Scenario

Ms CD, a 24-year-old white British woman, presents to your pharmacy asking for some
information around use of laxatives and diuretics. On further questioning, it appears that she
seems to be obsessed with her body weight. Her height is 1.64 m and her weight is 56 kg. Her
food intake is quite irregular, being characterised by periodical binges followed by fasting
periods. She reports that some recent blood tests have shown a few electrolyte imbalances,
including sodium 130 mmol/L, but she doesn’t understand what this means.

Questions
1a Calculate Ms CD’s body mass index (BMI).
1b What would be causing Ms CD’s electrolyte imbalances?
2 Monitoring and referral criteria; what signs and symptoms should you look out for which could
indicate a patient may have an eating disorder?
3 What are the treatment choices for the management of bulimia?
4 Ms CD was eventually prescribed fluoxetine 60 mg daily by her GP. What are the goals of
therapy, including monitoring and the role of the pharmacist/clinician?
5 What are the social pharmacy issues of this case, including alternative therapies and lifestyle
advice?

1a Calculate Ms CD’s body mass index (BMI).

The calculation of the BMI is given by the following formula: weight (kg)/ height (m)2
(calculations are not to be carried out using the Imperial system). In this case: 56/1.642 = 20.8.
The BMI normal value is in the range of 20–25.

1b What would be causing Ms CD’s electrolyte imbalances?

Due to frequent laxative intake and vomiting induction, a related electrolyte imbalance
may be observed in people with bulimia. Sodium normal reference values are in the range of
133–147 mmol/L.

2 Monitoring and referral criteria; what signs and symptoms should you look out for which
could indicate a patient may have an eating disorder?
Bulimia nervosa is an illness in which people feel that they have lost control over their
eating. People with bulimia nervosa show a cycle of eating large quantities of food (e.g. ‘binge
eating’), and then either vomiting, taking laxatives and diuretics, or excessive exercising and
fasting, in order to prevent weight increase. Most bulimic clients’ weight is normal. Low weight
or recent significant loss of weight; excessive concern about weight; vomiting are the most
obvious warning signs. Referral issues: the first step will often be given by an assessment and
possible treatment by a psychiatrist with special training in eating disorders. Most bulimic clients
can be treated as outpatients; an inpatient treatment may be considered when either the client’s
suicide risk or severe self-harm need to be managed.

3 What are the treatment choices for the management of bulimia?

Adults with bulimia nervosa may be offered a trial with an antidepressant drug. Patients
should be informed that antidepressant drugs can reduce the frequency of binge eating and
purging. Selective serotonin reuptake inhibitors (SSRIs), and specifically fluoxetine, are the
drugs of first choice for the treatment of bulimia 92 Pharmacy Case Studies Chapter 04
document 14/1/09 2:57 pm Page 92 nervosa. For these clients, the typical dose of fluoxetine (e.g.
60 mg daily) is higher than that for the treatment of depression. These drugs selectively block the
reuptake of 5-HT, leading to neuronal adaptive processes that produce the therapeutic effect.

4 Ms CD was eventually prescribed fluoxetine 60 mg daily by her GP. What are the goals of
therapy including monitoring and the role of the pharmacist/clinician?
People with bulimia can experience a range of physical problems. Those who are
vomiting frequently or taking large quantities of laxatives should have their fluid and electrolyte
balance assessed. When supplementation is required to restore electrolyte balance, oral rather
than intravenous administration is recommended, unless there are problems with gastrointestinal
absorption. Fluoxetine, especially when given at high dosages, might be associated with a
number of side-effects, including nausea, anorexia, transient increase in anxiety levels and
insomnia, headache and sexual dysfunction (delayed ejaculation, anorgasmia). Both the clinician
and the pharmacist should proactively explore these issues with their patients at each assessment.

5 What are the social pharmacy issues of this case, including alternative therapies and
lifestyle advice?
Fluoxetine has a long half-life, which may be useful in patients who occasionally forget
their medication and in helping to prevent any discontinuation syndrome on tapering down the
dosage. Prescribers will gradually reduce the SSRI doses of the drug over a four-week period,
although some people may require longer periods. Fluoxetine can usually be stopped over a
shorter period. For patients at high risk of suicide, a limited quantity of antidepressants should be
prescribed. When a patient with depression is assessed to be at high risk of suicide, the use of
additional support such as more frequent direct contacts with primary care staff or telephone
contacts should be considered. Particularly in the initial stages of SSRI treatment, healthcare
professionals should actively seek out signs of akathisia, suicidal ideation, and increased anxiety
and agitation. When prescribing an SSRI, consideration should be given to using a product in a
generic form.
When communicating with both clients or carers, healthcare professionals should use a
non-technical language. Where possible, all services should provide written material in the
language of the patient. Since people with bulimia are typically female, sometimes a same-
gender clinician might be preferred by the client. Community-based healthcare professionals
often play an important part in first identifying eating disorders. Both the client and the family
should be informed about self-help and support groups for people with eating disorders and how
to contact them.

General references
Newcastle University School of Neurology, Neurobiology & Psychiatry, Faculty of Medical 82
Pharmacy Case Studies Chapter 04 document 14/1/09 2:57 pm Page 82 Sciences (2005)
Antidepressants. Available at http://www.ncl.ac.uk/nnp/teaching/
management/drugrx/antdep.html [Accessed on 2 April 2007].
NICE (National Institute for Health and Clinical Excellence) (2004a) Eating disorders full
guideline. Available at www.nice.org.uk/CG009fullguideline [Accessed 1 July 2008].
NICE (2004b) Anorexia nervosa, bulimia nervosa and related eating disorders. Understanding
NICE guidance: a guide for people with eating disorders, their advocates and carers, and the
public. Available at www.nice.org.uk/CG009NICE guideline [Accessed 1 July 2008].
NICE (2004c) Depression. Available at www.nice.org.uk/CG023NICEguideline [Accessed 1
July 2008].
Winstead NS and Willard SG (2006) Gastrointestinal complaints in patients with eating
disorders. Journal of Clinical Gastroenterology 40: 678–682.

Patient 1 is a 27-year-old man who has been diagnosed with chronic paranoid
schizoprenia. He has been on a home pass for approximately 12 weeks and was doing well until
the afternoon of admission, when he began having seizures. After 4 to 5 major motor-type large
tounge laceration and is give 10 mg of diazepam in the emergency department. His current
medications are chlorpromazine and imipramine.
On admission, patient 1 has a pulse of 100 bpm, a temperature of 36.8 degree Celsius,
and blood pressure of 108/83 mm Hg. He is semicomatose and responds to painful stimuli. His
head is normocephalic without evidence of trauma, and his optic discs are sharp. He has a large
laceration on the left margin of his tounge. His neck is supple, his lungs are clear, and he has a
regular heart rhythm, with a grade II/IV systilic murmur. His abdomen is soft, with active bowel
sounds and no palpable masses or organomegaly. Extremities are free of edema or cyanosis. His
deep tendon reflexes are hypoactive but symmetrical ; the babinski’s signs are absent on boh
sides, and he moves in all extemities.
Serum electrolyte levels are as follows: sodium 116mEq/L; potassium 4.0 mEq/L;
chloride 88 mEq/L..