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The Use of Atypical Antipsychotics in Treating Anorexia Nervosa

Annie Horigan

October 8, 2009

 

Anorexia Nervosa (AN)

Anorexia nervosa is a type of eating disorder characterized by an intense fear of weight gain and preoccupation with thinness, as well as amenorrhea (lack of menstrual cycle).   Those with anorexia have distorted body image and often insist that they are ‘fat’, even when those around them can easily see that they are emaciated.  The effects of starvation caused by anorexia have serious, physiological and psychological implications, making it a disease of both the mind and body. 

Some of the Symptoms and Complications:

Physical/Physiological:

-                                                                                                                                  Abnormally slow heart rate (bradycardia)

-                                                                                                                                  Low blood pressure (hypotension)

-                                                                                                                                  Disturbances in the heart rhythm (arrhythmia)

-                                                                                                                                  Constipation

-                                                                                                                                  Abdominal pain

-                                                                                                                                  Amenorrhea (may affect fertility and bone density)

-                                                                                                                                  Dry, flaky skin

-                                                                                                                                  Fine, downy hair growth on the body

-                                                                                                                                  Electrolyte imbalance (especially in those who purge or abuse laxatives)

(http://www.medicinenet.com/anorexia_nervosa/page4.htm)

Psychological/Behavioral:

-          Depression

-          Withdrawal

-          Irritability

-          Disrupted sleep, fatigue

-          Need for control and perfection

-          Ritualistic behaviors, especially around food

-          Obsessive compulsive behavior and thought

-          Ruminations

-          Anxiety

 

 

 

Drug therapy: Part of a Multidisciplinary Approach to Treatment

Due to the complex nature of the disease, a multidisciplinary approach is necessary in treating anorexia nervosa.  This approach usually includes cognitive behavioral therapy or psychotherapy, nutrition counseling, family therapy, and pharmacotherapy.  Weight restoration alone may be a sign of physical progression towards ‘health’, but is by no means an indicator of psychological well being.  Thus, the professionals working with an anorexic patient are faced with the challenge of coming up with a treatment plan that addresses the multiple facets of anorexia nervosa in order to restore mental and physical health.

While thee are no medications that have been officially designated for the treatment of the primary condition of anorexia nervosa, three most common classes of drugs prescribed to patients are 1) antidepressants, 2) atypical antipsychotics, and 3) mood stabilizers.  The idea is that these medications (often a combination of two of the three, or all three) can address the ruminative thoughts, anxiety, depression, and other psychological factors that coexist with anorexia. 

Atypical Antipsychotics Used in the Treatment of Anorexia Nervosa:  Olanzapine and Quetiapine

Zyprexa (olanzapine) and Seroquel (quetiapine), are two of the most commonly prescribed antipsychotic drugs for the treatment of anorexia. 

-          Zyprexa (Olanzapine)- an atypical antipsychotic indicated for the treatment of Schizophrenia and of acute mixed or manic episodes associated with Bipolar I Disorder. (http://pi.lilly.com/us/zyprexa-pi.pdf)

 

-          Seroquel (quetiapine)- indicated for the treatment of various symptoms associated with bipolar disorder (depressive episodes, acute manic episodes), and for the maintenance treatment of bipolar disorder.  Seroquel is also indicated for the treatment of schizophrenia. (http://www.rxlist.com/seroquel-drug.htm)

Why use atypical antipsychotics as part of treatment?

While it might seem strange to prescribe eating-disordered individuals with medications indicated for the treatment of bipolar disorder and Schizophrenia, research supports their efficacy in inducing weight gain and helping lessen the frequency and intensity of intrusive anorexic thoughts.  Weight restoration is undoubtedly a critical aspect of recovery, yet it is also, for many patients, the most difficult.  During this weight restoration process, severe psychological distress and anxiety are not uncommon, as the often individual feels that she is ‘losing control’.  Current research literature suggests that atypical antipsychotics, particularly olanzapine, can be effective in reducing agitation and distress during this time. (http://clinicalevidence.bmj.com/ceweb/conditions/meh/1011/1011_I3.jsp#REF69).  Olanzapine is also known to have antidepressant as well as sedative effects, factors that can be instrumental in treatment, most notably during the weight restoration phase (Dunican and Deltotto, 2007).

 

What does the Research Literature say?

In their 2008 literature review on the use on the use of atypical antipsychotics in anorexia nervosa of children and adolescents, Mehler-Wex, Romanos, Kircheiner and Shulze present preliminary conclusions on both olanzapine and quetiapine.  The authors indicate that there is data supporting the notion that olanzapine seems to be effective in the psychopathology associated with anorexia and report no significant adverse side effects.  Due to the tendency for olanzapine to increase appetite, the ‘main challenge of olanzapine’ (105) is compliance.  Mehler-Wex and his colleagues indicate that quetiapine might be more favorable to patients because of its lower propensity to induce weight gain.  While they make no specific conclusions, namely due to the lack of research on its efficacy in children in adolescents, the authors suggest that quetiapine could be “a potentially promising option” for this age group, given the favorable outcomes found in studies on adults (Mehler-Wex et al., 2008).

Another literature review, published in 2007 by Dunican and DelDotto, examines the role of olanzapine in the treatment of anorexia (Dunican & DelDotto, 2007).  The authors review case reports, prospective clinical trials, and retrospective studies.  From here, they conclude that olanzapine can be beneficial as an integrative part of treatment when combined with other forms of behavioral and cognitive therapy in both inpatient and outpatient settings.  Still, as most authors seem to agree—there is a need for more data from randomized control trials in order to confirm the efficacy of olanzapine in the treatment of AN.

In a pilot study on the safety and efficacy of Quetiapine in patients with anorexia nervosa, Powers, Bannon, Eubanks and McCormick found that patients not only tolerated the medication well but also demonstrated significant improvements in scores on the PANSS (positive and negative syndrome scale).  Powers and her colleagues also report decreases in measures of anxiety (including obsessive compulsive symptoms) and depression among the patients. The average age of their 19-person sample was 26.8 years, with ages ranging from 14-48 years (6 of the 19 patients were between 14 and 18 years).  The authors indicate that their findings were similar to an earlier study with olanzapine, but that mean weight gain with quetiapine was not as significant, in fact, mean weight gain was not statistically significant at all. (Powers et al., 2007)

 

 

 

 

 

 

Safety, Side Effects, Concerns and Controversies:

 

 

-          Weight gain is a frequent side effect of Olanzapine which presumably seems like a favorable side effect (to clinicians, especially), yet can lead to issues with noncompliance.

-          Another concern is the association of some atypical antipsychotics with prolongation of the QTc interval, which has been linked to cases of sudden death (http://clinicalevidence.bmj.com/ceweb/conditions/meh/1011/1011_I3.jsp#REF69)

-          Given the fact that cardiac complications can be result from starvation in anorexia, some professionals worry about the safety of these drugs for anorexic patients.  In an article published in the Journal of Psychiatry and Neuroscience, psychiatrist Mimi Israël recommends that drugs that may compromise cardiac function should be administered with caution when treating the comorbid or medical complications of anorexia (Israël et al., 2005).

-          Safety and effectiveness of Zyprexa (Olanzapine) in children and adolescents has not yet been established. (http://pi.lilly.com/us/zyprexa-pi.pdf)  As with many medications, preliminary research and testing has been done with adults; which poses a possible concern in adolescents compose a large portion of those diagnosed with anorexia.

 

Conclusion:

Finding the right combination of medications can be a tedious process; yet ultimately, it appears that drug therapy plays a crucial role in treatment of anorexia nervosa.  Existing research literature on the use of atypical antipsychotics (particularly olanzapine and quetiapine) indicates that they can be effective in facilitating the weight restoration process and improving mood and cognition; yet there is an overriding consensus among professionals that data from randomized control trials will be necessary in order to draw reliable conclusions.  Moreover, these medications should be used as a

Overall, researchers have seemed to find considerable benefits in the use of olanzapine with anorexic patients—whether or not these benefits outweigh the concerns the prolongation of the QTc interval is an issue up for debate.  Nonetheless, none of the studies reviewed mentioned cardiac complications as being an issue in the sample, nor did any patients discontinue use of the given medication for side effects pertaining to heart problems.

In their 2005 article on olanzapine in the treatment of cognitions in AN, Mondraty and his colleagues write that “approximately one half of patients…are resistant to psychological, behavioural, pharmaceutical, family, nutritional and unconventional therapies” (Mondraty et al., 2005).  The journey back to health is often long and undoubtedly trying—both physically and mentally.  Given that anorexia nervosa has one of the highest mortality rates of any mental disorder, it is important to constantly reassess methods of treatment and ensure that patients are receiving appropriate and optimal care.  The research presented here provides an intriguing and hopeful glance at what may become a fundamental aspect of the treatment of anorexia nervosa in the near future.

 

References

Dunican K. C., & DelDotto D. (2007). The role of olanzapine in the treatment of anorexia nervosa.  The Annals of Pharmacotherapy, 41(1), 111–115.

Israël, M. (2005). What is the role of pharmacotherapy in the treatment of anorexia nervosa? Journal of Psychiatry & Neuroscience, 30(6), 464.

Lock, J D., & Fitzpatrick, K K. (2009). Anorexia nervosa. Clinical Evidence, 3(1011), 1-19.

Mehler-Mex, J. K., Romanos, M., Kirchheiner, J., & Schulze, U. M. E. (2008). Atypical antipsychotics in severe anorexia nervosa in children and adolescents: Review and case reports. European Eating Disorders Review, 16, 100-108.

Meltzer, H. Y. (2004). What's atypical about atypical antipsychotic drugs?. Current Opinion in Pharmacology, 4(1), 53-57.

Mondraty, N, Birmingham, C. L., Touyz, S., Sundakov, V., & Chapman, L. (2005). Randomized controlled trial of olanzapine in the treatment of cognitions in anorexia nervosa. Australian Psychiatry, 13(1), 72-75.

Nauret, R. (2009, January 19). Atypical antipsychotics have cardiac risks. Retrieved from http://psychcentral.com/news/2009/01/19/atypical-antipsychotics-have-cardiac-risks/3661.html

Powers, P. S., Bannon, Y., Eubanks, R., & McCormick, T. (2007) Quetiapine in anorexia nervosa patients: An open label outpatient pilot study. International Journal of Eating Disorders, 40(1), 21–26. 

Stõppler, M. C. (n.d.). Anorexia nervosa. Retrieved from http://www.medicinenet.com/anorexia_nervosa/article.htm

WebMD. (2009, January 6). Seroquel. Retrieved from http://www.rxlist.com/seroquel-drug.htm

 

 

 

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