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


Eating disorders are associated with many medical complications, which can even be fatal, especially in anorexia nervosa, and less frequently in bulimia nervosa. Most medical complications of BED are secondary to overweight/obesity, similar to the general population. Consideration and management of medical complications of eating disorders is not only important for short-term and long-term physical health, but also to foster insight and motivation for treatment in patients who may frequently be ambiguous towards or frankly against treatment. Some newer findings regarding refeeding, nutrition, hormone and antipsychotic treatment challenge traditional concepts of medical management and should be considered in the management of eating disordered patients aiming at improved overall outcomes. There is evidence for higher calorie refeeding protocols to accelerate weight gain in adolescent and adult patients.[23,24,27] This paradigm shift was included in recent guideline recommendations toward leaving the 'start low, go slow' approach, as this can underfeed patients and lead to severe consequences due to hypoglycemia and lack of energy required for renal and hepatic function as well as glucose metabolism.[47]

Psychopharmacological treatment of the eating disorder per se should almost always be secondary to the medical management of complications of eating disorders, nutritional management and psychotherapy, as well as treatment of psychiatric comorbidities if those are not a consequence of the eating disorder. Whereas for bulimia nervosa and BED antidepressants and for BED also psychostimulants play a role as adjunctive treatment options within stepped-care approaches, new findings support the use of antipsychotics, such as olanzapine, for anorexia nervosa. Especially for anorexia nervosa, further studies with antipsychotics and antidepressants are of great interest in view of the high percentage of treatment-refractory cases and its high mortality risk.

In underweight patients osteoporosis and bone loss are common and usually diagnosed by DEXA radiography. Supplementation with vitamin D and calcium is recommended. Supplementing estrogene (transdermally) has been recommended in anorexia nervosa to reduce the risk of bone loss. Recent data suggest that young underweight women have better bone mineral density values (DEXA and bone turnover markers) when taking vs. not taking oral contraceptives.[35]

The gut microbiome may play a role in the cause and progression of eating disorders,[36,37] yet studies analyzing altered microbiome composition in patients with anorexia nervosa have reported heterogeneous results.[38] Since alterations of the microbiome in anorexia nervosa patients persist after short-term weight restoration,[39] microbiome-directed interventions could become an adjunctive treatment (nutrional supplies, probiotics or prebiotics or drugs influencing the microbiome), but, clearly, more studies are needed in this regard.