1. PRESCRIBING PRACTICE IN INPATIENT EATING DISORDER MANAGEMENT Steven Voy (S.J.Voy@sms.ed.ac.uk) Supervisor: Dr Jane Morris

2.  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.

3.  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.

4.  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.

5.  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.

6.  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.

7.  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.

8.  38 inpatients with eating disorders were being treated across the 7 units in March 2011. ◦ 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.

12.  Of the 38 patients: ◦ 10 prescribed olanzapine:  7 adults – average daily dose was 9.6mg (range 2.5- 20)  3 children – average daily dose was 7.5mg (range 5- 10) ◦ 3 quetiapine ◦ 1 amisulpiride

13.  ~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.

14.  ~50% of adults were prescribed. ◦ Main medications were: Zopiclone and Diazepam  No children/adolescents were prescribed.

15.  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.

16.  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.

17.  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 7.5-9.6mg.  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.’

18.  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.

19.  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.

20.  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, 1027-1034.  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: 138-141

22.  Antipsychotics:

23.  Antidepressants:

24.  Anxiolytics:

25.  Nutritional Supplements