The Reply

Abstract

I read with interest the letter to the editor from Jamieson in regard to using denosumab in a patient with anorexia nervosa.1Westmoreland P. Krantz M.J. Mehler P.S. Medical complications of anorexia nervosa and bulimia.Am J Med. 2016; 129: 30-37Abstract Full Text Full Text PDF Scopus (211) Google Scholar The stark reality is that of all the litany of medical complications associated with anorexia nervosa, one of the only ones that can cause permanent harm, even after successful weight restoration, is osteoporosis. It is a highly prevalent problem in anorexia nervosa, which begins early in the course of the disease and affects female and male adult and adolescent patients with anorexia nervosa. This is especially important because the peak age of onset of anorexia nervosa occurs during the period of late adolescence, when 60% of peak bone mass is normally accrued. Therefore, failure to achieve maximum bone mass as a result of the hypogonadal state associated with anorexia nervosa results in a 3-fold increase and risk of subsequent bone fractures both in adolescence and in the adult years.2Vestergaard P. Emborg C. Soving R.K. Hagen C. Mosekilde L. Brixen K. Fractures in patients with anorexia nervosa, bulimia nervosa and other eating disorders—a nationwide register study.Int J Eat Disord. 2002; 32: 301-308Crossref PubMed Scopus (180) Google Scholar, 3Faje A.T. Fazeli P.K. Miller K.K. et al.Fracture risk and areal bone mineral density in adolescent females with anorexia nervosa.Int J Eat Disord. 2014; 47: 458-466Crossref PubMed Scopus (118) Google Scholar The exact etiology of the aggressive loss of bone mineral density associated with anorexia nervosa is not known. Putative causative factors include hypogonadism, elevated cortisol levels, low leptin levels, elevated inflammatory cytokine and sclerostin levels, and growth hormone resistance.4Suresh E. Abrahamsen B. Denosumab: a novel antiresorptive drug for osteoporosis.Cleve Clin J Med. 2015; 82: 105-114PubMed Google Scholar Moreover, the pathophysiology of the reduced bone mineral density in anorexia nervosa is unique and different from postmenopausal osteoporosis, in that it involves both increased bone resorption as well as decreased bone formation. To date treatment options have been limited. Oral estrogen is not effective, and although bisphosphonates have shown efficacy in anorexia nervosa, there is concern about their usage in women of childbearing ages. Therefore, there is understandable excitement about the potential utility in this population of denosumab, the novel antiresorptive drug, which seems to be safe, efficacious, and easy to use. However, at this time there are only anecdotal reports of its efficacy in anorexia nervosa. Our group has also prescribed it in a few patients with anorexia nervosa, with positive results similar to those reported by Jamieson. Denosumab, along with teriparatide, may offer hope to treat the osteoporosis of anorexia nervosa along with weight restoration and resumption of menses. However, future research is sorely needed to define the optimal treatment that is effective for promoting bone formation and optimizing peak bone mass acquisition, especially in adolescents with anorexia nervosa. Medical Complications of Anorexia Nervosa and BulimiaThe American Journal of MedicineVol. 129Issue 1PreviewAnorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic. We review the medical complications that are associated with anorexia nervosa and bulimia nervosa, as well as the treatment for the complications. Full-Text PDF