Table 1.
German guideline—changes in treatment recommendations for AN.
| Original guideline recommendations 2010 [15] | Guideline-revision recommendations 2019 [14] |
|---|---|
| General recommendations | |
| No recommendation concerning co-morbid conditions | (Evidence level IV; Clinical consensus point: good clinical practice): Co-morbid conditions should be systematically assessed and taken into consideration when treating patients with AN. |
| Treatment setting | |
| (Evidence level IV; 0): Inpatient treatment should take place in facilities able to offer a specialised multimodal treatment program. | (Evidence level IV; A): Same recommendation as original guideline, recommendation grading updated to A. |
| No recommendation concerning a stabilisation phase | (Evidence level IV; B): In order toreduce the probability of relapse, the final stage of inpatient therapy should aim to ensure that patients at least maintain their weight for a certain period and are prepared for the transition to an outpatient setting. |
| No specific recommendation concerning day hospital treatment for children and adolescents | (Evidence level Ib; A): A transfer to day hospital treatment after short-term inpatient treatment with sufficient physical stabilisation should be considered for children and adolescents, provided eating disorder-specific day hospital treatment can be carried out by the same treatment team, and close involvement of the relatives is ensured (evidence level Ib; A). |
| Psychotherapy | |
| (Evidence level II; B): Patients with AN are highly ambivalent towards change. Addressing ambivalence and motivation to change is a central task and should be maintained throughout the whole treatment process. | (Evidence level Ia; A): Same recommendation as original guideline, recommendation grading updated to A. |
| (Evidence level II; B): The outpatient treatment of first choice for AN should be evidence-based psychotherapy. (Clinical consensus point: good clinical practice): Patients with AN should be offered specialised therapy by a practitioner experienced with eating disorders. The choice of method should take into account the patient’s preference and age. |
(Evidence level Ib; B): Outpatient treatment of first choice for patients with AN should be evidence-based psychotherapy (FBT for children and adolescents; FPT, CBT-E, MANTRA or SSCM for adults), administered by practitioners experienced with eating disorders. |
| Nutritional management | |
| (Evidence level: not rated; statement): For orientation during the first days of treatment, the initial food intake (for enteral nutrition) of highly underweight patients can be quantified at approx. 30–40 kcal/kg. | (Evidence level IIa; statement): In patients with mild to moderate AN, an initial low caloric energy supply with gradual increase is not required for safe weight gain (avoidance of refeeding syndrome)—provided that medical monitoring is ensured. |
| No recommendation, but formulation of statements. For example, The basal metabolic rate is initially low and increases significantly with the onset of weight gain. The formulas for calculating basal metabolic rate obtained from normal and overweight people are not suitable for use with AN. | (Evidence level IV; Clinical consensus point: good clinical practice ): The energy supply for the expected weight gain is highly variable and should be individually tailored to the patients as well as to the treatment phase and be continuously monitored. |
| Pharmacotherapy | |
| (Evidence level Ib; B): Neuroleptics are not suitable for achieving weight gain in AN. (Evidence level Ia; A): Antidepressants are not recommended for achieving weight gain in AN. This applies to both initial therapy and relapse prevention. |
(Evidence level Ia; A): Same recommendations as original guideline, recommendation grading regarding neuroleptics updated to A. |
| (Evidence level IIa; B): If thinking is considerably restricted to weight phobia and eating and if hyperactivity is not controllable, an attempt to use low-dose neuroleptics (especially olanzapine) may be justified in individual cases. The indication for treatment should be limited to the duration of the symptoms mentioned above (no long-term treatment) and should only be applied within the framework of an overall treatment plan. |
Same recommendation as original guideline, with altered recommendation levels: (Evidence level IIa; downgrading to 0): If thinking is considerably restricted to weight phobia and eating and if hyperactivity is not controllable, an attempt to use low-dose neuroleptics (especially olanzapine) may be justified in individual cases. (Clinical consensus point: good clinical practice): The indication for treatment should be limited to the duration of the symptoms mentioned above (no long-term treatment) and should only be applied within the framework of an overall treatment plan. The patient must be informed about the circumstances of the off-label use. |
FBT, Family-Based Treatment; FPT, Focal Psychodynamic Therapy; CBT-E, Enhanced Cognitive Behaviour Therapy; MANTRA, Maudsley Model of Anorexia Nervosa Treatment for Adults; SSCM, Specialist Supportive Clinical Management.