Proton Pump Inhibition in the Management of Hypokalemia in Anorexia Nervosa with Self-Induced Vomiting

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Natalie Jane Wainwright
Arden Azim
John David Neary


Anorexia nervosa, vomiting, hypokalemia, proton pump inhibitors


Hypokalaemia is a dangerous complication in severe cases of eating disorders with self-induced vomiting and can result in rhabdomyolysis, cardiac arrhythmias, and death. Self-induced vomiting leads to hypokalaemia through two pathways.  First, loss of gastric acid causes hypochloraemic metabolic alkalosis, which increases filtered bicarbonate load in the nephron (exceeding the tubular resorptive threshold), and subsequently increases distal sodium bicarbonate delivery.  Secondly, hypovolaemia causes activation of the renin-angiotensin-aldosterone axis. Increased distal sodium delivery and mineralocorticoid activity together cause urinary potassium wasting.  Standard management of severe hypokalaemia in patients with anorexia or bulimia nervosa and persistent self-induced vomiting includes intravenous replacement of potassium and correction of hypovolaemia. However, hypokalaemia is often refractory in eating disorder outpatients who have ongoing self-induced vomiting after discharge. We present a case of hypokalaemia due to anorexia nervosa, binge-purge subtype with self-induced vomiting successfully treated with a proton pump inhibitor (PPI) in addition to standard therapy.
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1. Topf, Joel (@kidney_boy). “PPIs to prevent and saline to treat metabolic alkalosis. Will help with hypokalemia”. 2017 June 8, 08:07. Tweet.

2. Mehler PS, Walsh K. (2016). Electrolyte and acid-base abnormalities associated with purging behaviours. Int J Eating Disorders, 49(3): 311-18. doi: 10.1002/eat.22503.

3. Miller KK, Grinspoon SK, Ciampa J et al. (2005). Medical findings in outpatients with anorexia nervosa. Arch Intern Med, 165(5): 561-66. doi: 10.1001/archinte.165.5.561.

4. Strand DS, Kim D, Peura DA. (2017). 25 years of proton pump inhibitors: a comprehensive review. Gut and Liver, 11(1): 27-37. doi: 10.5009/gnl15502.

5. Eiro M, Katoh T, Watanabe T. (2002). The use of a proton-pump inhibitor for metabolic disturbances associated with anorexia nervosa. N Engl J Med, 346(2): 140. doi: 10.1056/NEJM200201103460218.

6. Unwin RJ, Luft FC, Shirley DG. (2011). Pathophysiology and management of hypokalemia: a clinical perspective. Nature Reviews Nephrology, 7(2): 75-84. doi: 10.1038/nrneph.2010.175.

7. Katoh T, Eiro M, Watanabe T. (2002). Authors reply: use of a proton-pump inhibitor for metabolic disturbances associated with anorexia nervosa. 347: 373-4. doi: 10.1056/NEJM200208013470520.