Post on 05-Dec-2014
description
Anorexia nervosa, re-feeding
syndrome and endocrine sequelaeMark Daly
Why this talk…..Traditionally eating disorders have been looked after by either gastro-enterologists or endocrinologists with the support of psychiatry
There are few conditions where such strong leadership is necessary in the best interests of the patient and may go counter to the instincts or wishes of members of staff
Anorexic woman from Wales to be force fed,
judge ordersA woman with "severe" anorexia who wanted to be allowed to die is to be force fed in her "best interests" by order of a High Court judge.
She was being looked after in a community hospital under a palliative care regime whose purpose was to allow her to die in comfort
Treatment - "does not merely entail bodily intrusion of the most intimate kind, but the overbearing of E's will in a way that she experiences as abusive".
A not unusual pathway of
care…..19 yr old girl, admitted BMI of 12
Intermittent institutionalised care since age 9 with Anorexia nervosa
Admitted because of recent further weight loss, minimal intake for 1 week
Agreed for a voluntary admission
Admission criteriaBased on recent change in the context of absolute BMI, physiological and functional parameters
Physical concernConcern Admit
BMI <14 <12
Wt loss (kg/week)
>0.5 >1
BP <90/70 <80/60
Postural drop >10 >20
Pulse <50 <40
Temp <35 <34
Muscular strength
Uses arms to stand
Can’t stand
WBC <4 <2
Hb <11 <9
Plts <130 <110
Physical concern(2)Concern Admit
NA+ <135 <130
K+ <3.5 <3.0
Mg2+ If depleted If depleted
Po4- If depleted If depleted
ECGqtc >450msec >450 or arrhythmia
ALT >45 >90
Bilirubin >20 >40
Alk phosp >110 >200
Albumin <35 <32
O/EWell presented
Gross cachexia
Hypotensive and bradycardic
Pre-pubertal
Initial investigations
Hb 11.0,WCC 2.0, Plts 78
Na+ 127, K+ 3.1, urea 1.8, creat 38, PO4- 0.75
ECG bradycardia, long QT
Initial planMedical
Initial assessmentNa+, K+, Urea, Creat, glucose, CRP
Mg2+, PO4-, Ca2+
Albumin, liver enzymes, INR
FBC, ferritin, folate, B12
FSH, LH Oest or testo
Thiamine 300mg daily, vit b complex strong 2 tabs od, multivit generic, sandophosp 2 tabs tds
Pabrinex
Initial planNutritional
5 kcal per kg stepping up over 5-7days to weight gain levels (+500kcal over estimates from Henry equation
(10kcal per kg if BMI>16)
Menu plans agreed with patient
Initial planBehavioural/other restrictions
Normal foods in preference to supplements
Bed rest/commode/wheelchair
Away from window, no fans
Restrictions according to Mental health status
Compliance essential
ProgressDay 3, non-compliance with feeding plan
Non-compliance with activity
Reviewed with psych
Formal section
Advised likely need to progress to NG feeding in absence of compliance and/or weight gain
Informed of need to search belongings
ProgressDay 5, intermittent compliance with feeding plan
Reviewed with psych
Razor blades and salt sachets removed
NG feeding under restraint, NG re-positioned/replaced 5 times first 24 hrs
Bolus feeds under restraint during periods of non-compliance
ProgressDay 8
Hypokalaemia and hypophosphataemia requiring IV replacement
Subsequent weight gain back to BMI 15
Established weight stability at BMI 15 on oral intake and basic mobility
Discharged to OP ED services
Anorexia nervosa
What is anorexia nervosa?Anorexia nervosa is defined as:
intense fear of weight gain
Weight consistently < 85th percentile for age and height (In women) three consecutive missed periods
Together with one of following: refusal to admit seriousness of weight loss undue influence of shape or weight on one’s
self-image disturbed experience in one’s shape or weight
DSM-IV-TR
Types of Anorexia
RestrictingWeight loss achieved by restricting calories
Following diets, fasting, and exercising to excess
• Purging– Weight loss
achieved by vomiting, laxatives, or diuretics
CausesAnorexia Nervosa patients tend to have
Low self-evaluation
Come from competitive, high-achieving, and protective families
Set perfectionist standards
Intensely concerned with how others perceive them
Fear falling short of expectations
Genetics
Culture
Idealize thinness
Have poor body image
Feel shame, depressed, and dissatisfied with their own bodies
SymptomsDramatic weight loss
Preoccupation with weight, food, calories, fat grams, and dieting
Refusal to eat certain foods, or whole categories of food (e.g. no carbohydrates)
Denial of hunger
Excessive, rigid exercise regimen
Withdrawal from usual friends and activities
Weight loss and dieting become primary concerns in life.
Constant excuses to avoid mealtimes
Anxiety about gaining weight or being fat
EpidemiologyUK
1 in 250 females
1 in 2000 males
SMR 9.5
Mortality of 0.6% per year
Higher in those presenting after age 20
50 years of treatment outcomesComparison of outcomes 1950-1999 to gauge
whether any improvement over time.
119 studies conducted 1950-1999
5,590 patients, adolescents and adults
Follow-ups clustered into three time frames:
- fewer than 4 years after hospitalization;
- 4-10 years;
- more than 10 years after
Steinhausen HC. Am J Psychiatry. 2002.
Outcome measuresBroad outcome measures: death, recovery, improvement, chronicity.
Symptom normalization measures: weight, menstruation, eating behavior
Psychopathologies such as affective disorders, OCD, anxiety, substance abuse.
Steinhausen HC. Am J Psychiatry. 2002
Outcome of Anorexia Nervosa in 119 Patient Series by Duration of Follow-Up and Age at Onset.
A total of 577 patients had less than 4 years of follow-up, 2,132 had 4–10 years of follow-up, and 438 had more than 10 years of follow-up.
“The mortality rate was much lower in the group of younger patients than that in the group with a much wider age at onset of illness. The rates of recovery, improvement, and chronicity were more favorable in the group with the younger patients.”
Steinhausen HC. Am J Psychiatry. 2002
Outcome of Anorexia Nervosa in 119 Patient Series by Duration of Follow-Up and Time Period of Study.
A total of 577 patients had less than 4 years of follow-up, 2,132 had 4–10 years of follow-up, and 438 had more than 10 years of follow-up.
“Anorexia nervosa did not lose its relatively poor prognosis in the20th century.”
Steinhausen HC. Am J Psychiatry. 2002.
Re-feeding syndrome
First described in American Japanese POW
Precipitated cardiac failure
clinical features of refeeding syndromerhabdomyolysis, leucocyte dysfunction, respiratory failure, cardiac failure, hypotension, arrhythmias, seizures, coma, and sudden death
Driven by low serum phosphate (<0.5)
Re-feeding syndrome -
pathophysiologyinsulin is decreased due to a reduced oral carbohydrates.
fat and protein stores are catabolized
Intracellular loss of electrolytes, esp. phosphate.
intracellular phosphate stores can be depleted despite normal serum phosphate concentrations
a sudden shift from fat to carbohydrate metabolism -secretion of insulin increases -stimulates cellular uptake of phosphate,
usually occurs within four days of starting to feed again.
Phosphate is necessary for ATP from ADP and AMP
How do we manage it?
Risk is obvious
Degree of risk is not
Assume risk is reduced after 1 week of good intake AND weight gain
Often use telemetry – some centres use it continuously for all patients
ECG daily is essential
Exeter protocol(with thanks to Roderick
Warren)Assume high risk in all cases. Medical inpatients with anorexia nervosa who require inpatient feeding are almost always at high risk of refeeding syndrome.
However, NICE guidance (2006 – CG32) states that the risk is high if:• One of: BMI<16, weight loss >15% in last 3-6 months, little or no nutrition >10 days, low potassium/phosphate/magnesium levels prior to feeding.• Two of: BMI <18.5, weight loss >10% in last 3-6 months, little or no nutrition >5 days, history of alcohol abuse or use of insulin/chemotherapy/antacids/diuretics/(laxatives)
Exeter protocol
Bloods before feeding:
Sodium, potassium, urea, creatinine, glucose, CRP
Magnesium, phosphate, calcium
Albumin, liver enzymes, INR
FBC, ferritin, folate, B12
FSH, LH, oestradiol (females) or testosterone (males)
Thiamine: 300mg per dayVitamin B Complex (Strong): 2 tablets, once per day Multivitamins: generic, 1 tablet, once per day Phosphate-Sandoz: 2 tablets, three times daily
Exeter protocol
Daily bloods while risk of refeeding syndrome is high:
• Sodium, potassium, urea, creat, glucose, magnesium, phosphate, calcium
Bloods once-twice weekly when stable (after 3-4 days of sustained feeding and no electrolyte abnormalities):
Sodium, potassium, urea, creatinine, glucose
Magnesium, phosphate, calcium
Albumin, liver enzymes
FBC
Exeter protocol
Mild deficiency (3.0 – 3.5 mmol/L)
• Sando-K or equivalent, 4-8 tablets daily
Moderate-severe deficiency (<3.0 mmol/L)• Intravenous, using pre-prepared bags of 1 litre 0.9% saline with 40 mmol potassium chloride, given over at least 4 hours (but usually longer e.g. 12 hours).
Anorexic patients may be chronically hypokalaemic.
Exeter protocol
Mild deficiency (>0.5 mmol/L and not falling rapidly) • Phosphate-Sandoz 2 tablets, three times daily
Moderate-severe deficiency (<0.5 mmol/L, or higher but falling)• Intravenous, using pre-prepared bags of Phosphates Polyfusor, 500ml over 24 hours.
– monitor calcium. Will precipitate if co-infused with calcium – always avoid infusing magnesium or calcium through the same cannula.
– check levels after 24 hours.
IV phosphate. Various recommendations suggest 9, 12 or 18 mmol administered over 12 hours. However, the use of an entire Polyfusor bag (containing 50 mmol phosphate) has been shown to be a simple, effective and safe approach. Mild hyperphosphataemia is not uncommon (levels up to 1.57 mmol/L have been seen) – consider a smaller dose (e.g. 250 ml over 12 hours) for less severe hypophosphataemia.
Exeter protocol
Mild deficiency (>0.6 mmol/L) Magnesium glycerophosphate 2 tablets, twice daily.
May cause GI irritation/diarrhoea. Avoid with co-admin with phosphate
Moderate-severe deficiency (<0.6 mmol/L) IV magnesium sulphate, 20 mmol over 12 hours, or 40 mmol over 24 hours. Can be given faster in emergencies
Will precipitate if co-infused with phosphate – always used a separate cannula.
Magnesium levels may drop rapidly after correction - several days of IV replenishment may be required before they become stable.
Exeter protocol- calcium
rarely necessary. Correction of hypomagnesaemia may improve calcium levels. Administration of phosphate may lower calcium levels.
Asymptomatic mild-moderate deficiency
Calcichew, 1-3 tablets daily.
Do not administer at same time as phosphate – insoluble CaPO4 will form. Symptomatic or severe deficiency
• IV calcium chloride or calcium gluconate, 10 mmol over at least 10 min (but usually longer e.g. 1 hour).
Followed by infusion of 40 mmol over 24 hours.
Must be diluted before administration
A more unusual case….
Douglas
To GP, Feb 2010
Weight loss feeling tired
Recent junior Exeter chiefs player
Creat high at 110, glucose 2.1, Hb12.6, WCC 3.4
Subsequent fall in WCC, rise in ALT
DouglasFt4 12.3, cortisol 594, fsh 0.6, lh 0.4, PRL 208, testo 0.8
GH 15.1, IGF1 8.6
68kg BMI 20.9, prior weight 111kg 6 mths earlier
Clinically cachectic, lanugo hair, but post-pubertal
Admitted – psych confirmed significant AN
Weight regain to 76kg, BMI 23
Partial recovery of pancytopaenias, no recovery of gonadotrophins despite weight regain and 2 trials of testosterone cessation
Anorexia and fertility
Very little data in men for longer term
Testo crashes during acute illness
Seems to be less marked than in females
Partly an adaptive response
Many recovered anorexic patients go on to successful pregnancies
ConlcusionsBehaviourally challenging
Strong leadership
Need to be physiologically alert