What is the pharmacological treatment for anorexia nervosa?

Pharmacological Treatment of Anorexia Nervosa

Currently, there are no FDA-approved medications specifically for the treatment of anorexia nervosa, and psychotherapy remains the cornerstone of treatment, with pharmacological interventions primarily used to address comorbid conditions and specific symptoms.

Primary Treatment Approach

• Eating disorder-focused psychotherapy is the foundation of treatment for anorexia nervosa, addressing both eating behaviors and psychological aspects of the disorder 1
• For adolescents and young adults with involved caregivers, family-based treatment is strongly recommended as the first-line intervention 1
• Nutritional rehabilitation with individualized goals for weekly weight gain and target weight is essential for recovery 1

Pharmacological Options for Anorexia Nervosa

Medications Showing Promise

• Olanzapine (atypical antipsychotic) has shown the most promising results for anorexia nervosa treatment, particularly for addressing obsessionality and resistance to treatment in underweight patients 2, 3

  • May help with weight gain and anxiety reduction
  • Particularly beneficial for patients with psychotic symptoms or extreme body image distortion 4

• Dronabinol (cannabinoid) has shown some promise as an appetite stimulant in anorexia nervosa 2

  • However, evidence is limited and it should be used cautiously, especially in elderly patients where it may induce delirium 5

Treatment of Comorbid Conditions

• Selective Serotonin Reuptake Inhibitors (SSRIs):

  • Fluoxetine may be beneficial during the weight maintenance phase to decrease relapse rates 4
  • SSRIs can help manage comorbid anxiety, depression, and obsessive-compulsive behaviors 1, 2
  • Note: SSRIs are generally less effective in severely underweight patients and should be used after weight restoration 2

• For comorbid depression, consider:

  • SSRIs or mirtazapine (which has appetite-stimulating properties) 6, 2
  • Avoid bupropion as it is contraindicated in anorexia nervosa 2

• For severe anxiety or acute suicidality:

  • Short-term use of benzodiazepines like lorazepam may be warranted 2

Special Considerations

Physical Health Management

• Address physical health consequences of malnutrition:
  • Consider proton-pump inhibitors for gastrointestinal symptoms 2
  • Gastroprokinetic drugs may help with early satiety 5
  • Monitor for bone health issues; bisphosphonates should be used with extreme caution in premenopausal women due to teratogenicity concerns 5

Treatment Setting and Monitoring

• Outpatient treatment is appropriate for most patients, but inpatient care is necessary when 1:

  • Severe medical complications are present
  • Significant psychiatric comorbidities exist
  • Weight is dangerously low (BMI <16 kg/m²)

• Regular monitoring should include:

  • Weight, vital signs, and laboratory parameters 1
  • Electrocardiogram for patients with restrictive eating or severe purging behaviors 1

Treatment Limitations and Cautions

• Bisphosphonates have a very long half-life and should be used with extreme caution in women of childbearing age due to teratogenicity concerns 5

  • Decision to use bisphosphonates should be made on a case-by-case basis in consultation with a specialist in metabolic bone diseases 5

• Non-pharmacological therapy is the mainstay of treatment for anorexia nervosa, with medications primarily used as adjunctive therapy 5, 1

• Pharmacological therapy should be considered when there is:

  • Lack of response to non-pharmacological therapy 5
  • Presence of significant comorbid psychiatric conditions 1, 2

Emerging Approaches

• Novel approaches being investigated include:
  • Hormone analogues 2
  • Immunological treatments 2
  • Microbiome-based interventions 2
  • Medications that enhance the effects of psychotherapy 2