Background: Hospitalist have not previously had a primary role in the setting of eating disorders beyond stabilization in an acute care setting. Following stabilization, patients in need of further treatment are transferred to an eating disorder facility. While in inpatient or residential care for their eating disorder, patient are monitored by physicians or mid-level providers. Most patients are chronically dehydrated and malnourished secondary to behaviors of restriction and purging prior to admission. Following initiation of a consistent meal plan, patient are a higher risk to retain fluid due to elevations in aldosterone levels, which is known as psuedo-Bartter’s syndrome. Patients who develop edema or rapid weight gain secondary to fluid retention have previously been required to be admitted to a local hospital. This results in an interruption in therapeutic care to address the acute medical complications, which can significantly set back eating disorder recovery.
Methods: Patients are screened on admission for higher risk of fluid retention following cessation of purging. Higher risk patients include, but are not limited to, a history of purging once daily or more, amhistory of extensive laxative use, and a history of recent diuretic abuse. Weights are monitored daily to determine who is appropriate for medical management. The diuretic used as first line is Spironolactone (Aldactone) for the specific pharmacologic effect as a aldosterone antagonist, acting primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule. Spironolactone is potassium sparing which is another important factor as high risk patients typically purge by vomiting which can lead to hypokalemia. In addition, high risk patients are being monitored for risk of refeeding syndrome which includes hypokalemia. Therefore, Spironolactone is first line for this patient population, despite having a milder diuresis effect. Medical management (Spironolactone) was initiated for patients with more than a 3-5 lb weight gain in 3 days or less, or sooner if a high risk patient has rapid weight gain of more than 2 lbs per day. Medications were increased if weight did not decrease or stabilize within a few days. For patients that continued to have weight gain with peripheral edema following addition of Spironolactone, oral Lasix was started and titrated. Weights and orthostatic vital signs were monitored a minimum of daily. Patient were seen by a medical provider daily and medications were adjusted frequently.
Results: All patients were monitored and treated medically at the eating disorder facility without need to transfer to higher level of care. No patients required intravenous or more aggressive diuresis due to early intervention with oral diuretics. Potassium sparing side effects of Spironolactone decreased side effects such as hypokalemia which other diuretics can cause. Patient continued therapeutic programming while receiving acute medical care from hospitalist.
Conclusions: The addition of hospitalists into the eating disorder facilities allowed co-management of acute medical complications while patients are receiving intensive multidisciplinary therapeutic care. High risk patients were identified and monitored closely by a medical provider daily to allow rapid intervention for weight gain secondary to fluid retention. Hospitalist experience regarding diuretics was critical to prevent escalation to higher level of care.