Medical Management of Eating Disorders: An Update

Ulrich Voderholzer; Verena Haas; Christoph U. Correll; Thorsten Körner


Curr Opin Psychiatry. 2020;33(6):542-553. 

In This Article

Life-threatening Medical Findings and Their Management

Among the most dangerous physical findings in eating disorders are severe electrolyte disturbances including hypophosphatemia and the associated risk of refeeding syndrome, and hypoglycemia with subsequent liver failure. Severe imbalances of different electrolytes are often caused by excessive purging or sometimes due to excessive drinking of water. The most common electrolyte imbalances are hyponatremia and hypokalemia. Among the life-threatening complications of these electrolyte imbalances are cardiac arrhythmias and seizures. An important risk factor for serious arrhythmias is QTc-interval prolongation. Recent evidence from the largest study on ECG changes in anorexia nervosa patients summarized that QTc-interval prolongation is not necessarily an inherent feature of eating disorders, but rather associated with electrolyte disturbances or side effects of psychotropic medications.[5] If electrolytes are carefully monitored, the cardiovascular findings in patients' with extreme anorexia nervosa, such as bradycardia, hypotension, myocardial atrophy, pericardial effusion, are rarely alone cause of fatal complications. Severe hypokalemia may also cause renal failure and require haemodialysis. Another serious condition can be hypophosphatemia, which can reach life-threatening proportions in relation to starvation and can be aggravated during refeeding if phosphate and thiamine are not adequately supplemented.[6] Initially, refeeding causes a change from a catabolic to an anabolic metabolism, and concomitant hyperparathyreoidism may contribute to the development of hypophosphatemia. This process can lead to a critical drop in the intracellular concentration of ATP and the energy supply of the cells.[7] Thiamine acts as a coenzyme for transketolase, pyruvate dehydrogenase and α-ketoglutarate dehydrogenase complexes, enzymes which play a fundamental role for intracellular glucose metabolism.[8] Clinical consequences range from severe organ dysfunction and rhabdomyolysis to seizures, delirium, coma and death.[9]

Monitoring and management of electrolyte disturbances is therefore one of the most important aspects of the initial diagnosis and medical management of eating disorders. Phosphate and thiamine supplementation during refeeding of severely malnourished patients with anorexia nervosa can be life saving.

A further and common life-threatening complication of extreme anorexia nervosa is hypoglycemia, which may lead to coma and death as a result of starvation and hepatic failure and consecutive impairment of gluconeogenesis.[10]

Gastrointestinal symptoms are extremely common in eating disorders, but rarely the cause of fatal complications, apart from liver necrosis in end-stage starvation.[10,11] In rare cases, reduced gastrointestinal motility may lead to serious complications, such as gastric dilatation or rupture or paralytic ileus or subileus when psychotropic medications are used that have anticholinergic potential that may further impair motility (e.g. olanzapine, quetiapine).[12]