02. Antipsychotics in the Treatment of Youth With Anorexia Nervosa

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Hi! David Rosenberg here for the Psychopharmacology Institute. In this CAP Smart Take, we delve into the question of antipsychotic medication’s safety and efficacy in children and adolescents diagnosed with anorexia nervosa. Notably, there is currently no FDA-approved pharmacotherapy for anorexia nervosa. Pharmacologic interventions play a limited role in treating this disorder, especially in younger populations. The rise in anorexia cases in recent years makes this investigation imperative. Typically, pharmacotherapy targets psychiatric comorbidities linked with anorexia nervosa, not its core symptoms. Some advocate for the use of antipsychotics—especially second-generation antipsychotics—due to their weight gain side effect, which can be more pronounced in younger patients. In individuals with anorexia nervosa, this might be considered a beneficial side effect. However, other adverse effects of second-generation antipsychotics, like diabetes and metabolic syndromes, can pose higher risks to pediatric patients compared with adults.

Pruccoli and colleagues explored this critical yet understudied area. Twenty-eight studies on antipsychotic use in children and adolescents with anorexia nervosa were scrutinized. Regrettably, the quality of these observational studies was largely unsatisfactory. Only 1 was deemed of good quality, whereas 5 were categorized as poor. Additionally, 13 were case reports or case studies. Although almost all studies reported improvements with olanzapine concerning weight and psychopathology, the sole study of good quality did not. Most studies indicated weight gain and improvements in comorbid conditions like depression, anxiety, and obsessions.

Thus, the evidence is insufficient to generalize the use of olanzapine in children and adolescents with anorexia nervosa. Olanzapine, a second-generation antipsychotic, is associated with weight gain—potentially beneficial for this population. However, each case must be judged independently.

Only 5 case reports documented risperidone use in youth with anorexia nervosa, indicating positive outcomes. Gathering evidence for aripiprazole’s use proved difficult with only 2 low-quality studies and a small case series available. Although there’s a potential role for aripiprazole in pediatric psychiatry, the lack of quality trials hinders conclusive recommendations.

A study examined various antipsychotics in youth with anorexia nervosa. Despite some promising results, these studies were hindered by their small sizes and varied medications. Although first-generation antipsychotics, like chlorpromazine and haloperidol, were occasionally reported, the current preference is for second-generation antipsychotics.

In conclusion, evidence-based treatments for anorexia nervosa mainly include psychological interventions, family therapy, education, and dietary guidance. Although the SSRI fluoxetine is FDA approved for bulimia nervosa, its use in weight-depleted anorexia nervosa patients is discouraged. However, once weight is restored, SSRIs can potentially reduce relapse risk. Interestingly, hospitalization data reveals that patients closer to their ideal body weight upon discharge are more likely to maintain it and avoid relapse. Unfortunately, insurance constraints often limit the extent of hospital care. It’s crucial to recall the severe consequences of anorexia nervosa; its mortality rate stands at 10%.

Abstract

Evidence about the use of pharmacologic agents in the treatment of Anorexia Nervosa (AN) is lacking, especially in childhood and adolescence. A systematic scoping review was conducted to outline current literature evidence about the use of antipsychotics in this population. A total of 499 studies were identified with the initial search, and 28 of these studies were selected regarding the use of olanzapine (n = 13), risperidone (n = 4), aripiprazole (n = 3), chlorpromazine (n = 3), pimozide (n = 1) clotiapine (n = 1) and multiple antipsychotics (n = 3) in these patients. Overall, major side effects were reported infrequently; improvements in psychopathology and weight measures have been suggested in the majority of the considered studies. Nonetheless, the lack of RCT or good-quality studies strongly limits the generalizability of results in clinical practice.

Reference

Pruccoli, J., Bergonzini, L., La Tempa, A., & Parmeggiani, A. (2022). Antipsychotics in the treatment of children and adolescents with anorexia nervosa: A systematic review. Biomedicines, 10(12), 3167.