Jennifer L. Gaudiani, MD, CEDS. Assistant Medical Director, ACUTE Associate Professor of Medicine, University of Colorado

Transcription

1 Jennifer L. Gaudiani, MD, CEDS Assistant Medical Director, ACUTE Associate Professor of Medicine, University of Colorado

2 Who are ACUTE patients? years old (average 26) 10% men Average BMI on admission 12.5 kg/m2 Wide variety of pre admission function Average length of stay around 2 weeks From all over the country

3 Falling through the cracks Too medically sick for me too mentally ill for you

4 Objectives: Motivation! Help empower you to translate to your client: Themedical complications of severecaloric restriction and underweight The medical complications of severe purging g The best practices of refeeding and detoxification from purging g( (advocate, educator) How to use knowledge of medical problems to promote recovery

5 Format: Discuss Two cases (Some) pathophysiology p Best practices to manage/fix What we say to our patients Literature/evidence

6 What is definitive stabilization? Use best medical evidence to providesafe safe, sensible, supported multidisciplinary care until patients meet our discharge criteria: (oral) a day: sufficient to be gaining >1 kg lean weight weekly Labs normal or normalizing Completed refeeding syndrome and no longer on electrolyte repletion Bowels working, minimal edema (fluid overload) Physically strong enough to transfer to mental health y y g g setting

7 Medical complications In AN R Organ dysfunction due to under weight and malnutrition High risk for refeeding syndrome In purging (AN or BN) Type of purging g used, frequency, and duration Detox can be complicated too

8 The good news: Nearly all medical complications can resolve with consistent nutrition and full weight restoration

9 Case: AN R A 23 year old started an intense workout program with her sorority sisters couldn t stop Over two years, weight 34 kg, 163 cm tall, 60% IBW, BMI 12.5 kg/m2 Insists on outpatient care the whole time Has good energy and works full time, volunteers minimal symptoms except early fullness when she eats Lb Labs are fi fine just some increase in her liver tests t and a low white blood cell count Finally team and family insist on admission to a program

10 Case: AN R On further questioning: Episodes of feeling sweaty and lightheaded Stopped working out a few weeks ago because she was too fatigued She struggles with any sense she s s ill Discounts words of concern and over values statements of normalcy/praise

11 AN R Refeeding syndrome Gastroparesis Ot Osteoporosis Low cell counts Hepatitis Hypoglycemia Vital sign abnormalities Cardiac abnormalities

12 Refeeding syndrome Potentially deadly syndrome that occurs when a starved person begins to take in nutrition

13 Refeeding syndrome Phosphoroush Metabolism of food pulls phosphorous into cells, used for energy building blocks Food (carbohydrates) consumed Low serum phosphorous

14 Refeeding syndrome Low phosphorous can be dangerous or deadly Full blown refeeding syndrome Respiratory fil failure Red and white blood cell dysfunction Muscle breakdown Seizures Congestive heart failure Cardiac arrest Refeeding hypophosphatemia can be caught and corrected before complications

15 Refeeding syndrome Close monitoringpreventsfull blown syndrome Start calories around /day, low salt, <40% kcals from carbohydrates Important Australian contributions at the leading edge Intensive dietician input and support Advance by 400kcal every 3 days, checking phosphorus levels daily in week 1, replete <3 mg/dl Encourage leg elevation, compression stockings Whitelaw M, Gilbertson H, Lam PY, Sawyer SM. Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? J Adolesc Health 2010;46: Kohn MR. Madden S. Clarke SD. Refeeding in anreoxa nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr 2011;23:

16 Gastroparesis Loss of normal stomach peristalsis (movement) Causes early fullness, nausea, bloating, gassiness Nearly universal in severe underweight Rarely is a nuclear med emptying study needed in this population

17 Gastroparesis Worsens - Smaller meals - High fiber diets - Liquids/semi solids - Long time - Low fiber underweight - With caution, - High fat diet metoclopramide Large meals mg before meals, or erythromycin limit y time use Helps

18 What we tell our patients: Your weight has fallen so low that your whole body is slowing down to conserve energy. This should fully resolve once you have restored your weight.

19 Pancytopenia Gelatinous Marrow Transformation Replacement of cell producing marrow with an acellular goo due to starvation All cell lines may be affected Source of inappropriate workup

20 What we tell our patients: Your bone marrow is so starved, it s stopped producing blood cells It will fully recover with weight restoration You don t need a bone marrow biopsy or any medicines i to s mulate your marrow this isn t a marrow problem, it s a starvation problem.

21 Vital signs Vital signs abnormalities highly prevalent Adaptive, compensatory responses to malnutrition, hibernation mode Bradycardia at rest (vagal tone) Tachycardia with movement Deconditioning, not orthostasis Helps distinguish between athetic and starved heart Hypotension, hypothermia

22 What we tell our patients: Your heart rate is abnormally low and high because you are underweight and weak. Sudden cardiac death accounts for 30% of deaths in anorexia, and we don t exactly know what triggers the heart to stop. A human shouldn t have hibernating vital signs. Your metabolism has slowed way down. As soon as you you start to eat consistently, your furnace will turn back on.

23 Osteoporosis The one potentially irreversible complication Onset of bone loss is rapid (2.5%/year) and severe By the end of the second decade, more than 90% of peak bone mass has been achieved in healthy h woman: in adolescent onset AN this never occurs Highly prevalent Mehler PS, Cleary BS, Gaudiani JL. Osteoporosis in anorexia nervosa. Eat Disord 2011;19:

24 Osteoporosis Goldstandard: weight restoration Until resumption of menstrual cycle in women 2010 Spanish study compared BMD improvement in AN patients restoring weight (20% mean increase in weight) with those who did not gain weight At 2 years, gainers hdi had improved dbone density 2 to 5% Non gainers had lost1% to 4% bone density Olmos JM et al. Time course of bone loss in patients with anorexia nervosa. Int J Eat Disord 2010;43(6):537 42

25 Osteoporosis Estrogen Virtually all RCTs conclude just say no to estrogen Use obscures the benefits of natural menstrual cycle resumption (and precipitates monthly blood loss)

26 Osteoporosis: Exercise Doesn t exercise help bone density? While underweight: exercise worsens bone density Once restored: even intense exercise helps bone density Waugh EJ et al. Effects of exercise on bone mass in young women with anorexia nervosa. Med Sci Sports Exerc May;43(5):755 63

27 What we tell our patients: Serious exercise is a privilege of recovery.

28 Osteoporosis Men Men typically have 1/3 the rate of osteoporotic ti hip and vertebral tb fracture rates of women Men with AN had greater loss of bone than women even though men typically had shorter duration of their disorder Men may fracture at higher bone density level than women Mehler PS et al. High risk of osteoporosis in male patients with eating disorders. Int J Eat Disord 2008;41(7):

29 Hepatitis Liver function tests (LFTs) are often elevated in severe AN *Starvation mediated*: Autophagy on biopsy, py, recovers with refeeding. More common. Often worsens for 1 st week of refeeding. Refeeding mediated: Steatohepatitis, i recovers with ihslowed refeeding

30 Hypoglycemia y Potentially deadly dl Glucoses < 60 mg/dl are low In underweight, result from depletion of glucose building g blocks in liver Liver tests > 3 x normal predict hypoglycemia

31 Case: Purging g A 46 year old woman with a lifetime of AN BP presents again for admission. She has a BMI of 14 kg/m2.

32 Case: Purging g 50 stimulant laxatives daily Purges by vomiting up to 30 times daily GP has prescribed lots of oral potassium pills In treatment may gain 5 10 kg of water weight within days Often fails to have a BM for 2 weeks straight Her cheeks typically swell painfully in treatment She leaves AMA a lot

33 Case: Purging g Sodium 123, potassium 1.9, bicarb 42, BUN 31 and Cr is 1.1 Parotid hypertrophy h

34 Purging g( (AN or BN) Properly managing volume depletion (dehydration) Avoiding volume overload The potassium problem Constipation and the perils of laxatives

35 Pseudo Bartter Syndrome Secondary hyperaldosteronism Responsible for swelling after purging cessation Causes urinary K loss Resolves after 2 weeks of hydrated state Bahia A. Mascolo M. Gaudiani JL. Mehler PS. PseudoBartter syndrome in eating disorders. Int J Eat Disord 2012;45(1): 150 3

36 Pseudo Bartter Syndrome Key points to treat 1. Stop purging 2. Slowly give IV fluid (no faster than 50 ml/hr) 3. (Or follow low sodium diet and 2 3 liters fluid a day), feet up 4. Treat the hormone over production until body downregulates

37 Pseudo Bartter Syndrome To prevent edema from Pseudo Bartter p Syndrome

38 Perils of stimulant use Constipation universal in severe underweight Slowed GI transit High fiber worsens at low weights

39 Constipation Manage expectantly Set expectations for normal range of bowel function Polyethylene glycol, no stimulants Intestine works best at K of 4.5 or so

40 X ray promise

41 X ray promise Minimal stool? Lots of stool?

42 Cathartic Colon Syndrome A.K.A Why we don t taper stimulant laxatives we STOP them

43 Questions?