What are the treatment guidelines for eating disorders?

Treatment Guidelines for Eating Disorders

All patients with eating disorders require a coordinated multidisciplinary treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise, with disorder-specific psychotherapy as the cornerstone of treatment. 1

Initial Assessment and Workup

Physical Examination and Vital Signs

• Measure temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure at initial evaluation 1
• Document height, weight, and BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents) 1
• Assess for physical signs of malnutrition or purging behaviors (e.g., Russell's sign, parotid enlargement, dental erosion) 1

Laboratory Assessment

• Obtain complete blood count to detect anemia, leukopenia, and other hematologic abnormalities 1, 2
• Order comprehensive metabolic panel including electrolytes (sodium, potassium, chloride, bicarbonate), liver enzymes, and renal function tests (BUN, creatinine) to identify hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, and hepatic or renal dysfunction 1, 2

Cardiac Evaluation

• Perform electrocardiogram in all patients with restrictive eating disorders, severe purging behaviors, or those taking QTc-prolonging medications 1
• Monitor for bradycardia and QTc prolongation, which are common complications 3

Psychiatric Assessment

• Screen for co-occurring psychiatric disorders, particularly depression (present in 49.5% of anorexia nervosa, 76.3% of bulimia nervosa, and 65.5% of binge-eating disorder) 3
• Assess suicide risk, as 25% of deaths in anorexia nervosa are from suicide 3

Disorder-Specific Treatment Approaches

Anorexia Nervosa

Adolescents and Emerging Adults

Family-based treatment (FBT) is the first-line psychotherapy for adolescents and emerging adults with anorexia nervosa who have an involved caregiver. 1

• FBT includes caregiver education aimed at normalizing eating and weight control behaviors and restoring weight 1
• FBT achieves remission rates of 48.6% at 6-12 months compared to 34.3% with individual treatment (OR 2.08,95% CI 1.07-4.03) 3

Adults

Adults with anorexia nervosa should receive eating disorder-focused psychotherapy that normalizes eating behaviors, restores weight, and addresses psychological aspects including fear of weight gain and body image disturbance. 1

Weight Restoration

• Set individualized goals for weekly weight gain and target weight for all patients requiring nutritional rehabilitation 1
• Medical management and nutritional rehabilitation are primary goals, particularly for inpatient treatment 4

Pharmacotherapy

• No medications are currently approved or effective for anorexia nervosa 3, 5
• Medications may be used to treat co-occurring psychiatric symptoms but not the core eating disorder 5

Bulimia Nervosa

Adults

Adults with bulimia nervosa should receive eating disorder-focused cognitive-behavioral therapy (CBT) combined with fluoxetine 60 mg daily, prescribed either initially or if minimal response to psychotherapy alone occurs by 6 weeks. 1

• Fluoxetine and other antidepressants decrease binge-eating episodes even in patients without depression (standardized mean difference -0.24,95% CI -0.41 to -0.08) 3
• CBT is the first-choice psychotherapy with demonstrated superiority over treatment as usual 6

Adolescents and Emerging Adults

• Family-based treatment should be offered to adolescents and emerging adults with bulimia nervosa who have an involved caregiver 1

Binge-Eating Disorder

Psychotherapy

Patients with binge-eating disorder should receive eating disorder-focused cognitive-behavioral therapy or interpersonal therapy, delivered in either individual or group formats. 1

• CBT demonstrates effectiveness as first-line treatment 3, 6
• Self-help interventions have some evidence of effectiveness in nonunderweight individuals 6

Pharmacotherapy

• For adults who prefer medication or have not responded to psychotherapy alone, prescribe either an antidepressant or lisdexamfetamine 1
• Antidepressants reduce binge frequency (standardized mean difference -0.29,95% CI -0.51 to -0.06) 3
• Lisdexamfetamine reduces binge frequency with medium effect size (Hedges g = 0.57,95% CI 0.28-0.86) 3

Level of Care Determination

Hospitalization Indications

• Admit patients with serious medical complications including severe bradycardia, significant electrolyte abnormalities, or cardiac arrhythmias 3
• Hospitalize patients with acute suicidality or severe psychiatric complications 3
• Specialized eating disorder inpatient units provide optimal care when available 4

Outpatient Treatment

• Outpatient clinics should provide individual psychotherapy with disorder-specific CBT techniques, family therapy, pharmacological treatment, and access to laboratory testing 4
• At least one structured meal with nutritional counseling is advisable for partial hospitalization and day treatment programs 4

Common Pitfalls and Caveats

• Mortality risk: Anorexia nervosa carries a mortality rate of 5.1 deaths per 1000 person-years, nearly 6 times higher than age-matched controls 3
• Treatment resistance: Many patients, particularly those with anorexia nervosa, do not derive sufficient benefit from existing treatments 5
• Early intervention: Early symptom improvement and adolescent age predict more favorable outcomes 6
• Avoid premature psychotherapy: Reverse the most severe weight loss before initiating intensive psychotherapeutic treatment in severely malnourished patients 7
• Monitor QTc intervals: Patients with restrictive eating or severe purging require ongoing cardiac monitoring due to risk of sudden cardiac death 1