CPG for Eating Disorders

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PHARMACOLOGICAL TREATMENTIn this section, scientific evidence on the efficacy and safety of several drugs studied for thetreatment of eating disorder patients is described. Only randomised controlled trials (RCT) ofsufficient quality have been included. The drugs assessed are included within the followinggroups: antidepressants, antipsychotics, appetite stimulants, opioid antagonists, anticonvulsants,psychostimulants and antiemetics.Although benzodiazepines such as alprazolam and lorazepam are indicated as anti-anxietydrugs no RCTs that address their use for eating disorders have been identified. A similarsituation has been encountered with lithium.9.9. AntidepressantsEvidence relating to eating disorders has been identified for the following antidepressants,according to the group they belong to:– Selective serotonin reuptake inhibitors (SSRIs): fluoxetine, citalopram, fluvoxamine.– Other antidepressants: sibutramine and trazodone.– Tricyclic antidepressants: amitriptyline, clomipramine and imipramine.9.9.1. Anorexia nervosa9.9.1.1. What is the efficacy of antidepressants in patients with AN?The answer is based on the NICE CPG (2004) 30 where the RCT results are described, on thehigh-quality SRSE (1++) elaborated by the AHRQ of the US (2006) 31 and on a more recentlypublished one conducted by Bulik, et al. (2007) 202 . The update search has not yielded any newevidence.Scientific EvidenceThere is limited evidence to indicate that there are significant differences betweenfluoxetine and placebo in body weight restoration in inpatients treated over one year (1RCT; N=35; Kaye, 2001 279 ; RR: 0.45; 95% CI: 0.23 to 0.86)In an RCT (Attia, 1998; USA) 280 fluoxetine (60 mg/day) was compared to placebo in 31female inpatients with AN (age: 16-45 years). Both groups experienced decreasedclinical symptoms related with eating disorders, obsessive-compulsive disorders,depressive behaviours and pre-occupation with food and its rituals. In both groups anincrease in the percentage of BMI was reported. There were no significant differencesbetween fluoxetine and placebo in any of the results.RCT1++RCT1++138CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS
In an RCT (Kaye, 2001; USA) 279 fluoxetine was compared to placebo in 39 adult femaleinpatients and outpatients with AN. Patients, before being discharged, received20mg/day of fluoxetine, which was adjusted to a maximum dose of 60mg/day at 52weeks. The group treated with fluoxetine presented significant increases in BMI anddecreases in depression, anxiety, obsessive-compulsive disorders and symptoms relatedwith eating disorders.In an RCT (Biederman, 1985; USA) 281 amitriptyline (175 mg/day) was compared toplacebo in 25 patients and outpatients (age: 11-17 years) with AN. There were nosignificant differences in symptoms related with eating disorders, behaviour or weightwhen compared to placebo.In an RCT (Halmi, 1986; USA) 282 amitriptyline (160 mg/day) was compared tocyproheptadine (appetite stimulant) (32 mg/day) and to placebo in 72 female inpatients(age: 13-36 years). In the group treated with cyproheptadine, daily calorie intake wassignificantly greater than in the placebo group. In the groups treated with amitriptylineand cyproheptadine, weight restoration increased in less days than the placebo group.Patients with nonbulimic AN obtained better results with cyproheptadine than withamitriptyline or placebo.RCT1+RCT1+RCT1+Summary of the EvidenceSRSE 311++CPG 30SRSE 311++SRSE 311++The literature that exists on pharmacological treatment of AN is scarce andinconclusive. Most RCTs are based on small samples and very few of themhave statistical value to support their conclusions. Many studies includepatients who are receiving other treatment, whether it is psychological orpharmacological. As far as cases studied, they include inpatients that laterreceive outpatient treatment, which prevents generalisation of results.There is evidence that indicates significant differences in weight increase by theend of multimode treatment with antidepressants when compared to placebo (4RCT; N=146;Attia, 1998 280 [fluoxetine]; Biederman, 1985 281 [amitriptyline];Halmi, 1986 282 [amitriptyline]; Lacey, 1980 283 [clomipramine]).There is insufficient evidence to determine that there are significant differencesbetween antidepressants (citalopram) and wait-list in weight gain by the end ofoutpatient treatment (1 RCT; N=26; Fassino, 2002) 284 .Tricyclic antidepressants can be associated with improvement of disorderssecondary to eating disorders. However, these results are no associated withweight increase.Recommendations(See recommendations 9.GPH.1. to 9.GPH.6.)139CLINICAL PRACTICE GUIDELINE FOR EATING DISORDERS
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Clinical Practice Guidelinefor Eati
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This clinical practice guideline (C
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Annex 2.7. Diagnostic Criteria for
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This CPG aims to provide the popula
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External Review of Patient Informat
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14. What is the efficacy and safety
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CLINICAL PRACTICE GUIDELINE FOR EAT
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D 6.2. In anorexia nervosa (AN), we
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D 8.6. Primary care centres should
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9.GM.02. Before initiating artifici
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Binge-Eating DisorderA 9.3.3.1. A s
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D 9.GP.11. In children and adolesce
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Binge-Eating DisorderD 9.GPH.6. In
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11. Prognosis of Eating Disorders (
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ED: Eating disorderEDNOS: Eating di
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1. IntroductionBackgroundThe develo
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However, there is a need for a guid
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Table 2. Studies on the prevalence
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2. Scope and ObjectivesTarget Popul
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Aspects not included in the CPGThe
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3. MethodologyThe methodology emplo
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- Synthesis and analysis of the sci
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4. Definition and Classification of
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- Other psychopathological disturba
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Sociocultural factorsThe studies id
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accompany eating disorders. However
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5. Prevention of Eating DisordersKe
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(causal factors). Participants in t
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is a programme that promotes a heal
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MA 1341++MA 1341++No definitive con
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Of all the proposed criteria and re
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Spanish version of the EAT-40In Spa
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of the five dimension results in th
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6.5. It is recommended to use quest
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7.2. How are eating disorders class
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to help them cope with the situatio
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Other examinationsTo ascertain whet
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- Initiating nutritional treatment
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8.2. In eating disorders, what clin
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8.3.2. Criteria for admission to da
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RecommendationsD 8.1. Individuals w
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Page 89 and 90: An RCT (Rigaud, 2007; France) 203 c
Page 91 and 92: 9.2. Nutritional Counselling (NC)9.
Page 93 and 94: Recommendations(See recommendations
Page 95 and 96: Anorexia nervosaRecommendationsD 9.
Page 97 and 98: PSYCHOLOGICAL THERAPIESIn this sect
Page 99 and 100: Summary of the Evidence(See also th
Page 101 and 102: There is limited evidence to sugges
Page 103 and 104: In an RCT (Wilson, 2002; USA) 234 C
Page 105 and 106: SRSE 2401++SRSE 2401++CBT treatment
Page 107 and 108: In an RCT (Bulik, 1998) 236 the ove
Page 109 and 110: Evidence indicates that it is unlik
Page 111 and 112: A 9.3.3.1. Adult patients with BED
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Page 115 and 116: Variable: reduction / remission of
Page 117 and 118: In yet another RCT (Carter, 1998 26
Page 120 and 121: Scientific EvidenceThere is insuffi
Page 122 and 123: Recommendations(See also recommenda
Page 124 and 125: Summary of the Evidence(See summary
Page 126 and 127: In an RCT (Lock, 2005) 271 , 20% of
Page 132 and 133: elaborated by the AHRQ of the US (2
Page 134 and 135: SUMMARY OF THE EVIDENCE FORPSYCHOLO
Page 136 and 137: D 9.GP.6. For patients with AN who
Page 140 and 141: 9.9.1.2. What is the safety of anti
Page 142 and 143: There is strong evidence that antid
Page 144 and 145: Summary of the EvidenceSRSE 311++SR
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Page 148 and 149: An RCT (Appolinario, 2003; Brazil)
Page 150 and 151: 9.10. AntipsychoticsEvidence in AN
Page 152 and 153: 9.11.2. What is the safety of cypro
Page 154 and 155: 9.13.1.2. What is the safety of top
Page 156 and 157: Recommendations(See recommendations
Page 158 and 159: SUMMARY OF THE EVIDENCE FORPHARMACO
Page 160 and 161: COMBINED INTERVENTIONSThis section
Page 162 and 163: Antidepressants vs. antidepressants
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Page 166 and 167: Summary of the EvidenceSRSE 311++SR
Page 168 and 169: 9.16.3. Binge-eating disorder9.16.3
Page 170 and 171: TREATMENT OF EATING DISORDERS THATO
Page 172 and 173: TREATMENT OF CHRONIC EATING DISORDE
Page 174 and 175: 10. Assessment of Eating DisordersK
Page 176 and 177: EDI-2 (Version 2 of the EDI-1)Later
Page 178 and 179: BIABody Image Assessment. Collins,
Page 180 and 181: 10.1.5. The use of questionnaires a
Page 182 and 183: has been widely used. It consists o
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the freedom of articles 17 of the S
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12.2. Is the informed consent of an
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RecommendationAccording to current
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Algorithm 2. Intervention if there
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9) Day care admission criteria:- Fr
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- Oral nutritional support in eatin
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Algorithm 4. Treatment of BN and BE
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14.Dissemination and implementation
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IntegralcareOutcomeSatisfaction ind
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15. Future research recommendations
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Annex 1. Levels of Evidence and Gra
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Annex 2. Clinical chaptersAnnex 2.1
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30. I eat diet food.31. I feel food
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Annex 2.4. Spanish version of the C
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6. Do you feel you have control ove
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20. I feel sad after eating more th
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33. APPLICABLE ONLY TO WOMEN. My la
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12. Do you eat reasonable amounts o
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Annex 2.7. Diagnostic Criteria for
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Within each guideline some variatio
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Bulimia nervosa (307.51)Diagnostic
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Annex 2.8. Spanish version of the E
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Formula:Patients with eating disord
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Annex 3. Information for patients w
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Alert SignsWhat signs can alert us
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members can seek support and guidan
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therapist who guides the sessions a
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negative attitudes towards weight a
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PizotifenThis drug belongs to the g
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TopiramateAnticonvulsant psychoacti
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BULIT Bulimia TestBULIT-R Revised v
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ISCIII Carlos III Health InstituteI
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General Directorate for Public Heal
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2) We identified 20 documents elabo
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estimator, establishing the followi
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17. Detecció i orientacions terap
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59. Lo importante es tu vida. No la
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98. Garner DM. Pathogenesis of anor
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141. Wilksch SM, Tiggemann M, Wade
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181. Rivas T, Jiménez M, Bersabé
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224. Fairburn CG, Jones R, Peveler
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262. McCann UD, Agras WS. Successfu
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302. McElroy SL, Casuto LS, Nelson
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341. Hodes M, Timimi S, Robinson P.
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388. Steinhausen HC. The outcome of
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427. Finnish Medical Society Duodec
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CPG for Eating Disorders

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