Friday, June 8, 2018

Medical Complications: A Troubling Presence at Admission

Vol. 29 / No. 2  

Comorbid medical complications were common among adults admitted with EDs.
The importance of medical complications in ED is well recognized within the ED treatment community, but a comprehensive view of their frequency has been lacking. Now, a team of researchers has found “a substantial and troubling presence of medical complications” in the largest single-site study thus far of medical conditions reported among adults being admitted for eating disorders treatment. The study included 1026 adult inpatients and residential care patients admitted to the Eating Recovery Center in Denver from October 2012 to July 2015. Dr. Phillip S. Mehler and colleagues also found that patients with severe eating disorders have increased complications related to the presence or absence of purging behaviors (Int J Eat Disord. 2018. DOI:10.1002/eat.22830).
The researchers used medical records from a transdiagnostic sample of patients with eating disorders (anorexia nervosa-binge-purge type, or AN-BP, AN-restrictive type, or AN-R, bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS) to find medical complications present on admission. Demographic, medical history, and clinical data were extracted from the records in retrospective review. Laboratory tests were used to detect hematologic, electrolyte and acid-base abnoramlities, including hyponatremia, hypokalemia, metabolic acidosis, hypoglycemia, and hypophosphatemia. Results from cardiac and bone mineral density (BMD) tests were also included.

General characteristics: mostly female, white, and under 30

The great majority of patients were Caucasian (93.2%); 96.3% were female, and the average age was 28.1 years (range: 17 to 69 years). Males were younger than females, had higher BMIs, and overall a shorter duration of illness. The average BMI was the same for patients with AN-R and AN-BP, 15.5 mg/kg2. In contrast, the average BMI for patients with BN was 20.8 mg/kg2. Among patients with purging behaviors, 79.5% used self-induced vomiting. More than a third (38.4%) of patients with AN-BP abused laxatives. Diuretics were abused by 8.0% of those with AN-BP, compared to 13.1% of those with BN.

Laboratory values: multiple abnormalities were seen

The authors reported that the admission laboratory results showed a large number of abnormalities. For example, hypokalemia was identified in 42.4% of those with AN-BP, while 16% of those with AN-R were found to have hyponatremia, as were 17.1% of patients with AN-BP.
Metabolic and biochemical abnormities were also seen. One of the most marked results was vitamin D deficiency and insufficiency, a particularly troublesome problem among ED patients Int J Eat Disord. 2015; 48:607). Vitamin D deficiency was found in 30.0% of those with AN-R, 33.9% with AN-R, 43.0% of those with BN, and 54.1% of patients diagnosed with EDNOS. Hypoglycemia was reported in 7.1% of those with AN-R, 5.0% of those with AN-BP, and 6.5% of those with BN.

Hematologic and bone abnormalities

Low white cello counts were reported in 38% of those with AN. Anemia, particularly macrocytic anemia, was seen in about 20% of AN patients. The authors pointed out that when microcytic anemia is present in patients with eating disorders, the eating disorder may not be the only cause.
On electrocardiograms, bradycardia (slow heart rate) was common. it was notable that normal QTc intervals were found in the vast majority of patients with AN. The authors made an interesting point about the long-time concern that marked increase of sudden cardiac death among AN patients might be partially caused by a prolonged QTc interval. However, newer evidence has shown that the QTc is not inherently prolonged in AN and when it is prolonged, it might be due to either aberrant electrolyte levels or to an adverse reaction to medication (Vascular Health & Risk Management. 2012; 8:91). The study results further show that when a patient with AN has a dangerously prolonged QTc interval (>480 milliseconds), it is best not to immediately ascribe it to AN but to look for other possible causes.
A final area of concern was the bone density results, which underscored the aggressive bone loss often seen among eating disorders patients. More than half of the patients with AN had significant loss of BMD, placing them in the osteopenic or osteoporotic categories. Among those with AN, 31.3% had osteopenia, and 25.9% had osteoporosis, leaving them at a lifetime risk of fragility fractures. The authors recommend that “each time a patient enters treatment, they should be asked when their last DXA scan was done.
The results from this valuable study of more than 1000 patients illustrates the wide array and high frequency of medical comorbidities found in adult patients with eating disorders, and once more underscores the importance of timely diagnosis and treatment, with continuing close involvement by skilled clinicians.

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