PRESCRIBING PRACTICE IN INPATIENT EATING DISORDER MANAGEMENT Steven Voy Supervisor: Dr Jane Morris
Majority should be managed on an outpatient basis Should consist of: ◦ Psychological therapies ◦ Dietetic input ◦ Regular assessment of motivation, co-morbidity, severity and personal requirements. Minority require inpatient care, which consists of: ◦ Refeeding and nutritional input. ◦ Intense psychological and behavioural therapies. ◦ Pharmacological interventions. Aim: reduce negative sequelae while promote positives – physically, psychologically and socially.
Medication should not be used as the primary treatment of any eating disorder. Gowers et al (2010) For Bulimia nervosa, the SSRI fluoxetine was FDA approved for treatment. AN has no FDA approved treatment and SSRI trials have proven largely ineffective. In recent years, antipsychotics have taken centre focus.
33 publications investigated antipsychotic use in AN. ◦ 8 Randomised-controlled trials (RCTs) ◦ 10 Open-label trials ◦ 2 Retrospective case-note analysis ◦ 13 Case studies Olanzapine was the most studied drug. The largest study managed to recruit 32 patients.
Olanzapine RCTs: ◦ Significantly more weight gain than placebos. Bissada et al (2008), Brambilla et al (2007) ◦ Decrease in ruminative thinking when compared with chlorpromazine. Mondraty et al (2005) Quetiapine RCT: Court et al (2010) ◦ No significant difference in weight gain. ◦ Significant difference in psychometric testing All open label and case studies were positive in terms of weight gain and/or improvement in eating disorder psychopathology.
Audit what patients with AN are currently being prescribed in the 7 inpatient units in Scotland. Observe trends in prescribing and compare between adult and child and adolescent. See if research interest matches prescribing practice in AN.
Centered around opinions on olanzapine prescribing and general prescribing practice in AN. Sent to lead clinicians in Scotland involved in the management of AN for a snapshot view of their views and personal prescribing habits.
38 inpatients with eating disorders were being treated across the 7 units in March ◦ 18 adults. ◦ 20 child and adolescents. Of these: ◦ 81.6% (31) - Anorexia nervosa ◦ 15.8% (6) – EDNOS ◦ 2.6% (1) – Bulimia nervosa 3 adult units and 2 child and adolescent units are included in analysis. 2 child and adolescent units were not currently being prescribed any regular medication.
Of the 38 patients: ◦ 10 prescribed olanzapine: 7 adults – average daily dose was 9.6mg (range ) 3 children – average daily dose was 7.5mg (range 5- 10) ◦ 3 quetiapine ◦ 1 amisulpiride
~2/3s: 12 adults and 11 adolescents Fluoxetine is the most commonly prescribed ◦ 10 patients: 7 adolescents and 3 adults. Citalopram in 5 patients Others included: paroxetine, clomipramine, mirtazapine, sertraline, amytriptyline, trazodone, venlafaxine and cyclizine.
~50% of adults were prescribed. ◦ Main medications were: Zopiclone and Diazepam No children/adolescents were prescribed.
Significantly more prescribed in adult (85%) than child and adolescents (45%.) In adults, thiamine was the most prescribed supplement. It was administered to 10/18. In children, calcichew and multivitamins were most frequently found.
Response: 8 out of 30. Of the 8 lead clinician responders: ◦ Average time spent in the field of eating disorders was 14 years. ◦ Majority worked in inpatient setting. ◦ Response to olanzapine overall was positive: 6 believe it to be effective in those with AN 7 have prescribed in those with AN Reasons for prescribing included: Ability to decrease agitation, anxiety and rigid thinking. Highly resistant patients. Literature base and colleagues experiences.
Recommended baseline tests included: Full blood count, renal and liver function tests, lipids, glucose and an ECG. Typical starting dose 2.5mg. Typical maintenance dose average was 5mg. ◦ Average dose of inpatients was between mg. Side effects encountered: ◦ Drowsiness was found by all 8 participants. ◦ Rarely lightheadedness. When asked about how important an advance in AN treatment it poses, responses ranged from ‘unimportant’ to ‘helpful,’ with the majority rating it ‘quite important.’
Olanzapine may be important in the treatment of AN. It is currently the most researched drug in AN with the largest evidence base. Scottish inpatient units prescribe olanzapine the most out of any antipsychotic medication, possibly because lead clinicians see the potential therapeutic benefits. However, more and larger RCTs need to be undertaken.
Hoek, H. W. (2006). Incidence, prevalence and mortality ofanorexia nervosa and other eating disorders. CurrentOpinion in Psychiatry, 19, 389–394. National Institute of Clinical Excellence. (2004). Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Bissada, H., Tasca, G. A., Barber, A. M., & Bradwejn, J. (2008). Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: A randomized, double-blind, placebo-controlled trial. American Journal of Psychiatry, 165, 1281–1288. Brambilla, F., Garcia, C. S., Fassino, S., Daga, G. A., Favaro, A., Santonastaso, P., et al. (2007a). Olanzapine therapy in anorexia nervosa: Psychobiological effects. International Clinical Psychopharmacology, 22, 197–204.
Mondraty, N., Birmingham, C. L., Touyz, S., Sundakov, V., Chapman, L., & Beumont, P. (2005a). Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa. Australasian Journal of Psychiatry, 13, 72–75. Court, A et al. (2010.) Investigating the effectiveness, safety and tolerability of quetiapine treatment of anorexia nervosa in young people: A pilot study. Journal of Psychiatric research, 44, Gowers, SG., Weetman, J., Shore, A., Hossain, F., and Elvins, R. (2000). Impact of hospitalisation on the outcome of adolescent anorexia nervosa. The British Journal of Psychiatry. 176:
Antipsychotics:
Antidepressants:
Anxiolytics:
Nutritional Supplements