All six patients were treated with the atypical antipsychotic medication olanzapine for its anti-anxiety properties plus appetite stimulation; four of the patients subsequently transitioned from olanzapine to an SSRI (such as fluoxetine) as they approached their treatment goal weight, and two remained on a low dose of olanzapine at bedtime in addition to an SSRI. These last two patients, who had a combination of chronic low appetite, picky eating, severe anxiety, and acute stressors, also required the appetite stimulant cyproheptadine in addition to olanzapine to help them reach their healthy weight.
The medications were all used off-label because of the lack of evidence for their role in the treatment of ARFID. Currently there is only one case series that explores the utility of olanzapine for treating ARFID. In the Brewerton and D’Agostino’s study,7 it was demonstrated that the use of low-dose adjunctive olanzapine may have improved patients’ appetites and weight gain and helped reduce symptoms of anxiety and depression for nine of the patients.
Some patients with anorexia nervosa may present with low weight, but deny body image concerns. In cases where the diagnosis is unclear, we would recommend proceeding with treatment focused on weight gain as described above. Moreover, the development of eating disorder-specific and ARFID-specific measures and diagnostic instruments should be considered.8,9 In cases of anorexia nervosa, the fear of weight gain typically becomes apparent during the course of treatment. In our eating disorders clinic, approximately 8% of 77 patients who presented initially with ARFID subsequently received a diagnosis of anorexia nervosa.
Additional research is needed to better understand which treatments or combinations of treatments are most effective for ARFID. There is a lack of evidence to guide clinicians, and in many cases, consultation with a feeding or eating disorder specialist is helpful. Moving forward, it will be important for researchers to conduct treatment outcome studies that investigate the effectiveness of various therapies and medications, alone and in combination, for the various subtypes of ARFID in both children and adults. Helping underweight patients reach their treatment goal weight is often an essential first step in address their physical and mental well-being.
Dr Spettigue is Associate Professor, Department of Psychiatry, University of Ottawa, Children’s Hospital of Ontario, Canada; Dr Norris is Associate Professor of Pediatrics, Adolescent Health Physician, Division of Adolescent Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario. The authors report no conflicts of interest concerning the subject matter of this article.
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