STUDY TYPE: Retrospective chart review 

Clinicians use olanzapine, mirtazapine, and other appetite-inducing medications off label to treat ARFID, but with little research to support their use. This study unpacks the potential role of medications in treating comorbid symptoms associated with ARFID. 

Researchers reviewed the charts of 53 children and teens with ARFID treated in a partial hospital program. These charts were selected because the patients were given either SSRIs only or SSRIs with hydroxyzine as part of their treatment. The group was largely pubertal females with body mass index (BMI) of 15–16. To track progress with weight gain, this study followed the percent median body mass index, or %MBMI: the patient’s BMI divided by the median BMI for their age, then multiplied by 100. A typical goal is for patients to achieve a %MBMI of 90 to consider the treatment clinically meaningful. 

All patients had significant anxiety. Those who took hydroxyzine in addition to SSRIs were older than those who did not (13 vs 11), were made up of fewer female patients (64% vs 92%), and had more depressive symptoms on the Child Depression Inventory (62 vs 53). All patients benefited from SSRIs, with reduced anxiety, depression, and fear of eating. Patients in both categories improved weight gain, with those on SSRIs alone experiencing a %MBMI increase from 88 to 96 over the course of a year, and those who received SSRIs + hydroxyzine up from 89 to 98 over the same period. Hydroxyzine also helped subjective fear of eating as well as nausea in the more severe cohort of patients who received both medications. Side effects included mild sedation and fatigue for hydroxyzine and headache for SSRIs. 

The authors suggest starting SSRIs at 5 mg of fluoxetine (or equivalent) and titrating slowly to prevent paradoxically increasing anxiety. Hydroxyzine takes 15–30 minutes to act and peaks around two hours. The authors recommend dosing 0.5 mg/kg every four to six hours as needed for anxiety. Hydroxyzine liquid is helpful for patients who have trouble swallowing pills. 

Carlat Take
While this was a small uncontrolled study of patients in a relatively high level of care, it reminds us to assess for anxiety in ARFID. Of course, we need more research, but in the meantime SSRIs may help anxiety in ARFID, and adding hydroxyzine to an SSRI may help in severe cases of ARFID with comorbid symptoms.