drug therapy for bone loss in anorexia: giving in or giving hope?

A friend sent me this article about a new drug approach for restoring bone in anorexia for patients who are not able to gain weight: www.medscape.com/viewarticle/731094

My response was: "I prefer food."

His thought: "I certainly share your gut reaction, but at the same time it opens an interesting ethical discussion: Would it be wrong to turn to drugs that promised to alleviate some of the damage caused by EDs while not treating the ED itself? Where does treatment for one condition become complicity for another? And even with the best of evidence-based efforts and intentions, there is still a big percentage of ED treatment failures; is it worthwhile to have other bullets in the gun in case weight restoration efforts fail? I think most parents would vote yes."

Parents? What do you think?


  1. It could be used along side therapy and other treatments to prolong someone's life and give them a little more of a chance. I heard about a girl who broke her pelvis one day (just by walking) during her recovery - basically part of it just splintered and a bit of bone made it to her heart in her blood stream. She died suddenly a few days later. If it can prevent one terrible outcome of eating disorders, why not treat patients with it?

    I don't have access to the article, so I'm not sure what you mean by not able to gain? If it's a child, they usually have that choice taken away from them and the doctors choose what's best in their health. If they're an adult and (assuming not sectioned) seeking out even this small token of treatment, it's not only their choice regardless of their weight, but could be a good preventative measure if they just need a little more boost into recovery.

    I'm not a parent, though. I'm an adult with an eating disorder. My diet leaves me with few nutrients, so I take a multivitamin. I avoid most dairy, so I take a calcium supplement. And some day, if/when I recover and I find my bones are weak and brittle, I'd really like the option of a medicine to help prevent broken bones or worse.

  2. I agree with your friend and think he makes a great point. While it makes me sad that there are people who would turn to this, in the end, I believe that no adult is going to get better if they don't want to get better, and so if they choose to continue on in their anorexia despite (hopefully) pleas/attempts to help etc from family and friends, that is ultimately their choice.

  3. I too cannot open the article, but I agree with Abby that as long as it can be used alongside other treatments then it sounds very hopeful. It would be GREAT if no-one needed it, and with better treatments it IS going to be the case that fewer do, but there will still be people who get osteoporosis whether as a result of low weight AN or of other illnesses and genetic predispositions, and if this is a treatment for it then I welcome it.

  4. www.medscape.com/viewarticle/731094
    Try the link above or Google:
    DHEA Plus Hormone Therapy Increases Bone Mass in Girls With Anorexia Nervosa

    The study was aimed as a temporary measure whilst full re-nourishment was being achieved. Age group 13-27years.
    Considering recent news about HRT I suspect many would be very wary of using this with their child and if explained fully, would opt for full re-nourishment as quickly as possible.

  5. Thank you! I fixed the link.

    The question my friend and I are debating is not whether to offer a drug while refeeding is going on, it is offering the drug to patients who are NOT being refed - instead of food because they aren't complying with treatment.

  6. I believe those worms are best covered in chocolate and eaten.

  7. Do you know if it has been tested in people with AN and if there is any worsening of mental health associated with this (due to less incentive to eat)?

    I think that perhaps it would be unethical not to give the drug to someone known to be at risk of a fracture. If it is efficacious in a malnourished person, and if the side effects do not differ because of the malnutrition, and if the risk of a fracture is known to be less in this patient population receiving the drug, it doesn't seem right not to give the medicine.

    I suppose if we think of an eating disorder as a mental illness that causes physical and mental suffering, it seems most compassionate to help with the physical suffering even if the mental suffering is not alleviated. It might help though, as it would tie the person into their doctor a bit more as they presumably would need to be seen and monitored to receive refills of the prescription.

    Perhaps if there were data to show that the person with anorexia had worsening mental health while taking the medication, this would be a bona fide contraindication and then it would not be good practice of medicine to give the medication.

  8. i think it's so important to work on bone density. if the patient isn't re-feeding (yet, we hope), we still want to strengthen her bones for later in life. if she's not going to eat now, we still want to preserve as much as we can of her future.

  9. I devoted 10 years of my research career to studying bone metabolism in conditions of energy deficit. The interest was largely inspired by my own predicament: seemingly chronic AN (and told I was chronic) and awful osteoporosis.

    Without going into the details of the metabolic mechanisms of low bone mass in AN, the cause is directly related to low weight and inadequate energy (+ nutrient) intake - and the effects widespread. It's not just steroid hormone deficiences. Most drug therapies are futile, but weight gain can produce very big gains in bone mass, even reversal of osteoporosis in young people with a history of AN.

    IMO AN patients shouldn't be offered false hope when there is a very effective treatment for the bone remodelling imbalance of AN: FOOD!

  10. I prefer food, too. But that is now. Once upon a time...I did not prefer food. And I probably would have tried to refuse the drug, since I was such an 'complicit' patient.

    That said, I wish that this drug had been around when I did not prefer food, AND that my doctor HAD given it to me -no matter my level of food intake at the time. I lost over 2 inches of height to my stupid eating disorder, and now my bones are weaker than most people my age. I wish I would have listened to all the doctors who told me, "One day you'll wish you had strong bones."
    They were right.
    I was also given vitamins when I was not eating what I needed to...I consider this a prevention similar to vitamins. If is does no harm, then I say: try it.
    Fight ED with whatever treatment does no (long term) harm.

  11. ...to clarify ---I support this drug being used "until" food intake is increased, not "because" someone won't eat. If you set the patient up for "you can take this drug instead of eating...", you're doing a disservice and injustice, imo. Offering the drug, "until you are eating what you need to in order for your body to heal"...that reminds the ED-mind that the patient will not be living on pills alone.

  12. All drugs have side effects, including DHEA, even though, like the sex steroid hormones it is a naturally occuring (adrenal) hormone.

    Reduced bone formation is concomitant with energy deprivation and low weight. As soon as re-feeding starts, bone formation increases, so why give a drug that may do the same thing, though not as effectively and may have side-effects? The magnitude of increase of bone density with weight gain is substantially higher than the increase reported in the study of DHEA treatment.

    Furthermore, AN is accompanied by malfunction of ALL tissues and organs, not just bone. If someone with AN wants to avoid or reverse the physical consequences of semi-starvation and low weight they need to eat and gain weight. DHEA won't prevent/reverse atrophy of the heart muscle, electrolyte imbalance, renal problems, gut problems etc. etc. Food and weight gain will.

  13. I'm grateful to you all for your comments, but have to cheer for and agree with Cathy here.

    Giving a drug as a substitute for food is not only a bad idea for health it makes the doctor and other people around the patient into complicit partners in avoiding the real issue.

    If someone can't nourish himself he needs help doing that - not a substitute and tacit acceptance of the dictates of the illness. Bone loss is only one symptom and the medicine, food, is the only one that helps turn around the mental symptoms INCLUDING the inability to eat.

  14. perhaps if there were quantifiable results showing that the drug does work for its supposed cause, then it would be beneficial to apply use of this drug in cases where the anorectic truly is on a path of recovery, because if used as a preventative measure, or as an aid to help an anorectic, it would be beneficial so long as the anorectic didn't continue to follow anorexic patterns. Anyway my point would be that this drug may be beneficial to people like me who are desperately trying to recover, and need all the help they can get to save their bodies in the long run however at the same time, should not be used as a method to say, this patient is not as much at risk therefore is lower priority, or well at least were protecting her from osteoporosis, so what if she wont eat.

  15. (Not a parent, sorry.)

    Food is better, absolutely, but I'm not clear what you mean here. I hope you're not saying patients should be denied treatment that would make them healthier because they deny the treatment that would make them healthiest. I find that idea pretty disturbing. The fact is that a lot of people even with diseases like cancer don't choose the treatment that doctors think would make them healthiest. If someone chooses not to undergo chemotherapy or surgery or whatever the doctors think is best, should they be denied all other treatment as well?

    If you're just saying that this makes you uncomfortable, then I agree. I'm not really comfortable with the idea, either. I can't help feel, though, that anything that makes someone healthier is a good thing.

  16. I'm a parent, and a doctor. I don't know if this medication DOES work in a malnourished patient and evidence would be needed in that setting before it is given.

    If this medicine combination is indeed effective in malnourished patients who aren't eating properly (seems unlikely doesn't it?), I think it would be no different than giving antibiotics and breathing treatments to smokers for bronchitis (yes, quitting smoking would work better) or treating any of their other smoking related problems. I don't think it would be ethical to refuse to provide an efficacious treatment on the basis that the person has a mental illness that is related to the problem.

  17. An interesting discussion . . . I am with all who are thinking that, of course, food is the preferred method to increase bone density, but Laura's question is whether or not to offer the treatment to people who are ill and are not refeeding. I agree with 4:15 pm poster who says that it wouldn't be ethical to not offer information about the treatment. DHEA is considered a dietary supplement and no prescription is required for it. HRT's would need the prescription, though.

    If the treatment actually works on malnourished patients (we've only seen the evidence for refeeding patients so far), then I wonder from which body system the ingredients for the increased bone mineral density would come. They aren't just magically created from nothing. Perhaps a benefit in one place, ie bone density, would just mean that another area would be worse off than before treatment.

  18. This is really relevant to me. I tried the contraceptive pill, lots of calcium and vitamin D, and I was terrified of bone loss but nothing helped me. The reality is, that when you are that malnourished, drugs aren't going to make all that much of a difference because your body isn't able to make much use of them anyway. On the other hand, if I had access to this kind of therapy I might not be in the position I am in now. I have severe osteoporosis and ongoing chronic pain. I have stress fractures in both femurs, my right tibia and possibly my rib now, and that's not even from doing any activity. They found that my bones thinned to the point of fracture, rather than actual stress being the culprit. I have seen specialists and they have said there is no point prescribing any of the medications they have for osteoporosis now because the factors contributing to mine make it very different from the 'usual', also they have said, the only way my bones will improve in any way is through nutrition.
    When I was going through my worst stages with anorexia, I was in even more pain than I am right now and terrified because I could feel something very, very wrong with my legs. I was terrified of ending up crippled and that is still a possibility. There were times I couldn't even stand as my legs were that weak, I could not hold up my own weight (this is not from the weakness of malnutrition, I had that, too, but the scarier weakness for me was that of my limbs themselves.) Yet even knowing what was happening and that if I didn't improve my intake fast it would deteriorate even more, I felt so unable to change and trapped, I couldn't do anything about it. That's why I agree that the bone therapy AND help to reestablish nutrition should go hand in hand.

    When most patients are at their worst, just happens to be the most crucial period for our bone health - when the body needs to be laying down stores. Missing that is something we can never make up for after recovery.

  19. I just read Laura's comment about the question being should it be offered instead of nutrition if the patient is not complying. while it would be great if every option to prevent bone loss was explored, I don't believe that it would make any difference really - if the patient were refusing nutrition their bodies most likely wouldn't be able to utilize the drug therapy anyway. Nothing I took helped. So I'd think it would be best in conjunction with nutrition.

  20. Wow! GIve food a chance, please.

    We are discussing young patients (oldest would be up to mid 30's since after that neither food nor medication can make much difference in terms of new bone growth)-- so if these young patients are not eating enough to restore bone health, that's on their treatment providers!

    For crying out loud, do not accept treatment that does not mandate adequate weight restoration, whether or not the patient "buys into it". Even if a young patient doesn't buy into their treatment, the fact that they are weight restored means that their bones are not weakened for the rest of their adult life and--more importantly--neither is their brain growth stunted. They may still struggle with the psychological deficits of AN as adults, but at least they will not contend with the irreversible deficits caused by prolonged under-nutrition.

    We check DEXA scans in our patients on admission to our program and yearly thereafter after weight restoration precisely to address the bone health issue--- and with weight restoration and nutrition, their bones recover


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