorexia Nervosa include
MDD
Anxiety disorders (social phobia & GAD)
OCD
Personality disorders
With EDO, a detailed history to clarify timeline is critical because treating the core issue is essential for recovery. ADHD treatment, anxiety and depression may also cause weight loss. MDD may cause loss of appetite.
Anorexia nervosa has the highest death rate of any mental health illness
is your best medicine in aneroxia nervosa
What is the primary aim in the beginning stages of treatment of aneroxia nervosa?
Normalize and regulate eating patterns
Treat with medications to help with mood, andanxiety
Begin family-based interventions
Individualized therapy interventions
Prior to medication initiation for anorexia nervosa, a prescriber needs to have
weight and height
% IBW
Orthostatic vitals
EKG
24 hour diet diary
SSRIs are the gold standard treament for sever depression, anxiety/OCD after during initial treatment before( after, during initial treatment before ) weight restoration
Which SSRI should be avoided with anorexia nervosa due to QTc prolongation?
Fluoxetine
Citalopram
Fluvoxamine
Paroxetine
SSRIs are FDA indicated for anorexia nervosa
Fluoxetine Setraline Paroxetine Fluvoxamine( Fluoxetine, Setraline, Paroxetine, Fluvoxamine ) and Setraline citalopram Fluvoxamine Paroxetine( Setraline, citalopram, Fluvoxamine, Paroxetine ) have some evidence for relapse prevention in weight-stored anorexics receiving treatment
MOA for SSRI
Low affinity for D2 receptors/High affinity for serotonin receptors (5HT2A)
Selectively inhibits serotonin reuptake resulting in enhanced serotonergic transmission in the CNS
: Interacts with GABA receptors to enhance GABA effects
Which atypical antipsychotic has some evidence to help restore weight more quickly as adjunctive treatment to other interventions?
Risperidone
Apiprazole
Olanzapine
MOA for atypical antipsychotic used in anorexia nervosa is
Selectively inhibits serotonin reuptake resulting in enhanced serotonergic transmission in the CN
Blocks voltage-dependent sodium & calcium channels
Cigarettes decrease increase( decrease, increase ) serum concentration of olanzapine
Olanzapine will interact with anything causing CNS depression including opioids, barbiturates, benzodiazepines, general anesthetics, and anticonvulsants such as pregabalin
There is mixed evidence for the use of BZ to reduce meal anxiety. Typically only ___________ used off-label
Alprazolam
Clonazepam
Lorazepam
Diazepam
BZ should be avoided with opioids
MOA for benzodiazepines is
Interaction with GABA receptors to enhance GABA effects
The epdimiology of Bulimia Nervosa is greater in females than males and onset is later than AN, either late adolescence or early adulthood at 19.4 years as compared to 15 years.
Comormid illnesses for bulimia nervosa are similar to AN with
Mood disorders
Anxiety Disorders
Substance abuse
Personality disorders (Cluster B - dramatic, erratic)
Medication of choice for bulimia nervosa is
Anticonvulsants
SSRIs
Atypical antipsychotics
TCA's
Combined pharmacotherapy and psychotherapy appears to be more efficacious than either alone for bingeing and purging. This should be continued for a minimum of
6 months
12 months
18 months
2 years
Which is considered 1st line for bulimia nervosa due to its efficacy and FDA approval for adults
Sertraline
TCAs and anticonvulsants have been shown in studies to help reduce beingeing and purging, but SSRI Fluxetine is considered first line SSRI therapy
Mechanism of action for Fluoxetine used in bulimia nervosa is
inhibition of 5HT receptor, which leads to an increase in serotonin level
inhibiting the neuronal reuptake of the neurotransmitters norepinephrine and serotonin. It binds the sodium-dependent serotonin transporter and sodium-dependent norepinephrine transporter reducing the reuptake of norepinephrine and serotonin by neurons
Combination of antagonism at D2 receptors in the mesolimbic pathway and 5HT2A receptors in the frontal cortex.
enhances the effects of GABA by increasing GABA affinity for the GABA recepto
Fluoxetine is contraindicated in use with the following drugs
Selegeline
Pimozide
Lithium
When prescribing SSRI Fluoxetine, need to consider other medications that have risk for serotonin syndrome
Triptans
Other antidepressants
5-HTP
St. John's Wort
Which anticonvulsants are used off label to treat Bulimia Nervosa
Topiramate
Zonisamide
Valpromide
Primidone
What is the MOA for Topiramate which is used off label for bulimia nervosa
Inhibits CNS neuronal uptake of serotonin
Blocks voltage- dependent sodium & calcium channels
GABA activity and antagonizes glutamate receptors
Binge eating disorder (BED) is the most common ED and almost as common in men as women. Age of onset is 18 years
Select the other comorbid disorders of Binge Eating Disorder
Other ED's
Schizophrenic disorders
Mood disorders (MDD, BPD)
PTSD
Elevated risk of suicide
What medications are used for Binge Eating Disorders (BED)?
SSRI's
Mood stabilizers
Stimulants
Antipsychotics
Topiramate, a mood stabilizer, has some evidence to suggest it is effective in which eating disorders
Anorexia nervosa
Binge Eating Disorder
Bulimia Nervosa
Avoidant Restrictive Feeding Intake Disorder (ARFID)
What are some of the concerns in using Topiramate (Topamax) for BN and BED
May trigger restriction and development of AN
Adverse S/E including sedation and cognitive slowing
Risk of EPS
Orthostatic hypotension
What is the MOA for Topiramate (Topamax)?
GABA activity and antagonizes glutamate receptors. Inhibits carbonic anhydrase
Non-selectively antagonizes central and peripheral histamine H1 receptors
Which drug interactions does a prescriber need to be concerned about with Topiramate (Topamax)?
Avoid with other sedating medications
Anything with CNS depression
Medications with potential to increase risk of metabolic acidosis
What is the first FDA-approved medication to treat moderate to severe binge eating disorder?
Atomoxetine
Lixdexamfetamine
Methylphenidate
Dextroamphetamine
What are some concerns with using Lisdexamfetamine for BED?
Risk of misuse or diversion
Numerous drug interactions that can increase CV events
Can cause EPS in high doses
Can cause constipation
What is the MOA for Lisdexamfetamine?
Stimulates CNS activity (sympathomimetic)
Interacts with GABA receptors to enhance GABA effects
Avoidant Restrictive Feeding Intake Disorder (ARFID) is more predominant in males than females and has a younger age of onset, 11, than other EDs
Which are true about ARFID?
Most common comorbidities are anxiety disorders, OCD, and neurodevelopmental disorders (autism, ADHD and intellectual disabilities)
More common in households with high anxiety
Some medical conditions are associated including GERD, GI problems, vomiting
Common with Personality Disorders Cluster B (dramatic, erratic)
Common comorbid illnesses for ARFID include:
Anxiety disorders (GAD)
Autism spectrum disorder
Learning disorders
Which appetite stimulants are used to treat ARFID?
Cyproheptadine
Cathine
Chlorphentermine
Diethylpropion
What is the MOA for Cyrpoheptadine?
Which drugs does Cyproheptadine interact with?
SSRI
MAOIs
TCAs
The following are symptoms of disordered eating
Picky eating – limited food choices, texture
Unhealthy dieting – calorie restriction
Unhealthy eating – skipping meals
Use of laxatives, diet pills, bingeing, vomiting
Related to choking fears
Related to food allergies
Related to emetaphoibia
What are symptoms of disordered eating as related to OCD?
Contamination (foods, stores, brands of food, contact with certain people, organic or “green” foods, avoidance of fast foods)
Color of foods (need to eat all tan foods/avoid red foods – devil or blood)
Symmetry related (need to eat same amount as sibling to maintain identical weight and shape or chewing same number of times on each side of mouth)
What are the guidelines for prescribing for disordered eating due to OCD?
Typically require higher doses as compared to patients with affective disorders or other anxiety disorders
May take 10-12 weeks in OCD to determine efficacy
Empirical data supports pharmacologic treatment of OCD
Multiple augmentation strategies for treatment-resistant OCD
Having your mom tell you to "just eat already" while pinching your cheek
The following types of drugs are used in the treatment of eating disorders due to OCD
TCA
These are pearls from Mary Carter about the treatment of EDOs
Patients with ED’s are more susceptible to adverse side effects, especially if they are purging or if they are at a low weight. START LOW AND GO SLOW!
Psychotropic medications do not work as well when nutrition status is poor.
Malnutrition may deplete trytophan which is necessary to make neurotransmitters like serotonin
Patients may begin to experience side effects when they are adequately weight restored possibly due to surge in neurotransmitters
Goal is to get to a dose that optimizes clinical efficacy while minimizing adverse effects
