2. Why this talk…..
Traditionally eating disorders have been looked after
by either gastro-enterologists or endocrinologists
with the support of psychiatry
There are few conditions where such strong
leadership is necessary in the best interests of the
patient and may go counter to the instincts or wishes
of members of staff
3. Anorexic woman from Wales
to be force fed, judge orders
A woman with "severe" anorexia who wanted to be
allowed to die is to be force fed in her "best
interests" by order of a High Court judge.
She was being looked after in a community hospital
under a palliative care regime whose purpose was to
allow her to die in comfort
Treatment - "does not merely entail bodily intrusion
of the most intimate kind, but the overbearing of E's
will in a way that she experiences as abusive".
4. A not unusual pathway
of care…..
19 yr old girl, admitted BMI of 12
Intermittent institutionalised care since age 9 with
Anorexia nervosa
Admitted because of recent further weight loss,
minimal intake for 1 week
Agreed for a voluntary admission
5. Admission criteria
Based on recent change in the context of absolute
BMI, physiological and functional parameters
6. Physical concern
Concern Admit
BMI <14 <12
Wt loss (kg/week) >0.5 >1
BP <90/70 <80/60
Postural drop >10 >20
Pulse <50 <40
Temp <35 <34
Muscular Uses arms to Can’t stand
strength stand
WBC <4 <2
Hb <11 <9
Plts <130 <110
7. Physical concern(2)
Concern Admit
NA+ <135 <130
K+ <3.5 <3.0
Mg2+ If depleted If depleted
Po4- If depleted If depleted
ECGqtc >450msec >450 or
arrhythmia
ALT >45 >90
Bilirubin >20 >40
Alk phosp >110 >200
Albumin <35 <32
10. Initial plan
Medical
Initial assessment
Na+, K+, Urea, Creat, glucose, CRP
Mg2+, PO4-, Ca2+
Albumin, liver enzymes, INR
FBC, ferritin, folate, B12
FSH, LH Oest or testo
Thiamine 300mg daily, vit b complex strong 2 tabs
od, multivit generic, sandophosp 2 tabs tds
Pabrinex
11. Initial plan
Nutritional
5 kcal per kg stepping up over 5-7days to weight gain
levels (+500kcal over estimates from Henry equation
(10kcal per kg if BMI>16)
Menu plans agreed with patient
12. Initial plan
Behavioural/other restrictions
Normal foods in preference to supplements
Bed rest/commode/wheelchair
Away from window, no fans
Restrictions according to Mental health status
Compliance essential
13. Progress
Day 3, non-compliance with feeding plan
Non-compliance with activity
Reviewed with psych
Formal section
Advised likely need to progress to NG feeding in
absence of compliance and/or weight gain
Informed of need to search belongings
14. Progress
Day 5, intermittent compliance with feeding plan
Reviewed with psych
Razor blades and salt sachets removed
NG feeding under restraint, NG re-
positioned/replaced 5 times first 24 hrs
Bolus feeds under restraint during periods of non-
compliance
15. Progress
Day 8
Hypokalaemia and hypophosphataemia requiring IV
replacement
Subsequent weight gain back to BMI 15
Established weight stability at BMI 15 on oral intake
and basic mobility
Discharged to OP ED services
17. What is anorexia nervosa?
Anorexia nervosa is defined as:
intense fear of weight gain
Weight consistently < 85th percentile for age and height
(In women) three consecutive missed periods
Together with one of following:
refusal to admit seriousness of weight loss
undue influence of shape or weight on one’s self-image
disturbed experience in one’s shape or weight
DSM-IV-TR
18. Types of Anorexia
• Purging
– Weight loss achieved by
vomiting, laxatives, or
diuretics
Restricting
Weight loss achieved by
restricting calories
Following diets, fasting, and exercising to
excess
19. Causes
Anorexia Nervosa patients tend to have
Low self-evaluation
Come from competitive, high-achieving, and protective
families
Set perfectionist standards
Intensely concerned with how others perceive them
Fear falling short of expectations
Genetics
Culture
Idealize thinness
Have poor body image
Feel shame, depressed, and dissatisfied with their own
bodies
20. Symptoms
Dramatic weight loss
Preoccupation with
weight, food, calories, fat grams, and
dieting
Refusal to eat certain foods, or whole
categories of food (e.g. no carbohydrates)
Denial of hunger
Excessive, rigid exercise regimen
Withdrawal from usual friends and
activities
Weight loss and dieting become primary
concerns in life.
Constant excuses to avoid mealtimes
Anxiety about gaining weight or being fat
21. Epidemiology
UK
1 in 250 females
1 in 2000 males
SMR 9.5
Mortality of 0.6% per year
Higher in those presenting after age 20
22. 50 years of treatment
outcomes
Comparison of outcomes 1950-1999 to gauge whether any
improvement over time.
119 studies conducted 1950-1999
5,590 patients, adolescents and adults
Follow-ups clustered into three time frames:
- fewer than 4 years after hospitalization;
- 4-10 years;
- more than 10 years after
Steinhausen HC. Am J Psychiatry. 2002.
24. “The mortality rate was much
lower in the group of younger
patients than that in the group
with a much wider age at onset
of illness. The rates of
recovery, improvement, and
chronicity were more favorable
in the group with the younger
patients.”
Outcome of Anorexia Nervosa
in 119 Patient Series by Duration
of Follow-Up and Age at Onset.
A total of 577 patients had less
than 4 years of follow-up, 2,132
had 4–10 years of follow-
up, and 438 had more than 10
years of follow-up.
Steinhausen HC. Am J Psychiatry. 2002
25. “Anorexia nervosa did not
lose its relatively poor
prognosis in the
20th century.”
Outcome of Anorexia Nervosa
in 119 Patient Series by
Duration of Follow-Up and
Time Period of Study.
A total of 577 patients had less
than 4 years of follow-up, 2,132
had 4–10 years of follow-
up, and 438 had more than 10
years of follow-up.
Steinhausen HC. Am J Psychiatry. 2002.
26.
27. Re-feeding syndrome
First described in American Japanese POW
Precipitated cardiac failure
clinical features of refeeding syndrome
rhabdomyolysis, leucocyte dysfunction, respiratory
failure, cardiac
failure, hypotension, arrhythmias, seizures, coma, and
sudden death
Driven by low serum phosphate (<0.5)
28. Re-feeding syndrome -
pathophysiology
insulin is decreased due to a reduced oral carbohydrates.
fat and protein stores are catabolized
Intracellular loss of electrolytes, esp. phosphate.
intracellular phosphate stores can be depleted despite normal
serum phosphate concentrations
a sudden shift from fat to carbohydrate metabolism -secretion
of insulin increases -stimulates cellular uptake of phosphate,
usually occurs within four days of starting to feed again.
Phosphate is necessary for ATP from ADP and AMP
29. How do we manage it?
Risk is obvious
Degree of risk is not
Assume risk is reduced after 1 week of good intake
AND weight gain
Often use telemetry – some centres use it
continuously for all patients
ECG daily is essential
30. Exeter protocol
(with thanks to Roderick Warren)
Assume high risk in all cases. Medical inpatients with
anorexia nervosa who require inpatient feeding are
almost always at high risk of refeeding syndrome.
However, NICE guidance (2006 – CG32) states that the risk
is high if:
• One of: BMI<16, weight loss >15% in last 3-6 months, little
or no nutrition >10 days, low
potassium/phosphate/magnesium levels prior to feeding.
• Two of: BMI <18.5, weight loss >10% in last 3-6 months,
little or no nutrition >5 days, history of alcohol abuse or
use of insulin/chemotherapy/antacids/diuretics/(laxatives)
31. Exeter protocol
Bloods before feeding:
Sodium, potassium, urea, creatinine, glucose, CRP
Magnesium, phosphate, calcium
Albumin, liver enzymes, INR
FBC, ferritin, folate, B12
FSH, LH, oestradiol (females) or testosterone (males)
Thiamine: 300mg per day
Vitamin B Complex (Strong): 2 tablets, once per day Multivitamins:
generic, 1 tablet, once per day Phosphate-Sandoz: 2 tablets, three
times daily
32. Exeter protocol
Daily bloods while risk of refeeding syndrome is high:
•
Sodium, potassium, urea, creat, glucose, magnesium, phosphate
, calcium
Bloods once-twice weekly when stable (after 3-4 days of
sustained feeding and no electrolyte abnormalities):
Sodium, potassium, urea, creatinine, glucose
Magnesium, phosphate, calcium
Albumin, liver enzymes
FBC
33. Exeter protocol
Mild deficiency (3.0 – 3.5 mmol/L)
• Sando-K or equivalent, 4-8 tablets daily
Moderate-severe deficiency (<3.0 mmol/L)
• Intravenous, using pre-prepared bags of 1 litre 0.9%
saline with 40 mmol potassium chloride, given over
at least 4 hours (but usually longer e.g. 12 hours).
Anorexic patients may be chronically hypokalaemic.
34. Exeter protocol
Mild deficiency (>0.5 mmol/L and not falling rapidly) • Phosphate-Sandoz 2 tablets,
three times daily
Moderate-severe deficiency (<0.5 mmol/L, or higher but falling)
• Intravenous, using pre-prepared bags of Phosphates Polyfusor, 500ml over 24
hours.
– monitor calcium. Will precipitate if co-infused with calcium – always avoid infusing
magnesium or calcium through the same cannula.
– check levels after 24 hours.
IV phosphate. Various recommendations suggest 9, 12 or 18 mmol administered over
12 hours. However, the use of an entire Polyfusor bag (containing 50 mmol
phosphate) has been shown to be a simple, effective and safe approach. Mild
hyperphosphataemia is not uncommon (levels up to 1.57 mmol/L have been seen) –
consider a smaller dose (e.g. 250 ml over 12 hours) for less severe
hypophosphataemia.
35. Exeter protocol
Mild deficiency (>0.6 mmol/L)
Magnesium glycerophosphate 2 tablets, twice daily.
May cause GI irritation/diarrhoea. Avoid with co-admin with
phosphate
Moderate-severe deficiency (<0.6 mmol/L)
IV magnesium sulphate, 20 mmol over 12 hours, or 40 mmol
over 24 hours. Can be given faster in emergencies
Will precipitate if co-infused with phosphate – always used a
separate cannula.
Magnesium levels may drop rapidly after correction -
several days of IV replenishment may be required before
they become stable.
36. Exeter protocol- calcium
rarely necessary. Correction of hypomagnesaemia may improve calcium
levels. Administration of phosphate may lower calcium levels.
Asymptomatic mild-moderate deficiency
Calcichew, 1-3 tablets daily.
Do not administer at same time as phosphate – insoluble CaPO4 will form.
Symptomatic or severe deficiency
• IV calcium chloride or calcium gluconate, 10 mmol over at least 10 min
(but usually longer e.g. 1 hour).
Followed by infusion of 40 mmol over 24 hours.
Must be diluted before administration
37. A more unusual case….
Douglas
To GP, Feb 2010
Weight loss feeling tired
Recent junior Exeter chiefs player
Creat high at 110, glucose 2.1, Hb12.6, WCC 3.4
Subsequent fall in WCC, rise in ALT
38. Douglas
Ft4 12.3, cortisol 594, fsh 0.6, lh 0.4, PRL 208, testo 0.8
GH 15.1, IGF1 8.6
68kg BMI 20.9, prior weight 111kg 6 mths earlier
Clinically cachectic, lanugo hair, but post-pubertal
Admitted – psych confirmed significant AN
Weight regain to 76kg, BMI 23
Partial recovery of pancytopaenias, no recovery of
gonadotrophins despite weight regain and 2 trials of
testosterone cessation
39. Anorexia and fertility
Very little data in men for longer term
Testo crashes during acute illness
Seems to be less marked than in females
Partly an adaptive response
Many recovered anorexic patients go on to
successful pregnancies
