Saturday, March 7, 2009: 9:00 AM-10:30 AM
Casablanca (Westin Long Beach)
Many eating disordered patients abuse non prescription substances in an attempt to lose weight. They typically use these drugs in supra therapeutic doses and in potentially toxic combinations. Our purpose is to alert the clinician to this dangerous and potentially lethal practice. We will describe the major categories of OTC drugs of abuse; diet pills, diuretics, laxatives and emetics. We will explain the clinical complications of abuse. We will present representative cases from our practice. We will review the prevalence data from our large multidisciplinary treatment program. Interspersed throughout the presentation we will include board review-type questions for discussion/debate.
I. Introduction, OTC drugs
A. Diagnostic categories
B. Prevalence data
1. Literature review
2. EDI statistics
C. Comorbidities
1. Polypharmacy
2. Novelty seeking
3. High risk behaviors
4. ETOH
5. Anxiety disorders
6. Axis II diagnoses
D. Review questions/discussion
II. Diet pills
A. Historic
1. Ephedra
2. Phenylpropanolamine
B. “Top Sellers”
1. Hydroxycut
2. Herbalife
3. Dexatrim
C. New products
1. Hoodia gordonii
2. Orlistat
D. Case history
E. Review questions/discussion
III. Diuretics
A. Diurex
B. Pamprin
C. Midol
D. Case History
E. Review questions/discussion
IV. Laxatives
A. Categories and examples
1. Stimulant, Correctol, Ex-lax, etc – most abused
2. Osmotic, Miralax
3. Bulk, Psillium
4. Emollient, Colace
B. Acute sequelae
1. Hypokalemia
2. Volume depletion
C. Chronic sequelae
1. Cathartic Colon
2. Melanosis coli
3. Rectal prolapse
4. Colectomy
D. Withdrawal
1. Hyperaldosteronism
2. Massive reflex edema
3. Body image disturbance
E. Addiction model, recitivism
F. Case history
G. Review questions/discussion
V. Emetics, ipecac
A. History
B. Toxicity myopathy and cardiomyopathy
C. Literature review, reported deaths
D. Case history
E. Review questions/discussion
VI. Conclusion
A. Constantly changing, need for update
B. Role of internet
C. Role of FDA
D. “Always ask”
Patients with eating disorders abuse over the counter medications with alarming frequency. The abuse occurs across the spectrum of diagnoses but is most common in patients with bulimia. Dosage is often supratherapeutic with resultant dangerous and toxic sequelae. The abuse may be surreptitious, making the diagnosis difficult. The astute clinician must be aware of these OTC drugs of abuse, their therapeutic effects and toxic complications There are four categories of OTC drugs of abuse: diet pills, diuretics, laxatives and emetics. We will describe each of these classes and give typical examples. Each class of drug will be illustrated by a case report. After each case we will offer discussion questions for audience participation. There are dozens of appetite suppressants available without a prescription, in an ever changing market. Ephredra and phenylpropanolamine have recently been banned by the FDA. New products have been introduced to supercede the old, namely Hoodia and Orlistat. The common ingredients in OTC diuretics are caffeine and pamabrom. These are weak diuretics such that hypokalemia and dehydration are unlikely in the case of overdose. Toxicity is more likely to occur from the acetaminophen contained in the product. Laxatives are commonly abused, especially the stimulant type. Acute sequelae include severe dehydration and hypokalemia. Withdrawal is difficult because of the development of reflex edema and the resultant assault on body image. Effects of chronic abuse include cathartic colon, rectal prolapse, and even renal failure. Ipecac is a known toxin. It is no longer recommended for use as a gastric decontaminant in acute poisoning. Yet it is still available at pharmacies without prescription and is a drug of abuse for eating disorder patients. The literature contains many case reports of myopathy and cardiomyopathy related to ipecac abuse, including several deaths. Our purpose is to alert the eating disorder professional to the many OTC products which are commonly abused by eating disordered patients. The scene is constantly shifting as new products replace those that have been banned. It behooves us all to stay up to date and informed.
Primary Presenter:
Deborah Mangham, MD
Deborah Mangham, MD is board cerftified in internal medicine and practiced primary care internal medicine before joining the Park Nicollet Methodist Eating Disorders Institute in 2000. She has been the Clinical Practice Director of the inpatient unit and the Clinical Practice Director of the residential program at the Anna Westin House. She is currently the Assistant Medical Director of the Institute. She was given many presentations on various eating disorder topics at both the local and national level (please see CV for details). She has been interviewed on television and in the popular press. She is currently completing a manuscript on ipecac myopathy. Research interests include intestinal bacterial overgrowth in patients with anorexia nervosa.
Co-Presenter:
Ann E. Vosti, MD
Ann Vosti MD is currently the lead physician at the Park Nicollet Methodist Eating Disorders Institute. She has been with the EDI since 2001. Dr. Vosti is board cerftified in Family Medicine and has practiced primary care. She also has BNS and MPH degrees. She has worked as a nurse in telemetry and in eating disorders. She has taught nursing at the College of St. Catherine in St.Paul, MN. Dr. Vosti has extensive public speaking experience both locally and nationally and is the author of a journal article on eating disorders in older women. In her leisure time whe enjoys hiking, riding and yoga. She has 2 young adult sons, 2 cats and a dog.
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