PHRM845 Exam 4 (Ott)

Question 1

What is anorexia nervosa?

Answer 1

-Restriction of energy intake leading to
a significantly low body weight (BMI<18.5)
-Intense fear of gaining weight or
becoming fat, or persistent behavior
that interferes with weight gain, even
though at a significantly low weight
-Disturbance in the way in which one’s
body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or persistent lack of recognition of the seriousness of the current low body weight
*Distorted self image no matter the weight the patient gets down to

Question 2

Prevalence of anorexia nervosa

Answer 2

More prevalent in females (diagnosed)
* ~0.9% lifetime prevalence in females
* Less is known about the prevalence in males, but AN is less common in males with ~ 3:1 female to male ratio
-Those with 1st degree relatives with AN are more likely to be affected
-Depression, obsessive compulsive disorder, and suicidal ideation are common in individuals AN

*men with this often get overlooked and left behind
*Most common comorbid diagnosis is depression

Question 3

Restricting type of anorexia nervosa

Answer 3

-During the last 3 months, the individual
has NOT engaged in recurrent episodes
of binge eating or purging behavior
-Weight loss is accomplished primarily
through dieting, fasting, and/or
excessive exercise

**Solely restricting intake; no purging

Question 4

Binge-eating/Purging anorexia nervosa

Answer 4

-During the last 3 months, the individual
has engaged in recurrent episodes of
binge eating or purging behavior (i.e.,
self-induced vomiting or the misuse of
laxatives, diuretics, or enemas)
**The difference between purging
subgroup and bulimia nervosa disorder is
the low body weight for AN

Question 5

BMI to diagnose anorexia nervosa according to the CDC and WHO

Answer 5

18.5 kg/m2 is the low end of normal

Question 6

Health consequences of anorexia nervosa

Answer 6

-Lack of energy to perform daily functions -slows down to preserve energy
-Abnormally slow heart rate, low blood pressure (Cardiac muscle atrophy, hypotension, arrhythmias)
-Decreased bone density (Hypoestrogenic state
Amenorrhea, infertility)
-Muscle loss, weakness
-Fainting, fatigue, decreased metabolic rate, weakness (electrolyte abnormalities; hypoglycemia)–from vomiting and not taking in enough nutrition
-Dry skin, hair loss (Hypercarotenemia (yellowing of skin))–falls out in clumps
-Severe dehydration (risk for renal injury and
failure)–decreased water intake because it leads to weight gain
-Downy layer of hair (lanugo) all over body
(body’s attempt to keep warm)–like hair on baby’s head
-Cold intolerance
-Delayed gastric emptying
-Constipation -from taking laxatives all the time

Question 7

Tx of anorexia nervosa

Answer 7

-Concern for re-feeding syndrome with initial treatment
-Correct electrolyte and fluid deficits, thiamine, vitamin B complex, multivitamin supplements
**Risk of issues with CNS if using dextrose to help replenish fluid; pt cannot OD on thiamine, so always try to give thiamine
-Increase calories slowly (often eating as low as 300 – 700 kcal/day)
* Inpatient re-feeding: Increase by 500 kcal/day every 4 days up to 3500 kcal/day
* Outpatient re-feeding: Initial re-feeding 1200 – 1500 kcal/day (increase weekly by 500 kcal)

**Normal goal: 2000 kcal/day

Question 8

Therapy for anorexia nervosa

Answer 8

CBT (best outcomes)
Psychotherapy

Question 9

Pharmacotherapy for pts with anorexia nervosa

Answer 9

-No drug therapy is FDA-approved
-Olanzapine – modest weight gain (interaction with leptin & causes weight gain that pts feel or don’t feel)
-SSRIs – little benefit for core symptoms (don’t work for anorexia on its own)
-Watch for appetite-suppressing medications
-Bupropion is contraindicated (boxed warning: bupropion increases risk for seizures and this is an issue due to lowering of electrolytes)

Question 10

Binge eating disorders

Answer 10

-Recurrent episodes of binge eating characterized by both of the following:
-Eating, in a discrete period of time an amount of food that is larger than what most people
would eat in a similar period of time
-A sense of lack of control over eating during the episode
-The binge-eating episodes are associated with
≥ 3 of the following:
 ~Eating much more rapidly than normal
 ~Eating until feeling uncomfortably full
 ~Eating large amounts of food when not feeling physically hungry
 ~Eating alone because of feeling embarrassed by how much one is eating
 ~Feeling disgusted with oneself, depressed, or very guilty afterward
-Marked distress regarding binge eating
-Occurs, on average, at least once a week for 3 months
-NOT associated with the recurrent use of inappropriate compensatory behavior (no excessive exercise, purging, or laxative use)

Question 11

How many calories count as binge?

Answer 11

On average, ~3,500 kcal, but some can eat
upwards of 6,000 – 10,000 kcal in one episode

Question 12

Binge eating disorder prevalence

Answer 12

-Lifetime prevalence in the US:
* Females 3.5%
* Males 2%
* Gender ratio is far less skewed (~1:0.7)
-Tends to run in families
* Unclear yet if this is genetic or environmental
-Depression, anxiety, borderline personality disorder, and substance use disorders are more common in individuals with BED

Question 13

How is the severity of binge-eating disorder found?

Answer 13

Looking at the number of episodes/week

Question 14

Health consequences of binge eating disorder

Answer 14

-HTN
-Elevated cholesterol
-CVD
-T2DM
-Gallbladder disease
*Similar to what is observed in obesity (metabolic issues)
*Cholethiasis: high intake of fats can lead to this

Question 15

Tx of binge-eating disorder

Answer 15

-Cognitive Behavioral Therapy
-Pharmacotherapy
* Lisdexamfetamine (Vyvanse®) is FDA approved for the treatment of moderate or severe binge eating disorder
* Studies regarding duration of therapy up to 6 months
* SSRIs, SNRIs, atomoxetine, TCAs, armodafinil, and topiramate have been studied (not FDA-approved)
-CBT + medication provides best outcomes

Question 16

Goal of treating binge eating disorder

Answer 16

Decrease the number of episodes of binge eating
**NOT WEIGHT LOSS

Question 17

Prevalence of bulimia nervosa

Answer 17

-More prevalent in females (diagnosed)
* ~1.5% lifetime prevalence in females
* Less is known about the prevalence in males, but BN is less common in males with ~ 3:1 female to male ratio
-Individuals with anxiety as a child, history of experiencing sexual or physical abuse, childhood obesity, or early pubertal maturation have an increased risk
-Atypical depression, seasonal affective disorder, and impulsive disorders (borderline personality disorder, substance use disorders,
bipolar disorder) are more common in individuals with BN

Question 18

Diagnosing bulimia nervosa

Answer 18

-Recurrent episodes of binge eating characterized by both of the following:
 ~Eating, in a discrete period of time an amount of food that is larger than what most individuals would eat in a similar period of time
 ~A sense of lack of control over eating during the episode
-Recurrent inappropriate compensatory behaviors in order to prevent weight gain (self-induced vomiting or misuse of laxatives, diuretics, or other medications,
fasting, or excessive exercise)
-Occur, on average, at least once a week for 3 months
-Self-evaluation is excessively influenced by body shape and weight
-The disturbance does not occur exclusively during episodes of anorexia nervosa (Need to clarify it is not anorexia nervosa)

Question 19

How to determine severity of bulimia nervosa?

Answer 19

Based on the number of episodes per week

Question 20

Health consequences of bulimia nervosa

Answer 20

-Recurrent bingeing and purging can affect the entire digestive tract
* Electrolyte imbalances due to dehydration and loss of electrolytes through purging (risk for irregular heartbeats and even heart failure and death)
* Inflammation, gastric rupture, and esophageal rupture from frequent vomiting
(Mallory Weiss Tears-tears in esophagus from purging)
* Tooth decay(especially on teeth in back), staining, and permanent loss of dental enamel from stomach acids
released during frequent vomiting
* Chronic irregular bowel movements and constipation as a result of laxative abuse
* Physical sores from exercising too much
* Diabetic Ketoacidosis from withholding insulin in Type 1 DM
-Amenorrhea, orthostatic hypotension, bradycardia, arrhythmias, osteopenia, osteoporosis

Question 21

Methods of purging in bulimia nervosa

Answer 21

-Vomiting (herbal products; fingers down throat)
-Laxatives
-Diuretics
-Excessive Exercise
-“Diabulimia”
* Patients with type 1 diabetes and bulimia give themselves less insulin than they need or stop taking insulin to promote weight loss

Question 22

Outward signs of purging from bulimia nervosa

Answer 22

-Calluses on knuckles used to induce vomiting
-Mallory-Weiss tears in esophagus; can grow and get bigger

Question 23

Treatment of bulimia nervosa

Answer 23

-Cognitive Behavioral Therapy (1st line)
-Pharmacotherapy
* Fluoxetine is FDA-approved (60 mg/day); also useful to treat underlying depression
* Can reduce binge-eating and purging independent of a mood disorder
* Citalopram and sertraline are well-studied
* TCAs and MAOIs may be helpful (not FDA approved, tolerability and safety limit
use)
-CBT + medication provides best outcomes (monitor closely)
-Treat resulting medical conditions