Pharmacological treatment options for low Bone Mineral Density and secondary osteoporosis in Anorexia Nervosa: A systematic review of the literature

•Women with AN have significantly lower BMD and a higher incidence of fractures than healthy women.•There are currently no recommended treatments to increase BMD and reduce fracture risk in women with AN.•Administration of Oral Contraceptives (OC) assume that a resumption of menses increases and protects BMD.•We found no evidence that the use of OCs will significantly increase vBMD in women with AN.•Bisphosphonates and transdermal estrogen patches significantly increased BMD in women with AN.

ObjectiveAlthough there are several evidence-based treatments available to increase Bone Mineral Density (BMD) and reduce fracture risk in aging men and women, there are still uncertainties regarding which treatments are efficacious in reducing lifetime fracture risk in women with Anorexia Nervosa (AN).MethodsMedline, PsychInfo, Embase and the Cochrane Database were searched for English Language Studies. Inclusion criteria were studies of females of any age with AN who received pharmacological treatment with the primary aim to increase BMD or reduce fracture risk. Data were extracted from each study regarding pharmacological treatment and dosage used, BMD and bone formation marker outcomes; and participant characteristics including age, Body Mass Index (BMI), duration of AN, and duration of amenorrhea.Results675 studies were reviewed, of which 19 fit the inclusion criteria and were included in the final review, investigating a total of 1119 participants; 10 of the 19 included studies were double-blind RCTs. The remaining studies consisted of prospective observational studies, a retrospective cohort study, a case-control study and five non-randomised control trials. Bisphosphonates were effective in increasing BMD in adult women with AN, while estrogen administered transdermally resulted in significant increases in BMD in mature adolescents with AN. Administration of oral contraceptives (OC) did not significantly increase BMD in randomised or controlled trials, however, lifetime OC use was associated with higher spinal BMD.ConclusionFuture research should clarify the safety of long-term bisphosphonate use in adult women with AN, and verify that transdermal estrogen replacement increases BMD in women with AN.