This is a new guideline from NICE on managing eating disorders. It is really targeted around anorexia nervosa and bulimia. Much of this is not new, but as we don't see patients with these disorders too often, I'll do a general summary, but concentrating on things I wasn't aware of.
This is not an exhaustive list, but these were some of the presentations I hadn't considered:
- Problems managing chronic conditions involving weight (eg diabetes or coeliac).
- Menstrual or other endocrine disorders, or unexplained GI symptoms.
- Physical symptoms (eg dizziness or faintness).
Assessment of patients
- Mental health problems may coexist (eg anxiety, depression, suicidal thoughts, OCD).
- Alcohol or substance misuse may be present.
1. Obs (pulse / BP)
2. Bloods (including glucose, electrolytes, LFT)
4. Sit and squat stand test (First ask patient to lie prone, then go to sitting. Then ask them to stand, squat then stand again. Score each of these 2 elements separately. 0 = unable. 1 = need to use hands to help. 2 = with difficulty. 3 = able with no difficulty. A score of 2 or less is very concerning, as is a rapid decrease in ability).
Assessing patients with possible severe anorexia
There are 2 very useful documents that should be referred to if you have a patient who is very unwell, or you suspect may be very unwell. They outline what criteria to look for and how concerned to be:
Junior MARSIPAN (young people)
Refer all patients with a suspected eating disorder. Do not use length of illness, need for treatment or BMI as criteria for referral.
Young people with eating disorders may have faltering growth or delayed pubertal development. They should be referred to a paediatrician.
Emergency referral should be made if their physical health is compromised or they are suicidal or if they have:
- Severe electrolyte imbalance.
- Severe malnutrition.
- Severe dehydration.
- Incipient organ failure.
Inpatient care may be needed. Obviously we will not decide this, but it is worth knowing the criteria advised as it will help us judge severity:
- Rapid weight loss (> 1kg per week).
- If medical monitoring is required (eg bloods, obs, ECG).
- Support is not adequate.
- If physical or mental health is rapidly declining.
- If there is suicidal risk (when psychiatric input may be needed).
Treatment of anorexia nervosa in general practice
The aim of treatment is to achieve a normal BMI or weight for age.
Patients can be discharged to primary care if they are not having treatment (eg if it has not helped or they have declined) and if they do not have severe or complex problems.
If they have severe or complex problems, even if they are not having treatment, they should stay under secondary care for monitoring of their physical health.
Medications - multivitamin supplements are advised until diet is adequate.
GP review - patients should be reviewed at least annually if they are not under secondary care. Review should include:
- Weight or BMI.
- Bloods if needed.
- Assessing any problems with daily functioning.
- Assessing risk - both physical and mental.
- ECG (if there is purging or significant weight change)
- Discussion of treatment options.
- Growth and development monitoring in young people
Young people need a bone scan after 1 year and adults after 2 years. If there is bone pain or recurrent fractures, then a bone scan should be done sooner. They should be repeated no more than annually as long as the patient remains underweight. Specialist advise should be sought before starting any treatment.
Diabetes and eating disorders
- Consider insulin misuse.
- Do not try to rapidly correct hyperglycaemia by increasing insulin doses as this can cause retinopathy and neuropathy.
- Patients are at higher risk of hypokalaemia, other electrolyte imbalance, bradycardia and long QT. You may need to offer ECG to patients on medications that could affect these.
Pregnancy and eating disorders
- There is a higher risk of not conceiving and of miscarriage.
- Beware of maternal concerns re gaining weight.
- There is a higher risk of mental health problems in the perinatal period.
Advice to give patients
- Exercise - advise to stop. Need to avoid weight bearing exercise or exercise with a risk of falls if there is low BMD.
- Vomiting - advise to have regular dental reviews. Avoid brushing teeth straight after vomiting. Avoid highly acidic foods and drinks. Rinse with a non-acidic mouthwash after vomiting.
- Laxative and diuretic use - advise patients that these do not reduce calorie absorption and so do not aid weight loss. They should gradually wean off them.