Anorexia Nervosa

Clinical Question/Comparison/Clinical Evidence StatementBaseline riskForest plotStatement code
Clinical Question - Physical: 3a. What is the best practice in the management of osteoporosis in people with AN?
Oestrogen supplementation in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between oestrogen supplementation and no oestrogen in terms of bone density by the end of treatment (GRINSPOON2002, KLIBANSKI1995). I

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S5
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between oestrogen supplementation and no oestrogen in terms of the number of people leaving the study early due to any reason by the end of treatment (GRINSPOON2002, KLIBANSKI1995). I

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S5
Oral DHEA vs. Hormone Replacement Therapy (HRT) in AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between DHEA and HRT in terms of bone density by the end of 12 months of out-patient treatment (N = 1; n = 61; GORDON2002). I

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S5
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between DHEA and HRT in terms of the number of people leaving the study early due to any reason by the end of in-patient treatment (N = 1; n = 61; RR = 0.65; 95% CI, 0.20 to 2.06). I

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S5
rhIGF-I vs. placebo in adults with AN
Efficacy of treatment (by the end of treatment)
There is limited evidence suggesting that there is a clinically significant difference between rhIGF-I and placebo with IGF-I being superior in terms of bone turnover/ density by the end of treatment (GRINSPOON1996, GRINSPOON2002). I

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S2
rhIGF-I + oral contraceptive vs. placebo in adults with AN
Efficacy of treatment (by the end of treatment)
There is limited evidence suggesting that there is a clinically significant difference between rhIGF-I + oral contraceptive and placebo with the combination being superior in terms of bone density by the end of treatment (GRINSPOON2002). I

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S2
Clinical Question - Physical: 4a. Do antipsychotic drugs produce benefits/ harms on the specified outcomes in people with AN compared to placebo?
Antipsychotic drugs vs. placebo in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence from two small short-term cross-over studies to determine if there is a clinically significant difference between antipsychotic drugs and placebo in terms of weight gain by the end of multi-modal in-patient treatment (N = 2; n = 32; VANDEREYCKEN1982; VANDEREYCKEN1984). I

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S5
Acceptability of treatment (by the end of treatment)
There is insufficient evidence from two small short-term cross-over studies to determine if there is a clinically significant difference between antipsychotic drugs and placebo in terms of the number of people leaving the study early due to any reason by the end of multi-modal in-patient treatment (N = 2; n = 32; Vandereycken, 1982; Vandereycken, 1984). I

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S5
Tolerability of treatment (by the end of treatment)
There is insufficient evidence from two small short-term cross-over studies to determine if there is a clinically significant difference between antipsychotic drugs and placebo in terms of the number of people leaving the study early due to adverse events by the end of multi-modal in-patient treatment (N = 2; n = 32; Vandereycken, 1982; Vandereycken, 1984). I 

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S5
Clinical Question - Physical: 4b. Do antidepressant drugs produce benefits/ harms on the specified outcomes in people with AN compared to placebo/ wait-list control?
Antidepressant drugs vs. placebo/ wait-list control in adults with AN
Efficacy of treatment (by the end of treatment)
There is evidence suggesting that it is unlikely there is a clinically significant difference between antidepressant drugs and placebo on weight gain by the end of multi-modal in-patient treatment (N = 4; n = 146; ATTIA 1998; BIEDERMAN 1985; HALMI 1986; LACEY1980). I

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S3
There is insufficient evidence to determine if there is a clinically significant difference between antidepressants and wait-list control on weight gain by the end of out-patient treatment (N = 1; n = 26; FASSINO2002). I

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S5
There is limited evidence suggesting that there is a clinically significant difference between antidepressants and placebo with fewer service users deteriorating clinically following in-patient weight restoration if given fluoxetine for one year (N = 1; n = 35; RR = 0.45; 95% CI, 0.23 to 0.86). I
.84#40:01:01S2
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between antidepressants and placebo on the number of people leaving the study early due to any reason by the end of in-patient treatment (N = 2; n = 47; RR = 1.26; 95% CI, 0.44 to 3.56). I#40:02S5
There is insufficient evidence to determine if there is a clinically significant difference between antidepressants and wait-list control on the number of people leaving the study early due to any reason by the end of out-patient treatment (N = 1; n = 26; FASSINO2002). I

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S5
Tolerability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between antidepressants and placebo on the number of people leaving the study early due to adverse events by the end of in-patient treatment (N = 1; n = 16; RR = 1.00; 95% CI, 0.07 to 13.37). I#40:03S5
Clinical Question - Physical: 4j. Do antihistamine drugs produce benefits/ harms on the specified outcomes in people with AN compared to placebo?
Antihistamine drugs vs. placebo in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between antihistamines and placebo on weight gain by the end of multi-modal in-patient treatment (N = 2; n = 177; GOLDBERG1980; HALMI 1986). I

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S5
Clinical Question - Physical: 5b. Does exercise/ massage produce benefits/ harms in the specified outcomes in people with AN?
'Standard care' + exercise vs. 'standard care' alone in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between exercise and 'standard care' on weight gain by the end of out-patient treatment (N = 1; n = 12; SMD = -0.16; 95% CI, -1.30 to 0.99). I

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S5
There is insufficient evidence to determine if there is a clinically significant difference between exercise and 'standard care' on social functioning by the end of out-patient treatment (N = 1; n = 12; SMD = -0.92; 95% CI, -2.15 to 0.31). I

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S5
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between exercise and 'standard care'  
 on weight gain by the end of out-patient treatment (N = 1; n = 16; RR = 3.00; 95% CI, 0.39 to 23.07). I

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S5
'Standard care' + massage vs. 'standard care' in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between massage and 'standard care' on weight gain by the end of treatment (N = 1; n = 19; HART2001). I

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S5
There is limited evidence suggesting that there is a clinically significant difference between massage and 'standard care' with massage being superior on EDI scores by the end of treatment (N = 1; n = 16; SMD = 1.06; 95% CI, 0.02 to 2.09). I

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S2
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between massage and 'standard care' on weight gain by the end of treatment (N = 1; n = 19; HART2001). I

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S5
Clinical Question - Physical: 5e. Does nutritional or vitamin supplementation/ nasogastric feeding/ gastrotomy (PEG)/ total parenteral nutrition (TPN)/ enteral feeding improve weight gain/ target weight in people with AN?
Zinc vs. placebo/ 'standard care' in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between zinc supplementation and placebo on weight gain by the end of multi-modal in-patient treatment (N = 2; n = 68; BIRMINGHAM1994; KATZ1987). I

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S5
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between zinc supplementation and placebo on the number of people leaving the study early due to any reason by the end of in-patient treatment (N = 2; n = 68; BIRMINGHAM1994; KATZ1987). I

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S5
Zinc vs. no zinc in children with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between zinc supplementation and no zinc supplementation on weight gain by the end of multi-modal in-patient treatment (N = 1; n = 26; LASK1993). II

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S5
Nasogastric feeding vs. 'standard care' in adults with AN
Efficacy of treatment (by the end of treatment)
There is limited evidence suggesting that there is a clinically significant difference between nasogastric feeding and 'standard care' with nasgastric feeding being superior in terms of weight gain by the end of multi-modal in-patient treatment (N = 2; n = 116; ARII1996; ROBB2002). II

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S2
Acceptability of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between nasogastric feeding and 'standard care' on the number of people leaving the study early due to any reason by the end of in-patient treatment (N = 1; n = 16; RR = 2.33; 95% CI, 0.30 to 17.88). II

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S5
Total Parenteral Nutrition (TPN) vs. 'standard care' in adults with AN
Efficacy of treatment (by the end of treatment)
There is insufficient evidence to determine if there is a clinically significant difference between TPN and 'standard care' on weight gain by the end of multi-modal in-patient treatment (N = 1; n = 22; PERTSCHUK1981). II

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S5
Tolerability of treatment (by the end of treatment)
There is limited evidence suggesting that there is a clinically significant difference between TPN and 'standard care' with placebo being superior in terms of the number of people experiencing adverse events by the end of treatment (N = 1; n = 22 ; PERTSCHUK1981). II

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S2

From: Evidence Statements

Cover of Eating Disorders
Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders.
NICE Clinical Guidelines, No. 9.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society (UK); 2004.
Copyright © 2004, The British Psychological Society & The Royal College of Psychiatrists.

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