The Waco Guide

Yes
No
Yes
weight ≥ 1.5kg/wk or
electrolyte instability
Refeeding
syndrome present
Yes
No
Inadequate
Response
No
Anorexia Nervosa
Adolescent (≥13yo) and Adult
Atypical Anorexia Nervosa
may be present in
normal/overweight individuals
with rapid weight loss while
meeting other DSM criteria
regardless of BMI
Does patient meet indication
for hospitalization?
Hospital Admission Indications:
• Medical / Psychiatric Instability
• Cardiac Dysrhythmias or qTc ≥ 500 msec
• Pulse < 40 bpm
• BP < 80/60 mmHg
• Orthostatic Hypotension
• Severe Dehydration
• Electrolyte imbalance
(K < 3, Phos < 2, Hypoglycemia)
• Temp < 97 degrees
• BMI < 15 or IBW < 70%
• Marked edema
• Marked suicidality or possible recent attempt
Inpatient hospitalization
Outpatient treatment
Is comorbid psychiatric
disorder present?
See corresponding
decision support Avoid Bupropion/TCA's
Pretreatment Evaluation
Vital signs, Orthostatics, BMI, EKG
UA, CBC, CMP, TSH, INR
Phosphorus, Magnesium, Amylase
UPT, UDS, 25-OH VitD
Multidisciplinary
Intervention
(Initial goal of
treatment is weight gain)
Psychotherapy:
• CBT or CBT-E
• Motivational interviewing
• Family based therapy
• Cognitive remediation
Nutritional Rehabilitation:
• Monitoring
• Behavioral management
• Nutritional counseling
Closely monitor for medical complications,
especially refeeding syndrome
• Monitor vital signs, weight, BMI
• Weekly CMP, phosphorus, magnesium
• Target outpatient weight gain 0.2-0.5kg/wk
• Avoid rapid weight gain
Twice weekly CMP, phosphorus,
magnesium to monitor
for refeeding syndrome and/or medical
instability
Inpatient
hospitalization
Successful weight gain
resulting in
BMI ≥ 18.5kg/m²?
Reevaluate for
Remaining Psychiatric disorder
Comorbid Psychiatric
disorder present
See corresponding
Decision Support
Avoid Bupropion/
TCA's
None
Maintenance psychotherapy
relapse prevention
Failure to gain weight despite
nutritional rehabilitation
and psychotherapy Olanzapine
Quetiapine
Consider referral to
higher level of care

What is the phase of treatment?