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Pharmaceutical Treatment of Anorexia: A Literature Review
By: Mallory Gilliam
May 2, 2009
While there has been a great deal of research in recent years on the role of medication in treating bulimia nervosa and binge eating, there has been much less focus on the pharmacotherapy of anorexia nervosa. There is meager evidence as to the effectiveness of prescription medication in anorexia patients and there are no drugs currently approved by the FDA for anorexia nervosa treatment. However, a few recent studies have investigated the use of off-label use of certain atypical anti-psychotic agents including olanzapine, quetiapine, and fluoxetine, each of which would treat a different aspect of the disease. The objective of this review is to examine the effectiveness of these drugs in the treatment of anorexia nervosa patients.
The immediate goal in treating anorexia nervosa is restoring the patient to a normal weight, or at least to a weight that is not perilously low. This step is imperative for the patient’s physical health and must be accomplished in order for psychological recovery to begin. Although olanzapine was originally marketed for schizophrenia, many health professionals in the field believe that it can be effective in producing this initial weight gain, and perhaps even lessen anxiety and obsessional thinking.
Powers et. al (2002) conducted a study to determine whether or not olanzapine is effective in causing weight gain in anorexia nervosa patients.
The method was a 10 week open label study of olanzapine 10 mg with twenty anorexia nervosa patients (restricting or binge/purge subtype), without schizophrenia, schizoaffective disorder or bipolar disorder. Patients also had to attend group medication adherence and drug monitoring sessions weekly.
The results were as follows: of the 18 patients that received the treatment, 14 patients completed the study. The 4 patients that did not complete the study saw an average weight gain of 3.25 lbs at the time of their last session. Of the remaining 14 patients, 10 saw an average weight gain of 8.75 lbs and only 4 continued to lose weight, at an average of 2.25 lbs over the 10 week study. Out of the 10 that did gain weight, 3 patients were able to achieve the ideal weight for their body.
These results are promising as only 4 out of 18 patients (22.2%) lost weight during the study and the rest saw a clinically significant weight gain with 3 out of 18 patients (16.6%) even attaining their ideal body weight, all during a brief 10 week period.
The possible criticism of this study is that it included both restricting and binge/purge subtypes of anorexia nervosa and did not break down the number of each type in the sample or differentiate between the two in the results. Because of this, it is possible that the medication was more effective in one subtype than another and is not an effective treatment for weight gain in all anorexics. It could also be beneficial to conduct a double-blind study with the drug and a placebo to create a control group and to increase the sample size.
Quetiapine, another drug originally intended for the treatment of severe psychological disorders like schizophrenia, but has been thought to be beneficial in treating the core psychopathology of anorexia nervosa. While it probably would not assist patients with weight gain, the drug may improve mood and/or reduce obsessive thinking.
Powers et. al (2006) conducted a study to test the drug quetiapine’s effectiveness in reducing scores on the positive and negative syndrome scale (PANSS), as well as the symptoms of anxiety and depression in anorexia nervosa. The drug’s effect on patients’ weight was also recorded.
19 anorexic patients (without comorbidity of schizophrenia or schizoaffective disorder) were studied in an open label design in which each patient was given 150-300 mg of quetiapine daily for a 10 week period.
Of the 19 patients, 15 completed the 10 week study. Scores on the general psychopathology, depression, and total scales of the PANSS decreased significantly for every patient (those that dropped out of the study were included at the last observation carried forward). The measures of anxiety, obsessive compulsive symptoms, and depression also improved in each patient. Even a slight average weight gain was recorded at 1.6 lbs.
The study yielded very positive results in reducing the psychological symptoms of anorexia nervosa as every single patient (100%), even those that discontinued the study before the full 10 week period ended, saw significant improvements in the measures used to assess each symptom.
Once again, the study could be improved by using a double-blind method in which a control group is administered a placebo and increasing the sample size. It might also be helpful to know if any percentage of the subjects fit the criteria for major depressive disorder or obsessive-compulsive disorder as comorbidities to anorexia nervosa.
Fluoxetine is a Selective Serotonin Re-uptake Inhibitor or SSRI, which serves as an antidepressant. It functions by preventing the reuptake of serotonin, a brain chemical that is known to regulate mood, by nerve cells after it has been released. There has been much success in the use of this drug in treating binge eating and purging in patients with bulimia nervosa. For this reason, many medical officials believe that it could also be beneficial in the recovery process for anorexics. Once the patient has gained enough weight back, the drug would be implemented in order to prevent relapse and deter the formerly anorexic patient from slipping into a bingeing cycle, which is not a rare occurrence.
Walsh et. al (2006) conducted a study to test whether the drug fluoxetine can promote recovery and delay the time to relapse in patients with anorexia nervosa after their weight had been restored.
The study was a randomized, double-blind, placebo-controlled trial in which 93 patients with anorexia nervosa who had received intensive inpatient or day-program treatment at either Toronto General Hospital of New York State Psychiatric Institute and had regained enough weight to reach a minimum body mass index (BMI) of 19.0 where eligible participate in the trial. The patients were randomly assigned to receive fluoxetine or a placebo and were then underwent outpatient therapy for a period up to 1 year in double-blind fashion. In addition to receiving the drug, each patient also received personal cognitive behavioral therapy.
Of the 93 patients that participated in the trial, 49 were assigned to fluoxetine while the remaining 44 were administered placebos. The percentage of patients that remained in the study for 52 weeks and maintained a BMI of at least 18.5 was similar for both fluoxetine (26.5%) and the placebo (31.5%), with the placebo actually yielding slightly better results than the drug. A Cox proportional hazards analysis also revealed that there was no significant difference between the placebo and fluoxetine in the time-to-relapse for the patients that did eventually relapse during the study.
The study did not demonstrate any benefit from the use of fluoxetine for the treatment of patients with anorexia nervosa post weight restoration. Therefore, future investigations should instead focus on constructing new models to better understand the nature of persistence of this illness and then exploring new possible pharmacological treatment approaches for the recovery stage of anorexia nervosa.
Although this particular study did utilize a more ideal method (randomized, double-blind, and placebo-controlled versus open-label) than the other two studies, it still featured a few possible flaws. It had no criteria for the discrepancy of any possible comorbidities in the patients studied or specify subtype of anorexic. Also, the little positive result that was yielded in the fluoxetine group may have been exaggerated due to the use of cognitive behavioral therapy in tandem with the administration of the drug (which is probably why the results for the drug and the placebo were near equal). It may have been that the only source of positive results was in fact from the cognitive behavior therapy.
Two out of three of the studies reviewed presented promising findings in regards to the use of atypical anti-psychotic drugs in the treatment of anorexia. In very recent studies, olanzapine proved very effective in aiding anorexic patients with weight restoration, while quetiapine showed to be useful in addressing the psychological affects the disease has on its sufferers. More studies, perhaps with better method, need to be conducted to solidify these findings. If positive results continue to be seen, more research should be done in regards to possibly using these drugs successively in order to develop a more holistic treatment. As fluoxetine did not prove effective in preventing/delaying relapse, more research should be done to find other drugs capable of addressing that particular stage in the recovery process. The pathobiology and etiology of eating disorders is complex, and there is still much that is not understood about their nature. Further insight into these areas and the genetic and neurochemical abnormalities occurring in anorexia nervosa would assist in finding better therapeutic agents, like pharmaceuticals, for treating the disorder.
Mickley, D. (2004). Medication for Anorexia Nervosa and Bulimia Nervosa. The Journal of Treatment and Prevention and Eating Disorders Today. Gurze Books. Retrieved April 27, 2009, from http://www.gurze.com
Peterson, M. (2005, February 17). Antidepressants. In Vassar Student Association - The Source. Retrieved April 28, 2009, from http://vsa.vassar.edu/~source/drugs/antideps.html
Powers, P. S., Bannon, Y., Eubanks, R., & McCormick, T. (2006). Quetiapine in anorexia nervosa patients: An open label outpatient pilot study. International Journal of Eating Disorders, 40(1), 21-26. Retrieved April 26, 2009, from Wiley InterScience.
Powers, P. S., Santana, C. A., & Bannon, Y. S. (2002). Olanzapine in the treatment of anorexia nervosa: An open label trial. International Journal of Eating Disorders, 32(2), 146-154. Retrieved April 26, 2009, from Wiley InterScience.
Sharma, A. (2001). Anorexia nervosa and bulimia nervosa: An appraisal [Abstract]. Drugs of Today, 37(4), 229. Retrieved April 25, 2009, from Journals on the Web.
Walsh, B. T., Kaplan, A. S., Attia, E., Olmsted, M., Parides, M., Carter, J. C., et al. (2006). Fluoxetine After Weight Restoration in Anorexia Nervosa. Journal of the American Medical Association, 295(22), 2605-2612. Retrieved April 27, 2009, from JAMA.
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