In a patient with co-occurring alcoholism and eating disorder, which condition should be treated first?

Treatment Priority in Co-Occurring Alcoholism and Eating Disorders

Both conditions must be addressed simultaneously using a coordinated multidisciplinary approach, with immediate medical stabilization of life-threatening complications taking precedence regardless of which disorder is causing them. 1

Immediate Assessment and Stabilization

The first priority is determining which condition poses the most immediate threat to life:

Critical Medical Emergencies Requiring Immediate Hospitalization

Alcohol withdrawal syndrome (AWS) is a severe medical condition that can progress to delirium tremens, seizures, coma, cardiac arrest, and death within 6-24 hours of the last drink. 2 This represents an immediate life-threatening emergency requiring urgent treatment with benzodiazepines (the gold standard for AWS), with long-acting agents like diazepam or chlordiazepoxide providing better protection against seizures and delirium. 2

Severe eating disorder complications also constitute medical emergencies, including cardiac arrhythmias from electrolyte abnormalities, severe bradycardia, QTc prolongation, and refeeding syndrome risk. 3 Up to one-third of deaths in anorexia nervosa are cardiac-related, with sudden cardiac death being a frequent cause of mortality. 3

Initial Medical Workup

Obtain vital signs including temperature, resting heart rate, blood pressure, and orthostatic measurements to assess hemodynamic stability. 2, 3

Measure weight, height, and BMI to quantify nutritional status. 2, 3

Order complete blood count and comprehensive metabolic panel including electrolytes (sodium, potassium, chloride, bicarbonate), liver enzymes, and renal function tests to identify hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, and hepatic or renal dysfunction. 2, 3

Perform electrocardiogram in all patients given the cardiac risks from both conditions—alcohol-related cardiomyopathy and eating disorder-related QTc prolongation. 3, 4

Treatment Algorithm After Stabilization

Step 1: Simultaneous Treatment Approach

The literature clearly indicates that the eating disorder and substance use disorder should be addressed simultaneously using a multidisciplinary approach, not sequentially. 1 Research demonstrates that eating disorder patients who abuse substances show worse symptomatology and poorer outcomes than those with eating disorders alone, including increased medical complications, longer recovery times, and higher relapse rates. 1

Step 2: Understanding the Functional Relationship

The functional relationship between the eating disorder and alcohol use varies and must be carefully assessed for each patient. 1 Alcohol may be used for emotional regulation, as part of impulsive behavior patterns, or to cope with problems caused by the eating disorder. 1, 5

Restricting anorexics have low rates of co-morbid substance abuse, while bulimics and binge eaters are more prone to alcohol use and represent distinct subgroups within the eating disordered population. 5

Step 3: Coordinated Treatment Components

Common therapeutic interventions should include psychoeducation about the aetiological commonalities, risks and sequelae of concurrent eating disorder behaviors and substance abuse. 1

Provide dietary education and planning alongside cognitive challenging of eating disordered attitudes and beliefs. 1

Build skills and coping mechanisms while addressing obstacles to improvement and preventing relapse. 1

Cognitive behavioral therapy has been frequently used in treatment of co-morbid eating disorders and substance use disorders, though randomized controlled trials are lacking. 1 More recently, dialectical behavioral therapy has shown efficacy in reducing both eating disorder and substance use behaviors. 1

Step 4: Pharmacotherapy Considerations

For alcohol dependence, naltrexone reduces the likelihood of return to any drinking by 5% and binge-drinking risk by 10%, and should be prescribed as first-line medication. 6 However, naltrexone has potential hepatotoxicity and has not been tested in patients with alcoholic liver disease, so its use requires caution if liver dysfunction is present. 2

Acamprosate is an alternative alcohol pharmacotherapy with confirmed efficacy, though it also has not been tested in patients with cirrhosis. 2

For bulimia nervosa specifically, fluoxetine 60 mg daily should be prescribed either initially or if minimal response to psychotherapy occurs by 6 weeks. 3, 4

Opioid antagonists like naltrexone may be useful in treating both eating and alcohol use disorders given shared neurobiological pathways. 5

Critical Pitfalls to Avoid

Do not attempt to treat one condition while ignoring the other—this sequential approach leads to worse outcomes and higher relapse rates. 1

Do not initiate rapid nutritional rehabilitation without careful monitoring, as this increases the risk of fatal refeeding syndrome, particularly in severely malnourished patients who are also alcohol-dependent. 3 Initiate slow, cautious refeeding with phosphorus supplementation. 3

Do not delay hospitalization based on patient or family denial of illness severity—both conditions are life-threatening and require aggressive early intervention. 3

Avoid power struggles and emphasize building a collaborative therapeutic relationship. 1

Long-Term Management

Alcohol and other drug use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse. 7 Treatment should include continuing care to reduce relapse risk, with extended treatment models providing a continuum of care rather than distinct phases. 7

Monitor for relapse of either condition, as excessive alcohol intake can reoccur even after initial improvements, accompanied by increases in negative affect and eating disorder impairment. 8 Longer-term therapy is required for patients with co-occurring conditions. 8